Supporting doctors in difficulty: remedial training question and answer web resource


August 2007

This question and answer web resource has been produced by the Medical education subcommittee of the Board of Science. It is aimed at doctors experiencing difficulties with their performance at work and want to know what happens when the need for extra (remedial) training or support is identified. Such situations can be very stressful and difficult for doctors to deal with particularly if they lack appropriate support. This resource provides doctors with information about what support is available to them and what they should expect from different organisations.

Note: This web resource focuses on the current systems that are in place. The resource will be updated to reflect the implementation of forthcoming changes in the regulation of doctors, including requirements for revalidation, re-certification and re-licensure, as proposed in the document Trust, assurance and safety: the regulation of health professionals (2007). BMA members can contact AskBMA if they need to undertake some further ,targetted training and want advice about what processesmay be involved or information about sources of support.

1) What is remedial training?
The terms ‘remedial training’ and ‘remediation’ may not be commonly used by doctors. In the absence of standardised terminology, however, they are used here to describe specific or targeted training or supervision following the identification of serious or complex concerns about a doctor’s performance. This resource highlights these particular terms because they are used in the proposals contained in the recent White Paper Trust, assurance and safety: the regulation of health professionals. This document states that there ‘needs to be a greater emphasis on remediation, rehabilitation and support for those health professionals who have struggled to cope’. Professional support, targeted support or other similar terms may, however, be more familiar to some doctors.

Note: In this context, addressing performance problems and implementing remedial training are not the same as general personal development and training to maintain skills and knowledge and progress in a doctor’s career. Such professional and personal development is covered elsewhere.


2 a) What should I do if I am experiencing difficulties?
Your primary duty as a doctor is to protect patient safety and maintain the highest possible professional standards. These and other duties are enshrined within the GMC’s Good Medical Practice document, which states that as a doctor you have a duty to:
  • make the care of patients your first concern
  • keep your professional knowledge and skills up to date
  • recognise and work within the limits of your competence
  • act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.
If you feel under pressure, or you are having difficulties at work, it is your duty to act appropriately. You may be reluctant to admit you are having difficulties or to ask for help but it is vital that you seek advice as soon as possible so that you can get the support you need and any problems are not allowed to escalate. Depending on the nature of your concerns you may, for example, wish to speak to your manager, a colleague, your educational supervisor or someone at your deanery; but you may not always find it is easy. Seeking advice early on may help you to get expert help to evaluate your performance or direct you to appropriate sources of support.

Self- assessment tools may initially help you to recognise or understand any difficulties you are having. Your employer or deanery may be able to provide some relevant resources. The following questions have been adapted from some of the early warning signs, identified during a series of workshops involving trainees in difficulty. They may be useful if you are concerned that you are experiencing problems or if you are finding self-reflection difficult (see reference 1):
  • Do you find yourself not answering bleeps, disappearing between clinics and wards, often being late or taking excessive amounts of sick leave?
  • Does your work rate seem slow compared to colleagues, for example are you arriving early and staying late and still not getting a reasonable workload done?
  • Do you react when your decisions are questioned or have inappropriate disagreements with colleagues or patients?
  • Do you find that you are unable to compromise or are having difficulty prioritising your workload?
  • Do junior colleagues or nurses find ways to avoid seeking your opinion?
  • Are you having difficulty with exams or feeling uncertain/disillusioned about your career choice?
  • Do you tend to reject constructive criticism or get defensive?
A number of needs assessment tools are also available from BMJ Learning; in the main these are intended for assisting healthcare professionals personal development plans but they are also useful if you are experiencing difficulties with your performance.

The most important thing to do if you are experiencing difficulties, if you think you may need some further training or if this need has already been identified is to seek appropriate advice as soon as possible. You may contact your employer or local danery, for example, or you may also wish to seek advice from your medical defence union. If you are a BMA member, contact AskBMA for advice about what may happen and what support is available throughout these processes.

Further information:
BMJ Learning needs assessment tools
AskBMA

2b) What should I do if I think a colleague is experiencing difficulties?
All medical professionals and healthcare employers have a duty to protect patients so if you believe there are problems with a doctor’s performance you should be sure to raise the matter. You should do this as soon as possible rather than waiting for a formal appraisal to come around. For doctors this duty is included in the GMC’s Good Medical Practice which states that a doctor must ‘act without delay if you have good reason to believe that you or a colleague may be putting patients at risk’. (see reference 2)

In most cases, if a doctor has concerns about a colleague they should follow their employer’s procedures or inform an appropriate person locally, for example a senior clinician, clinical governance lead or Chief Executive. If concerns are very serious and patient safety or a doctor’s fitness to practice is questioned a referral should be made to the GMC.

