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Undue investigations: the GPs targeted by NHS England

The Doctor Issue 10 – June 2019 sword

NHS England performance investigations can bring down a GP practice – yet data is kept secret, investigators have little training, and the process prolonged and bewildering. Tim Tonkin reports

It’s hard to imagine much progress in medicine without the means to measure and compare. How, otherwise, can we tell if something is working or not?

If naval surgeon James Lind had worked for NHS England, it’s hard to believe it would have been all that interested in the dramatic recovery of sailors with scurvy given citrus fruit compared with those dosed with seawater. Or that the results would have been published for anyone else’s benefit.

That certainly seems to be its attitude on performance investigations, which, as we saw in the November 2018 issue of The Doctor, can have a profoundly damaging effect on a GP’s professional life and wellbeing.

How many have taken place? How many occurred in each geographical area? How many were deemed high risk and escalated to the more serious level of investigation?

Does NHS England monitor whether black and minority ethnic doctors are disproportionately affected?


Defensive medicine

The responses to these questions have varied between ‘don’t know’, it’s too much effort to find out, or the answer is held elsewhere (when it wasn’t).

So how, NHS England, do you know if the process is fair and whether it can be improved?

The thing is, if NHS England is responsible for the health service, it has a responsibility to those who work in it too. And so, if it is taking action at a local level against GPs that will inevitably be expensive and destabilising, wouldn’t it like to know and share whether its processes and actions are fair, proportionate and consistent across the country? We continue to wait, and to press.

‘There are no competency-based national qualifications to qualify you as a case investigator’

A reminder of why it matters so much; in the November issue, we described how a complaint brought a thriving GP practice to the brink of collapse. Misleading claims were made about the quality of care, there were procedural failings, and a consistently accusative tone. The practice had to wait a year to be cleared of any wrongdoing.

That practice’s experience is echoed by two other GPs who have spoken to The Doctor (see case studies below). One said they were likely to practise defensive medicine forever after as a result.


Need for support

Leading GPs have called for the process to be made fairer.

‘The NHS regulatory process needs to be entirely fair, reasonable and transparent,’ says Nottinghamshire local medical committee director Marcus Bicknell.

The Doctor Issue 10 – June 2019 overwhelming

Dr Bicknell says annual data relating needs to performance investigations must be shared with LMCs, and that regional NHS bodies should publish annual figures on the numbers of investigations undertaken and their outcomes.

‘Where it identifies dangerous and inadequate practice, it must address that but generally it needs to be much more supportive.

‘I do think that NHS England has realised that general practice and GPs are so important, and that our profession is in such crisis, that it is now working towards being more supportive and less restrictive.’


Regional variation

Dr Bicknell says the review process in his area had improved and is now fairer and more sophisticated, but there are often too many inconsistencies in the way performance investigations are pursued.

‘There seems to be huge local variation,’ he says. ‘Our experience in Nottinghamshire and the East Midlands was that there were loads of PAGs [performance advisory groups] against Nottinghamshire GPs and very few against Derbyshire GPs.

‘The reason for that seemed to us to be that they had different people leading the processes.’

A GP performance investigation can be triggered by a single adverse incident, or as a result of a complaint made by a patient, their relatives, or by anybody employed by or associated with a practice.


Limited training

The local PAG represents the first stage in any performance investigation, with panels empowered to apply sanctions in the form of ‘voluntary undertakings’, such as referring a doctor to the National Clinical Assessment Service.

In the event of more serious findings, the PAG can refer a doctor to the PLDP (performers list decision making panel), the next tier in the process.

Any decisions reached by a PAG panel are based on the report produced by a case investigator – an individual tasked with investigating a practice by interviewing staff, gathering evidence and establishing the facts around a complaint.

These reports therefore have an enormous professional effect on individual GPs and practices under investigation.

The power wielded by case investigators when examining a practice is considerable, yet there is concern with the limited level of training required by such investigators.


Few barriers

A document published by NHS Resolution, which organises and oversees the official training programme for case investigators, states that investigators must make sure that they are ‘robust, efficient and transparent’ in performing their duties.

It adds that: ‘A process that is straightforward and fair gives practitioners confidence that they will be treated appropriately and effectively. It is essential that case investigators are trained and supported to carry out their responsibilities.’

The person specification requires any would-be case investigator to be educated to postgraduate level or equivalent, with experience in medical management, education or appraisal.

Top of the list of required skills for the role is a ‘high level of interpersonal and communication skills’.

The document makes clear that the training is not accredited and states: ‘There are no competency-based national qualifications to qualify you as a case investigator.’


Two-day course

However, a GP who has completed case-investigator training reports that the course lasted just 12 and a half hours over two days.

