Tackling performance problems is rarely easy, but there is experienced support to call on. Dr Rosemary Field explains

What does analysis of the type of cases NHS organisations bring to the National Clinical Assessment Authority say about the problems faced and solutions sought?

Of around 1,700 referrals to the organisation that supports the NHS in addressing performance concerns about clinicians, about two-thirds of cases involve clinical concerns (such as clinical decision-making, consultation skills and record-keeping), two-thirds behavioural difficulties and one-fifth related to the practitioner's health.

In a further sample of 50 cases reviewed in depth by the NCAS, 21 concerned doctors from hospital and community health services, 26 were about GPs and three about dentists. Concerns related to clinical work, behaviour, health and organisational issues. In most cases, there were concerns in more than one area.

What action should we take?

Organisations contact NCAS to help clarify the process. They want advice on how to conduct an investigation, monitor progress in performance cases or manage a case conference.

Some organisations may work with a practitioner for months, but make little progress. In other cases, action may be needed to help an individual return to work - we can facilitate a meeting with a practitioner and advise on retraining packages.

Our role is to support the organisation - the responsibility for taking decisions remains with them.

We advise on how to work with a practitioner during the course of the case. Everyone needs to be clear about expectations and responsibilities and set clear timelines. Acute and primary care trusts should encourage practitioners to arrange personal support while concerns are monitored - perhaps from a colleague, mentor or the local medical or dental committee.

A relatively small number of cases relate to concerns about locums, and trusts may want advice about their responsibilities when a person no longer works for them.

Should we refer to the regulator?

How does our role fits with that of the General Medical Council or General Dental Council? An organisation may ask whether a case needs to be referred to the regulator. The primary need is to protect quality of care and patient safety, so we advise referral where there are concerns that raise doubt about an individual's fitness to practise.

Fitness to practise is a decision for the regulator. NCAS has no regulatory powers. We can help an organisation handle a case while awaiting a General Medical Council hearing, where there are concerns about patient safety or matters that are not the subject of the referral to the regulator. Only 4 per cent of general practice and 2 per cent of hospital and community health cases have GMC involvement when an organisation first contacts us.

NCAS offers information about the roles and responsibilities of other organisations that may need to be involved. These could include the deanery or royal college, the police, the NHS Counter Fraud and Security Management Service, the strategic health authority or family health services appeals authority.

Trusts in England must notify us about exclusions of doctors or dentists and primary care organisations are encouraged to do so, as are foundation trusts and employers in Wales and Northern Ireland.

NCAS has a responsibility to help reduce inappropriate exclusions. Since 2003 (when NCAS took on this role) the number of exclusions lasting more than six months has dropped by two-thirds, to fewer than 25. This is a significant saving: the National Audit Office estimated in 2003 that the average direct cost of an exclusion of an NHS doctor or dentist was£188,000.

We help trusts identify and use relevant regulations, legislation or guidelines. This often means advising on the use of PCT performance list powers, general medical services, general dental services and other contracts. However, we do not replace the need for organisations to take legal advice when required.

Is there a health problem?

An organisation may be unsure about the significance of a practitioner's health problem and the possible risk to patients and the practitioner - particularly when this involves mental health problems or alcohol misuse.

They also ask about how to sensitively manage discussions about a health problem with a practitioner when it has been reported by a colleague. We provide advice on using local occupational health services.

The wider organisation

We can help an acute or primary care trust to consider wider organisational issues, such as team function, department or practice management arrangements. We do not provide interventions, but may suggest sources of help.

The NCAS can advise on handling the national and local media and on how to maintain public confidence when concerns have reached the newspapers.

Cases involving concerns about doctors and dentists may be relatively rare but are worrying and time-consuming. Trusts have to respect confidentiality while providing information on a need-to-know basis.

Handling the risks and the complexity of these cases requires experience, knowledge of the relevant procedures and good judgement. While some trusts have such staff, others have people who are new to this field. The expertise of NCAS advisers and casework staff can be called on.

Dr Rosemary Field is deputy director of the National Clinical Assessment Service.