Further information:
What to do if you have concerns about a colleague’s performance – advice leaflet for primary care health professionals.
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3) Why might I need remedial training?
Working as a doctor is very demanding and can create a lot of pressure and stress for an individual. Doctors also put a lot of pressure on themselves to perform well, all of which can mean that from time to time you may experience difficulties which require attention. If you feel that you may be experiencing difficulties or concerns have been raised about you, for whatever reason, it is important to remember that there is help and support available to get yourself back on track. You should also bear in mind that in most cases problems are not serious and will be resolved through local partnership, with input from you, your employer and/or educational supervisor.

The reasons for performance problems are complex and often go beyond clinical knowledge and skills. Numerous other factors, including physical and psychological health, cognitive impairment, personality, attitudes, workload, organisational culture and teamwork have the potential to impact upon your performance and effectiveness in dealing with any problems. A summary report, Understanding performance difficulties in doctors (2004) discusses each of these factors in more detail.

In Scotland, the varied nature of performance problems is formally recognised within guidance relating to disciplinary procedures which include the following three categorisations:
  • personal conduct: performance or behaviour of practitioners not associated with the exercise of medical or dental skills.
  • professional conduct: performance or behaviour of practitioners arising from the exercise of their medical or dental skills.
  • professional competence: adequacy of performance of practitioners related to the exercise of their medical or dental skills and professional judgement. (see reference 3)
The Career development unit at the Oxford postgraduate deanery uses similar categories and identifies some more specific examples of the types of problems that you might experience in your working life:
  • personal conduct - including theft, fraud, assault on another member of staff, rudeness, bullying, racial and sexual harassment, and attitude problems in relation to colleagues, other staff and patients;
  • professional conduct - including research misconduct, failure to take consent properly, prescribing issues, improper relationships with patients, improper certification issues, and breach of confidentiality;
  • competence or performance issues - including a single serious mistake, or poor results clinically, possibly found as a result of audit, poor timekeeping, poor communication skills, poor consultation skills and repeated failure to attend educational events;
  • health problems – including physical and mental health problems and infectious diseases. (see reference 4)
These performance problems may be dealt with very differently and will not all require remedial training. For example, personal conduct may be dealt with through the appropriate and approved disciplinary procedures, while health problems and sickness absence are usually best dealt with through an employer’s occupational health scheme or other services for sick doctors. It is likely, however, that they will not occur in isolation and may influence one another or be symptomatic of underlying performance problems which themselves may need addressing using remediation. A holistic approach to addressing concerns is likely to result in a more appropriate action plan being developed, which may include elements of remedial training in conjunction, for example, with disciplinary actions.

See case study
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4) How will the need for remedial training be identified?
Problems with your performance may relate to clinical competence, professional behaviour, or problems with your physical or mental health; they may be ongoing or present themselves as an acute or serious incident. It is most likely that difficulties will become apparent during the course of your work through informal mechanisms such as observation, clinical audit, ongoing review and feedback. A colleague may, for example, raise concerns if they notice that you are under particular stress, that your working relationships are strained or that you need greater assistance with particular aspects of your work.

Formal review mechanisms may also bring problems to light. Concerns may be identified during reviews such as an annual NHS appraisal, or educational appraisal if you are a doctor in training. The components of revalidation (re-licensure and re-certification) will in future provide formal review processes for all doctors in the UK. The main purpose of these mechanisms is to evaluate your performance, confirm that professional standards are being maintained and identify any personal and professional development needs. (see reference 5) While it will be exceptional for serious concerns about your performance to be first identified during a formal performance review, it is possible that this might happen. If your appraiser does have such concerns he or she, as a registered medical practitioner, should refer this to the appropriate contact within your employer or contracting body (or, in extreme cases, to the GMC (see Q8)). Your NHS body (see Q6) should then take appropriate action which, where appropriate, may include referral to the National Clinical Assessment Service (NCAS) (see Q7). Concerns may also be identified following a formal patient complaint to your NHS employer or to the GMC. Instances judged by the GMC not to be serious, will normally be referred back to the NHS to be settled locally.

