underperforming doctors

The UK has a poor record on retraining underperforming doctors and rehabilitating sick ones. But that is set to change. Wendy Moore examines new attitudes and plans of action aimed at meeting the demands of the clinical governance revolution

Doctors can finally come out of denial. After the Bristol baby deaths and the continuing catalogue of medical mishaps still grabbing the headlines, no one now pretends doctors are perfect.

The health service, the public and even the medical profession are finally beginning to accept that doctors are only human. They make mistakes, they get rusty, they get ill, they get stressed, they get addicted to drink and drugs, they have bad days - just like the rest of society.

'Every doctor who has practised medicine has made mistakes,' admits Dr Richard Smith, editor of the British Medical Journal, in a new book, Medical Mishaps.1 He goes on to confess his own worst error, when he injected a local anaesthetic into a young boy's arm without first inflating the blood pressure cuff, with potentially serious consequences. The boy was fine.

But confession is just the beginning. With the coming clinical governance revolution, poor performance and conduct among doctors - and other health professionals - will become increasingly apparent. So what is to be done about our imperfect doctors? It is neither practical nor appropriate to sack them all: there has to be a third way.

'In the new world, the clinical director will have to guarantee that each and every doctor on his or her firm or directorate is up to the mark,' says Dr Jenny Simpson, chief executive of the British Association of Medical Managers. 'It will be a very brave medical director, post-Bristol, who will allow someone who he or she thinks is not competent anywhere near a patient.'

Appraisal of doctors, through schemes set up by individual hospitals or the revalidation system being developed by the profession, will throw up many examples where performance or conduct are below par, she says. In any case where patients are at risk, managers have no option but to act immediately to prevent the doctor doing further harm, she stresses. That might mean suspension, leading to disciplinary action.

But there may be many more grey areas, where doctors are not as up-to- date as they should be, performance is moderately below par, or there are gaps in skills or knowledge, she says. This is where education and other creative ways to resolve the problem will be needed.

'It is part of a spectrum,' says Dr Simpson. 'Clearly, it is far better to pick up problems before they become a problem and re-educate on the basis that nobody wants to do a bad job anyhow.'

Training or re-training may be needed to help tackle clinical concerns, such as a surgeon who falls down on one particular procedure, or behavioural problems, like a doctor who is rude to patients. But all clinicians, Dr Simpson believes, will have to be more ready to accept they need regular training. 'The big hole now is to help doctors understand that this is necessary and this is what the future is going to be like,' she says.

The likely scale of the problem is unclear. Because there has previously been little acceptance that doctors can make mistakes, they have not been systematically documented. Medical Mishaps cites research from the US which found that 36 per cent of patients admitted to a teaching hospital suffered harm caused by hospital staff, and a quarter of these instances were serious or life-threatening. More than half were due to medication errors. Another study, cited in the book, found a 1 per cent error rate in activities in an intensive care unit.

Persistent problems involving individual doctors may be more intractable. Research by Professor Liam Donaldson, before he became chief medical officer, found that, over five years, 6 per cent of consultants in Northern and Yorkshire region were guilty of conduct serious enough to warrant disciplinary action.2

Research in the US has found that about 7 per cent of doctors are alcoholic, according to the Sick Doctors' Trust, which helps doctors who abuse drink and drugs. About 3 per cent abuse opiate drugs and a further 3 per cent soft drugs, like tranquillisers. There is no reason why the figures should be different for the UK, the trust says. Indeed, British figures from the Office for National Statistics show that doctors are three times more likely than average to die from cirrhosis. Rates of suicide are also higher.

Meanwhile, legal claims for medical negligence are rising by about 15 per cent every year, according to the Medical Defence Union. Suspensions of doctors are also increasing. Department of Health figures reveal that since March 1995, 43 doctors have been suspended for more than six months and 14 of these - including nine consultants - are still suspended. It is not known how much these are costing the NHS.

Former health minister Alan Milburn announced a review of suspensions procedures last October, arguing that 'precious NHS resources are being squandered' through doctors being suspended for long periods. He hoped to speed up the process.

Both the MDU and the King's Fund believe that informal suspensions - where doctors are simply told to take prolonged leave - are also rising. This may be because managers are erring on the side of caution since Bristol, but want to avoid complaints to the General Medical Council and lengthy disciplinary procedures. Now the cost and difficulties involved in the two usual routes for tackling poor performance - the GMC and the NHS disciplinary system - are prompting some health authorities and trusts to develop new alternatives. Going through the disciplinary system can take years - in the worst case, consultant paediatrician Bridget O'Connell was off work for more than 10 years at a cost of£1m.

She was suspended by North East Thames regional health authority in December 1982, accused of 'inability to relate effectively with her clinical colleagues'. In May 1994, she accepted early retirement, an apology and a cash settlement.

And suspending a doctor when just one aspect of their performance might not be up to scratch is wasteful, argues Winston Peters, president of the Hospital Consultants and Specialists Association. It also puts them in 'double jeopardy', he says. They might be off work for a year for personal misconduct after being rude to patients. When they return, their work is so rusty they are then found guilty of professional misconduct.