Modules on ‘What constitutes a concern?’ took less than an hour, while training on ‘How to manage a clinical concern and determining when a local investigation might be necessary’, lasted just 75 minutes.

The GP believes this to be entirely insufficient.

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‘It is extremely concerning that the training and preparation undertaken by someone who will eventually be tasked with investigating a GP or practice on a performance issue can be completed in less than two days,’ he says.

‘School crossing wardens could expect more training and preparation.

‘NHS Resolution’s own pre-training reading material makes clear that performance investigations can be complex and onerous, so you would expect the training for such a role to be comprehensive and competency-based.

‘There is no summative assessment of competency following the course, and there is no calibration to ensure that individual investigators apply consistent or appropriate standards.’


Blow up

GPs have been expressing concerns about performance investigations for years, but not only has there been little evidence of such concerns being addressed at national level, but some anecdotal evidence that the accusative climate has worsened.

That’s the experience of one LMC medical secretary who says, in his area, the process has become increasingly ‘hawkish’ in recent years.

‘The pressure that is being put on practitioners by the process is quite substantial,’ he says.

He says he has witnessed examples of doctors with single, relatively minor complaints against them suddenly finding themselves being investigated on a whole range of unrelated issues owing to the domino effect of the review process.

‘People will have a single clinical problem – not something that reaches the standard that the GMC will be interested in. It ends up with the PAG who will send a clinical adviser in to look at [that doctor’s] records for that patient. They may conclude that the notes could be better.’

He describes how a clinical adviser might then decide to look at a randomised selection of all that doctor’s records against Royal College of GPs standards and decide the notes don’t meet those standards.

The doctor might then be informed that they must complete a note-keeping course and face another review in six months.

‘We’ve had practitioners who have effectively been under review for a year for the quality of their notes, when the actual complaint had nothing to do with notes in the first place.’


Case study: conflict of interest

He adds that, in his experience, roughly 80 to 90 per cent of the complaints handled by PAGs never went beyond this stage of review and were closed with ‘little to no action’ being taken against a doctor.

‘The [case] managers have the power to do an awful lot of harm to GPs without [the latter] having any defence.

‘A GP could have a complaint that could be investigated, and a decision made on it by a group of managers without any coalface experience.’

He says that the clinical adviser – who is themselves a GP – is appointed for and paid by the panel, which creates a potential conflict of interest.

‘There’s a danger that if he [the clinical adviser] doesn’t say what they want him to say, next month they’ll use a different clinical adviser and he won’t get paid.

‘The performance list regulations and how they’re managed is really fraught with conflicts of interest and I personally don’t think we should have them at all.

‘Why should GPs have a double level of performance management in the form of the performance list and the GMC? No other clinical specialist has a double layer like this.’


Case study: sanctions imposed

LMC presence at PAG and PLDP reviews is at the discretion of NHS England so there is no guarantee that an LMC representative will be able to attend.

The LMC medical secretary also speaks of his frustration at how performers list decision-making panels would sometimes choose to continue to impose conditions on a doctor even when separate conditions imposed by the GMC had been lifted.

‘The GMC is our professional regulator which works to protect patient safety and it said that this [particular] doctor was fit to practise, but the local panel decided that it wanted a bit more supervision.

‘Clinical or educational supervision are imposed on you, but you as the doctor have to pay for that yourself.

‘We’ve had practitioners who have effectively been under review for a year for the quality of their notes’

‘We’re starting to get people in our area who would previously have served as clinical supervisors refusing because they, themselves are concerned about coming to the attention of NHS England.’

Following numerous requests for data on performance investigations to be released, BMA GPs committee chair Richard Vautrey (pictured below) wrote to NHS England’s acting director of primary care Nikita Kanani, emphasising the seriousness of many GPs’ concerns about the impact of investigations.

Last month, GPC deputy chair Mark Sanford-Wood and GPC UK policy lead for contracts and regulations, Bob Morley, met with NHS England to discuss a way forward to obtain information, with NHS England saying it they would work towards providing the association with some regionally held data on investigations in the near future.

It was also agreed that a joint working group comprising of NHS England, the BMA and LMC representatives, would be set up to look again at aspects of the framework underpinning performance investigations, and to agree on the data that needs to be routinely collected.

Dr Vautrey says that while he welcomed the constructive outcome of the meeting, there were still many questions that needed to be answered and much work that needed to be done, to address the association’s long-standing concerns with the performance-review process.

‘All doctors accept the importance of oversight and regulation as vital safeguards to patient care, and the having the opportunity to learn from errors and, where necessary, take the necessary steps to remediate and improve,’ he says.

‘For this to happen effectively it is vital that such investigatory processes are transparent, fair to all doctors and rooted in trust.

‘Based on the accounts reported to us by many GPs, we know that this is sadly not always the experience of doctors faced with performance reviews.’ 

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