All NHS employers should have procedures in place which enable concerns about performance to be communicated and recorded as quickly as possible, regardless of how they are identified. These procedures should facilitate appropriate assessment and/or referral to determine if action is needed and should include arrangements for addressing problems through training, whether those concerns are relatively minor or whether targeted specific remedial training is needed. If concerns are more serious, complex or persistent and cannot be easily dealt with, a thorough needs assessment will be carried out, either by your employer, your deanery or royal college, the NCAS or the GMC. Only after this is complete, can the need for remedial training be fully identified and an appropriate, detailed and targeted action plan be developed and agreed with you. If concerns are raised about your performance, by whatever means, it is important to remember that this does not automatically mean they are serious concerns or that you will have to undertake remedial training.

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5) What sort of training/activities/supervision might I be asked to complete?
The type and level of intervention needed to address performance difficulties should always be assessed on an individual basis. For any programme of remedial training to be effective you need to see it as necessary and relevant. It must be specific and targeted to your individual needs and the difficulties you are experiencing. Different action will be needed if you are having problems with communication, working with colleagues or if you are having problems with your clinical performance. Effective investigation and assessment are essential for an appropriate and constructive action plan to be developed. Some of the interventions which might be employed include (see reference 6):
  • Tutorials
  • Case based discussion
  • Workshops and courses
  • Clinical placements (usually during a return to work programme only)
  • Coaching
  • Mentoring
  • 360-degree feedback by colleagues and patients
  • A reflective log diary, eg using Patient Unmet Needs and Doctor Educational Needs.
If, for example, you were having difficulties with your working relationships or communication you may undergo some coaching. This should be an interactive process which may consist of one-to-one discussions and observation in your workplace. It is designed to create a learning environment in which you are able to reflect upon behavioural issues and develop self-awareness. The development of an action plan with your coach should enable you to take positive steps to improve your personal effectiveness through the acquisition of skills and knowledge by focussing upon behaviours and attitudes.

The NCAS directory of resources provides information and contacts details of various independent national and regional providers of support for doctors. These are organised under four main areas on which you may need further support:
  • Careers, mentoring, coaching
  • Personal effectiveness - self reflection, leadership, equity diversity, management skills, communication skills, stress management, time management, motivation
  • Clinical competence – clinical competency, consultation skills, clinical placements
  • Clinical governance – clinical audit, record keeping, risk management.
The NCAS resource is unlikely to include all possible local providers. Your employer and/or postgraduate deanery are also likely to have details and contacts of local providers of different types of remedial training and support; for example, they may know of individuals locally who act as coaches or mentors to people experiencing difficulties at work.

Given the need for tailored remedial action plan and the variety of different interventions that you could be asked to complete it is not possible to estimate how long remedial training will take. This will also depend on how well you progress through the training and on the complexity of the difficulties you are having. Your case should be reviewed regularly in order to assess progress against the objectives in your action plan and to identify whether you any other types of training or support are needed or would be more effective.

Regardless of whether small local interventions or a fuller programme of remedial training is necessary, you should be fully supported throughout the period when concerns are being investigated, assessed, addressed or progress reviewed.

Further information:
BMJ Learning – provides evidence-based online learning resources which cover clinical and non-clinical topics.
Exploring mentoring (BMA, 2004)
Mentoring for doctors: Signposts to current practice for career grade doctors (Department of Health)
NCAS resource pack – includes factsheets about different training initiatives
NCAS directory of resources: educational support for individuals – includes links to regional and national independent providers of support and training for doctors.
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6) What should I expect from my NHS employer or contracting body?
If you work within the NHS your employer or contracting body is responsible for dealing with any concerns that are raised about your performance and for ensuring that performance management policies and procedures, including remedial training, are in place and implemented effectively. NHS organisations also, however, have a duty of care to their staff and should, therefore, provide appropriate support to you if concerns are raised about your performance.

In the first instance your employer should carry out any necessary local investigation. Problems can usually be worked out within local support and training structures, provided that you, your employer/contracting body and/or educational supervisor give full commitment to the process.

If your difficulties persist, are complex or are more serious it is likely that some form of remediation will be necessary. In the first instance serious concerns must be registered with your Chief Executive who must ensure that a case manager is appointed. Initially, some further investigation will be needed and your employer/contracting body may consider whether they need to place any restrictions on your practice, including possible exclusion (see Q9), while this is undertaken. They may seek advice from or refer your case to the National Clinical Assessment Service (NCAS) so that a clinical needs assessment can be carried out (see Q7). They should then work in partnership with you and all relevant individuals to agree a targeted action plan for addressing the concerns. Whether you work in primary or secondary care, your NHS employer/contracting body should provide appropriate managerial and infrastructure support for you and/or your practice, should agree the funding arrangements for the training programme, and should oversee your progress against the agreed goals.