'You may say to a surgeon your gall bladders are all bad. We should be able to say you can do everything but cholecystostomy and then send the person for retraining in that one area,' says Mr Peters, a surgeon at Poole Hospital trust.

The HCSA is leading efforts within the medical profession to put forward a fast-track suspensions policy, along the lines of a system pioneered at Poole. The proposed scheme works from a six-point checklist.

There must be a timetable for action, with the clock beginning immediately.

A panel with representatives of the different parties and an independent chair, normally a QC, should assess whether suspension is justified. The panel would have powers to reinstate the doctor or insist that the trust begins disciplinary proceedings.

The charge must be clear and not changed at a later date.

If the case is unresolved after six months it can go to court.

Doctors reinstated after wrongful suspension should receive compensation.

Retraining for doctors whose performance has been found to be lacking - sometimes called remedial training - is rarely offered, according to the HCSA. There is no formal system to arrange, supervise or pay for such training, so it is usually organised on an ad hoc basis through informal networks.

The GMC occasionally recommends retraining when it suspends a doctor from the medical register for professional misconduct. Under the new performance procedures to deal with cases of persistently deficient performance, which came into effect in 1997, training and counselling will increasingly be recommended. But the onus will still be on the doctor to arrange this.

Usually a doctor would be pointed towards the regional postgraduate medical dean to arrange remedial training, explains Dr Linda Patterson, medical director of Burnley Health Care trust, and a GMC member. After the suspension period they are reassessed to ensure that their performance has improved.

But the new performance procedures emphasise that trusts should aim to avoid a formal GMC case by trying local resolution first, she stresses. That might involve sending the doctor to another hospital for retraining or appointing a mentor to oversee their work. They might have to stop doing a certain procedure or only do it under supervision.

'If patients are at risk you have to do something,' she says. 'There is no question about that. It is not about protecting namby-pamby doctors. If you have to get rid of a doctor and stop them practising that is a real loss to the country because doctors are a scarce resource.'

Dr Allan Cole, medical director of Glenfield Hospital trust in Leicester, agrees. 'Throwing people on the scrapheap is not a particularly good idea.' He believes most doctors fall into trouble of some sort during their 30- to 40-year career. All doctors therefore need training at various times, and remedial training should be seen as just one end of a training spectrum.

'You don't have this in-depth training for half your life and then suddenly when you get appointed a consultant you don't need any more,' he says. 'Everyone needs to continually have training in areas of their practice, partly because things change, partly because your memory falls off or your ability in a particular area falls off, and for all sorts of reasons.'

Glenfield is one of the first hospitals to begin introducing annual appraisal for consultants - likely to become commonplace under clinical governance. It aims to have completed appraisals on every consultant within the next 12 months.

That, says Dr Cole, is likely to identify gaps in skills and knowledge in many areas. The trust has just appointed an associate medical director for clinical education to co-ordinate training needs identified by appraisal.

Some of the skills gaps may be urgent and need immediate action, he says. Others will be longer-term, requiring training in new clinical skills, communications or computers.

The trust aims to provide some training in-house - such as the course in bereavement counselling recently organised for consultants. Where a serious problem is identified it would be more likely that the doctor would be sent for retraining to another hospital, Dr Cole believes. In one case, Glenfield has provided such training for a doctor who had been out of practice for several years following a drink problem.

According to Dr Ian Joiner, chief executive of the Sick Doctors' Trust, such retraining is rarely available. In three years, the trust has helped more than 120 doctors with drug and alcohol problems. But Dr Joiner, who has himself returned to practice after alcoholism, knows of only three who have had training to help them return to work.

'We have had great difficulty getting people back into work, particularly if they have been out of work for maybe two years,' he says. No formal system exists to arrange training, unlike in the US where many states run re-entry schemes.

Another difficulty is the stigma attached to drug problems. This is despite the fact that the trust's programme, which offers doctors counselling and other support, has only a 5 per cent relapse rate.

'It is far more of a problem when people are working under the influence of drink and drugs and are not doing anything about it,' he says.

Dr Alastair Scotland, director of medical education at the Chelsea and Westminster Healthcare trust, hopes remedial training will become a much easier and more acceptable option in future.

He welcomes the new GMC framework, with its emphasis on local solutions. 'Doctors are an expensive resource. They cost a great deal to train. They cost a great deal to maintain in their training.'

Guy Rotherham, senior research fellow with Sheffield University's school of health and related research, supports the same approach with GPs. His study of measures to help GPs whose performance is under question, published two years ago, outlines a framework for HAs to identify and tackle performance difficulties.3

It concludes that one-to-one contact with respected peers is the most effective way to change GPs' behaviour. It proposes support teams of managers and senior doctors to examine concerns about performance and recommend action.

The most useful interventions, it found, were training, improvements to the practice infrastructure and support for health problems. Several HAs in Trent region are now piloting the ideas (see box, left).

Mr Rotherham says: 'Underperformance is potentially threatening, potentially dangerous at its most extreme end. It is dangerous to be inefficient or ineffective. If you can provide support at a particular time it can enable people to go on and provide very effective care in the future.'

Helping doctors to regain their peak performance needs sensitive handling and creative thinking, he says. 'It is part art and part science.'