For information and links to the different regulatory and performance management frameworks within the NHS in England, Wales and Northern Ireland see the 'must knows' section of the NCAS website.

In Scotland, provisions for dealing with performance difficulties have not been modernised over recent years and are still referred to as ‘disciplinary’ procedures. NHS board, as employers, therefore carry full responsibility for addressing performance concerns of most doctors. Because the NCAS does not operate in Scotland, this includes completing investigations when concerns are raised, even where they are more serious or complex. They are then responsible for establishing their own local ‘disciplinary’ procedures for medical and dental staff in respect of personal conduct and must follow the provisions in the relevant NHS circulars issued by the Scottish Executive Health Department for other disciplinary matters. If you are a doctor in training in Scotland you can also expect significant input from your local postgraduate deanery, as overseen by NHS Education for Scotland.

The following are useful guidance documents relating to procedures in Scotland: Working outside the NHS – see Q14
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7) My employer has contacted the NCAS about my performance, what will they do?
The National Clinical Assessment Service (NCAS), formerly the National Clinical Assessment Authority (NCAA), provides confidential advice and support to the NHS in England, Wales and Northern Ireland, in individual cases where the performance of a doctor or dentist is giving cause for concern. At present the NCAS does not have service level agreement to provide services to Scotland; although it appears that some medical directors have approached the NCAS for advice and support. (see reference 7)

If concerns about your performance cannot be resolved locally your employer or contracting body may contact the NCAS for advice. The NCAS will then work with all relevant parties to clarify the concerns and make recommendations to help you continue to deliver a high quality and safe service to patients. (see reference 8) The NCAS strive to deal with all cases as sensitively as possible. While the primary aim is to protect patient safety, the NCAS recognise that practitioners will have valuable experience and a continuing contribution to make to patient care and want to help practitioners get safely back on track wherever possible.
Your employer or contracting body will retain full responsibility for handling your case throughout the process; the role of the NCAS is purely advisory and it is not involved in the provision of any further training.

Following a referral, the response from the NCAS will depend on the nature and seriousness of the concerns. In the majority of cases the NCAS will use their expertise to provide independent advice or support to your employer to help them to effectively work through the problems locally. They may, for example, help to identify the next steps in addressing the concerns (eg a programme of remediation), help to facilitate meetings between local parties or may advise on the need for local investigation.

If your case is more complex, the NCAS may recommend that it should carry out a clinical performance assessment (this is only necessary in about 1 in 15 referrals). The NCAS assessments are intensive and will usually comprise:
  • An occupational health assessment – to establish whether any health problems or work environment factors are contributing to the difficulties you are experiencing
  • A behavioural assessment – looks at your personal attributes to see how these may be shaping your behaviour at work
  • An on-site clinical assessment – involving a review of information provided by your employer/contracting body; a clinical record review; collection and consideration of views from your colleagues and patients; direct observation of practice; review of your working environment; assessment of your clinical decision-making and an interview. This assessment is based on the standards within Good Medical Practice and any guidelines set by the relevant royal college or faculty.
Each of these assessments is carried out by a qualified professional nominated and trained by the NCAS.

The results and recommendations of any assessment will be shared with you, your employer/contracting body and a named person at your deanery or royal college if appropriate. All parties should then work together to agree an action plan to implement the NCAS’s recommendations. It is not the role of the NCAS to implement the action plan or to monitor progress.

The NCAS is also likely to be involved where an NHS employer is considering excluding a practitioner. Here, the NCAS has a role to play ensuring that cases are progressed fairly, quickly and effectively. NCAS can also help to ensure that inappropriate exclusions are prevented (see Q9)

Useful resources available from the NCAS:
  • NCAS website: www.ncas.npsa.nhs.uk
  • The NCAS Handbook - this handbook contains full information about the roles and responsibilities of the NCAS in handling casework relating to a doctors performance.
  • Back on track – restoring doctors and dentists to safe professional practice (2006) - describes a framework and principles to support practitioners who have either been subject to a formal clinical assessment or review related to performance concerns or have been absent or out of practice for a significant period, for whatever reason.
  • NCAS toolkit – this is a toolkit for NHS managers to promote the development of good practice and helps improve local management of performance concerns. It focuses on how to effectively support doctors experiencing difficulties.
  • NCAS directory of resources – a directory of resources intended to help with the implementation of recommendations following an NCAS assessment of a doctor. Links are provided to various independent providers of training and support for doctors.


Case study: Supporting a GP in difficulty following referral to the NCAS
A primary care organisation had long running concerns about a single handed GP which it had failed to resolve locally. The Primary Care Trust (PCT) referred the GP to the NCAS for an assessment.

The Deanery was sent a copy of the NCAS Final Report to comment on what educational support they could provide to the GP. A final Action Plan based on the NCAS recommendations was agreed at a meeting between the GP and representatives from the NCAS, the PCT and the Deanery. Areas to be addressed were:

  1. Learning Needs, personal and practice development plans
  2. Consultation Skills
  3. Record keeping
  4. Antibiotic and prescribing skills
  5. Chronic and acute Disease Management
  6. Palliative Care (opiate and benzodiazepine prescribing)
  7. Skill mix
  8. Communication with the PCT

Areas 1-6 were to be included in the Doctor’s 6 month educational support programme. Areas 7 & 8 were to be addressed by the PCT. The GP was still able to work during the further training programme.

The Deanery identified an educational facilitator in a neighbouring PCO. The GP spent one day a week in the training practice and the following week the educational facilitator visited the GPs practice. Other members of the training practice including the practice nurse and practice manager were involved in the delivery of the support programme.

The educational facilitator supported the GP to meet pre-set educational objectives identified by the NCAS and other educational needs identified during the placement. The GP engaged enthusiastically in the educational programme.

The PCO funded the educational support programme and the GP paid for locum cover.

The educational facilitator supplied the Deanery with structured weekly reports on progress. Every 6 weeks the Deanery sent a progress report to the PCO. The placement culminated in a final report. It was made clear at the outset of the placement that the decision on the future fitness to practice of the GP rested with the PCO.

The PCO felt the placement was successful and agreed to ensure ongoing monitoring and support for the GP when the placement was completed.

Source: provided by the NCAS
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8) What will happen if I am referred to the GMC?
If the GMC judges, following a complaint or a referral, that the difficulties you are having raise questions about your fitness to practise they will carry out an investigation which may include assessments of your performance and/or health. One of the actions the GMC may take following this invesitgation may be to ask you to agree to undertakings on matters relating to your health and/or performance. If you agree undertakings, these will include restrictions on your practice and a commitment from you to undergo training and/or treatment. If your difficulties relate to performance, undertakings may be agreed or conditions imposed which require remedial training; in such cases the GMC advise you to seek the advice of a postgraduate dean about what training is appropriate and will share the full assessment report with a named individual selected by you. You may also find useful information about appropriate training via the NCAS resource directory. If there are undertakings or conditions on your registration, it is likely that you will be required to undergo a performance assessment before you regain unrestricted registration.

For further information and guidance see: GMC, Doctors under investigation

9) Could I be excluded from work?
Where there are serious concerns about your performance or professional conduct, your employer or contracting body may consider whether you should be excluded from work or from the performers list while further investigations are carried out. Exclusion should usually be used as an interim measure and should only be considered where there is no alternative. If you have been excluded from work or are in a situation where this is being considered, you will inevitably be under significant stress. In these circumstances you should seek advice from the BMA (see AskBMA), a local union representative and/or your medical defence union as soon as possible.

You should also be aware that in these circumstances your employer or contracting body is required to follow specific procedures as laid down in the relevant regulations. The procedures governing exclusion from work differ between doctors employed by the NHS and practitioners working under performer list regulations. They also differ among the four countries of the UK.

If you are excluded from work your case should be managed by your employer or contracting body and it must be reviewed at specified intervals. These reviews should include discussion about a plan for bringing your exclusion to an end and any further action that is needed. The NCAS advises any NHS organisation considering exclusion to contact them in the first instance for advice. Indeed, some NHS organisations in England are required to contact the NCAS in such circumstances.

The NCAS has developed the Back on track, which describes a framework for supporting doctors who have been ‘absent or out of practice for a significant period, for whatever reason – from a conscious career decision to suspension or exclusion from work by a third party’. (see reference 9) The document sets out the principles and framework identified for return to work programmes and presents proposals on the roles and responsibilities of different parties, funding arrangements and indemnity cover. This framework can also be applied to doctors who are going through a formal assessment or review related to performance concerns.

If you are involved in disciplinary procedures or are excluded from work you may be experiencing significant stress and should be sure to seek appropriate support or advice (see Q15). You may also feel that you want to seek some form of careers advice; there are many different people that can help you with this, including your local deanery, BMJ Careers advice zone or commercial careers advice services. Information about BMA careers service can be accessed via this website.

Further information:
See NCAS must knows for information about the regulatory frameworks in England, Wales and Northern Ireland.
In Scotland see - Report of the short life working group on suspension of medical and dental staff – Suspensions: a new perspective
Back on track
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10 a) What should I expect from my postgraduate deanery?
Your local postgraduate deanery is responsible for overseeing your postgraduate medical education while you are still training and will provide any educational or personal development support which you need. Where problems go beyond the normal scope of this educational support, your employer or contracting body should take the lead in overseeing and supporting you through any necessary remedial training (see Q.6). Your NHS employer/contracting body should ensure that they keep your deanery informed of any concerns that have been raised about your performance and any actions that are taken. Postgraduate deaneries do not have any responsibility to implement or fund arrangements for remedial training or return to work programmes; instead their role is primarily an advisory one. (see reference 9) The educational expertise within your deanery means that they may be able to provide support and advice to you and your NHS employer/contractor in such circumstances and it may be helpful for them to be involved in developing the remediation action plan. Furthermore, your deanery may help to monitor your progress against the goals set.

The Committee of General Practice Education Directors (COGPED) has signed an agreement with the GMC and the NCAS which outlines the responsibilities of the relevant NHS contracting body, the GP, the NCAS, the GMC and the deanery when dealing with a GP who is experiencing performance difficulties. The agreement covers all GPs, not just those in training, and highlights the advisory role deaneries have relating to both individual cases and the procedures used to manage performance problems. The agreement indicates that your deanery should:
  • advise your PCT on handling concerns about you
  • be involved in planning and advise on provision of a further training programme following local performance procedures, NCAS or GMC assessment
  • agree arrangements for monitoring against objectives in action plans if the deanery has a specific contribution to your action plan
  • advise on provision of staff to supervise educational programmes
  • advise on provision of mentoring and coaching when required
  • have a key role in recruitment, training and support for local staff who assist in carrying out investigations
  • collaborate on working towards common standards and consistency across Deaneries, to include competencies, training for trainers, outcomes data and quality assurance.
Some postgraduate deaneries may also use their expertise to provide some of the remedial training and support to doctors within their region. This is additional to their remit, however, and funding for this will not be available from deanery budgets. A number of postgraduate deaneries have developed their performance management expertise quite substantially and offer more in depth information, assessment and advice services. The Career Development Unit at the Oxford deanery, for example, provides a careers service and performance support for all doctors in primary and secondary care in its region. The unit provides confidential personal coaching for individual doctors who self-refer, or to trusts who want to purchase personal coaching services to help doctors who are experiencing performance difficulties. The unit also provides guidance and workshops to help trainers manage performance issues and has developed a detailed checklist for managing trainees. (see reference 10)

10 b) What should I expect from my medical royal college or faculty?
The role of medical royal colleges and their faculties in dealing with concerns about performance is mainly advisory. Royal colleges provide guidance on the standards of clinical care in their specialty and are thus able to advise trusts how to deal with performance concerns for doctors who are on the specialist register. Royal colleges may use their specialty expertise to advise on the appropriateness of different remedial or retraining packages. They may also signpost suitable training provision but they do not have any formal responsibility to implement or oversee any arrangements for remedial training.

In the case of general practice, the royal college does not at present provide assistance to GPs in difficulty. COGPED has instead agreed that the deaneries will fulfil an advisory role for all GPs, not just those in training.

When the arrangements for re-certification are implemented, the role of royal colleges relating to performance management will expand as it is proposed that they will set and assess the standards required of specialists, including GPs, which apply to their particular specialty.

10 c) What should I expect from my university employer (for medical academics)?
If you are a medical academic, your NHS and university employers will have shared responsibility for ensuring that standards are maintained in education and training as well as in research and service delivery. University and NHS employers should, therefore, work in partnership to ensure jointly agreed procedures are in place for dealing with any concerns about your performance. One of the key principles for joint working between the NHS and universities is that they each have management accountability for the governance of their respective lead areas.

If you are a clinical academic you may experience difficulties with your teaching or research as well as your clinical work. This is reflected in the NHS appraisal arrangements for clinical academics which indicate that all three activities should be covered and that there should be appropriate input from your university employer to cover this work. If you are having problems with any aspects of your work these should be raised with both your NHS and university employers and should be dealt with through the applicable procedures. Your university should therefore support any further training that you require which relates to your teaching or research activities.
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11) How will my remedial training be funded?
You should always ensure that the funding arrangements for any remediation are agreed at the beginning of your training programme. This agreement should include the cost of providing training, how your salary/remuneration will be covered during periods of training and/or exclusion as well as the costs of covering your workload during training or exclusion, for example through locum cover.

While a number of organisations may be involved in arranging and implementing your remedial training programme, funding is not as widely available. Your deaneries, for example, will not have a budget to provide remedial training beyond their own educational support structures. In the main, it will be the responsibility of your NHS employer or contracting body to provide funding, resources and the necessary infrastructure for performance review, investigations, action planning which are implemented locally and for any further training which you require. (see reference 11) This includes employing the appropriate level of skilled staff and providing reasonable managerial support. If your case is referred to the NCAS or the GMC, they should provide funding and resources for the further investigation that they undertake; the NCAS or GMC will not fund the remedial training itself.

If your case is more serious, you are returning to work after being excluded and/or you require significant further training your employer may only be able to provide limited funding or such funding may be dependent on you making reasonable progress against your agreed objectives (see reference 9). In these circumstances it is likely that you will be required to make a reasonable contribution to the cost of any recommended training. You may find it necessary to take out a loan which you will then repay once you are back in practice. You may, for example, be expected to contribute substantially to the costs if you use a coach or programme supervisor during your remedial or back-to-work training programme. It is important that you seek appropriate advice relating to the funding of any further training you are required to unddertake both your medical defence body and, if you are a BMA member, AskBMA should be able to provide relevant advice.

Further information:
AskBMA - BMA members should contact AskBMA if they need advice regarding the funding arrangements for remedial training

See case study
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12) Will my confidentiality be protected?
If concerns have been raised about your performance or you are undergoing remedial training your confidentiality should be protected as far as is possible. Much of the assessment or training may take place in your normal working environment; therefore some people are likely to be informed. Information about concerns should, however, only be shared on a need to know basis. (see reference 12) Even if your employer does not have a explicit confidentiality agreement, you should be assured by them that every effort is made to ensure that disclosure of information is handled appropriately and that consent is sought from any party involved.

You may be worried that information about the concerns will be shared with patients. The Back on track framework, however, indicates that as long as you are under an appropriate level of supervision and are clear about the level and limits of your role, it will be reasonable to invite patients to consent to being seen ‘by a practitioner who is undertaking a period of further training’.

All healthcare organisations should also have an agreed policy on dealing with any media enquires about your case, which should appropriately protect your confidentiality. The NCAS, for example, has a strict policy about confidentiality and the media which means that they will not comment on any cases referred to them or even confirm that a referral has been made. (see reference 12)

Further information:
NCAS toolkit for NHS managers – includes model policy and briefing on confidentiality
Back on track
Maintaining high professional standards in the modern NHS – contains brief guidance for NHS employers on confidentiality and handling media interest during disciplinary procedures.
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13) Will I still have indemnity cover?
While your employer/contracting body should provide clear indemnity arrangements for doctors requiring or supporting remedial training, it is vital that you are sure that you have full indemnity cover for any further training or supervised work that you undertake. All doctors working in the NHS are covered by NHS indemnity. It is important, however, to be aware of the limitations of this scheme and you should be sure to verify the specific terms of your contract and what this indemnity does and does not cover. NHS indemnity does not, for example, usually cover any work which does not fall strictly within your NHS contract. The BMA strongly advises all doctors to take out further indemnity cover with a medical defence union or other insurer to provide cover beyond that provided by the NHS scheme.

If you are involved in providing further training, supervision or clinical placements you should also check that your employer has clear indemnity arrangements to cover you. You may consider taking out additional cover for such circumstances. GP trainers involved in remediation or return to work programmes should contact their Deanery to determine what local indemnity arrangements are in place.

Further information:
NHS indemnity
Back on track – contains information about indemnity cover during targeted training and return to work programmes including the responsibilities of NHS and other relevant organisations.
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14) What if I work outside the NHS?
If you do some or all of your work outside the NHS you are still bound by the professional responsibilities described in Good Medical Practice (see Q2a). If concerns about your performance arise, the arrangements for assessing the problems and for providing remedial training are likely to depend on the particular policies of the relevant private provider and on whether you have a contract of employment with that provider or simply have practicing privileges. All independent healthcare providers have a responsibility to safeguard the quality of care given to patients and to ensure that the medical practitioners who receive practice privileges with them are of an appropriate and satisfactory standard. If you work for an independent provider and concerns are raised about your performance either through the appraisal system or because of a serious clinical incident, a health issue or fitness to practice issue then the provider should carry out a review of your practising privileges which could lead to those privileges being restricted, withdrawn or suspended. More generally, private providers are also required by the Care Standards Act 2000 to review the practising privileges of each practitioner every two years.

All doctors working in private practice need to undergo annual appraisal; those doctors who are not employed but have practising privileges with one or more private provider are expected to complete annual appraisal documentation in order to gain renewal of those practising privileges. If you work in the NHS and have practicing privileges at independent hospitals, it is recommended that you complete whole practice appraisal, whereby any work you do in the independent sector will be appraised at the same time as your NHS work. Advice and information about appraisal for doctors doing work outside the NHS, including consultants practising entirely in the private sector, is available on the BMA website. Appraisal structures in private practice are considered by the BMA and the Independent Healthcare Forum to be the gateway to both GMC revalidation and the biennial renewal of a doctor’s practicing privileges.

If concerns about your performance are raised through annual appraisal and the biennial reviews of practising privileges then it is the responsibility of the private hospital to act appropriately. This may lead to a private hospitals restricting, suspending or withdrawing practising privileges. Where remedial training is necessary, doctors who only have practising privileges and therefore have a contract for services rather than a contract of employment with a private hospital will have to fund any remedial training themselves. Alternatively, if you have a contract of employment with a private hospital you should check whether this may be covered, at least in part, by your employer.

Further information:
Private practice appraisal
Independent Healthcare Advisory Service
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15) I am feeling under a lot of stress, where can I find help?
Performance difficulties at work are likely to cause significant stress and your physical or mental health or your personal relationships may be affected. It is important that you do not go through these experiences alone and that you seek further support or counselling and that you contact your GP if you are concerned about your health. There are many different national and local organisations which can help you. Your employer may offer you counselling as part of the support they provide or be able to identify relevant contacts in your local area. Alternatively, the NCAS directory of resources and support for doctors contains a comprehensive list of organisations which deal specifically with the needs of doctors in difficulty, including membership organisations, independent counsellors and special interest groups.

The BMA also provides personal and emotional support for doctors in difficulty:
  • BMA counselling service – provides members with access to a confidential professional telephone counselling service, which is available 24 hours a day, every day.
  • BMA Doctors for Doctors unit - an enhancement of the counselling service giving doctors in distress or difficulty the choice of speaking in confidence to a volunteer doctor-adviser. A wide range of problems are dealt with including drug and alcohol problems, bullying at work and mental health issues, as well as with doctors who have been referred to the GMC or the NCAS. The doctor-adviser works with you to gain insight into your problems, supporting and helping you to move on by adopting a holistic approach to your situation.
To contact the BMA Counselling Service and Doctors for Doctors telephone 08459 200 169 (calls are charged at local rates and lines are open 24-hours a day, seven days a week).

If any of your difficulties are employment related and you are a BMA member you should contact askBMA in the first instance; they will either deal with your query or refer you to an appropriate regional services employment advisor. You may also wish for a BMA representative to be present during any disciplinary hearings or assessment meetings that you are required to attend. If you require legal advice or representation for clinical-related problems, you must be sure to seek advice from your medical defence union as early as possible.

If you feel that you want to seek some careers advice, the BMJ Careers advice zone may be a useful resource in the first instance.
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References
  1. Paice E (2006) The role of education and training. In: Cox J, King J & Hutchinson A et al (eds), Understanding doctors’ performance. Oxford: Radcliffe publishing
  2. GMC (2006) Good Medical Practice.
  3. NHS Circular: PCS(DD)2001/9
  4. www.oxforddeanerycdu.org.uk/performance/trainee_performance/deanery_policy.html
  5. DH website, Appraisal for doctors.
  6. NCAS (2006) Training initiatives for the individual factsheet.
  7. Scottish Executive (2004) Safer for patients, supportive for professionals: a framework for managing poor performance of health professionals and teams in NHS Scotland – a consultation.
  8. NCAS (2007) National Clinical Assessment Service Handbook, 3rd edition.
  9. NCAS (2006) Back on track – restoring doctors and dentists to safe professional practice.
  10. Oxford postgraduate deanery, Career development unit. Managing trainee’s performance.
  11. COPGPED, GMC, NCAS agreement.
  12. NCAS (2007) National Clinical Assessment Service Handbook, 3rd edition.

    © British Medical Association 2008

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