FILLING THE GOVERNANCE GAP

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FILLING THE GOVERNANCE GAP Five Years
Experience of Promoting Confidence in Doctors
and Dentists IAMRA 2006 Wellington, New
Zealand Professor Alastair Scotland FRCS FRCP FFPH
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Overview

• The UKs challenges in governance, patient safety
  and poor practitioner performance, and how they
  have been tackled
• The National Clinical Assessment Service and the
  governance gap
• How NCAS has developed since 2001
• What we have seen referral patterns
• What we have found support cases and assessment
  cases
• Future developments responding to a changing
  environment
• So what? How does NCAS fill the governance gap

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The Governance Challenge and the UK Response
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The Late 16th Century Challenge
Physicians are some of them so pleasing, and
comfortable to the humour of the patient, as they
press not the true cure of the disease and some
other are so regular, in proceeding according to
art, for the disease, as they respect not
sufficiently the condition of the patient. Sir
Francis Bacon Essays (1597) Of Regiment of
Health
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The Late 20th Century Challenge
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The Governance Challenge

• Medical scandals
• Was poor performance tolerated more than it
  should have been?
• Repeated common features in service and
  individual failures
• Was the NHS able to learn from its own mistakes?
• Systems for responding to these failures not fit
  for purpose
• Outdated, unwieldy and bureaucratic
• Excessively legalistic, adversarial and
  court-like
• Media response focused on blame
• Difficult or impossible to separate out
  individual failure, system failure and untoward
  incidents which were no-ones fault

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The Response

• Statutory duty of clinical quality as a core
  accounting responsibility
• Placed on every health care organisation
• Underpinned by national quality standards and
  support to local governance frameworks
• National regulatory framework for private and
  public sector health services
• National initiative to build systems for learning
  lessons on patient safety
• National service supporting the resolution of
  concerns at practitioner performance (NCAS)

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Systems Failures and Performance Failures
Ref Good Doctors, Safer Patients II.xxix
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Partners in Performance
Professional Regulators
Healthcare Commission
Systems and Services
Fitness to Practise
NCAS
Fitness for Purpose
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The National Clinical Assessment Service and
The Governance Gap
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Rôle of NCAS Promoting Confidence in Doctors
and Dentists

• What is our purpose?
• To give advice and support to health care
  organisations where the performance of doctors
  and dentists is giving cause for concern
• Who can contact us for help?
• UK healthcare organisations within or contracted
  to the public sector
• Individual practitioners
• How do we do this?
• Advice one to one telephone advice
• Support more detailed specialist support by an
  NCAS team
• Assessment diagnostic work to clarify and get
  behind the concern
• Action planning to facilitate resolution of the
  concerns
• How are we funded?
• Government funding free at the point of delivery

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NCAS Core Service Products and Powers

• Responding to requests for help on performance
  concerns
• Advice, support, assessment and action planning
• NHS medical and dental disciplinary procedures
• Requirement to involve NCAS when considering
  suspension
• National monitoring and reporting responsibility
  on suspensions
• Similar responsibilities for reformed
  disciplinary framework
• Developing and managing a web-based alert
  system for all health care practitioners in cases
  of serious unresolved concern
• Regulations on contracting with general / family
  practitioners
• Similar arrangements on suspension to employed
  service
• GPs must give details of NCAS assessment

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NCAS Case Classification Defined by our
response!

• Advice cases
• Handled by telephone advice on a one-to-one basis
• Focus tends to be more on the use of local or
  national systems and processes and less on the
  details of the particular practitioner
• Support cases
• Essentially ongoing support and help to resolve
  a performance dispute between an organisation and
  one of its practitioners
• Nature of the performance concern must be clear
  or irrelevant to the handling of the case
• Automatically includes suspension or exclusion
  cases
• Primary modus operandi is NCAS-team based case
  conference
• Assessment cases
• Where detailed diagnostic work is needed to get
  behind the concern

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Referrals by specialty group April 2001
September 2006
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Age at Referral by Sector April 2001 March
2006
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Overview of NCAS First Five Years 1

• c2.5 of active doctors and dentists referred
  from 97 of NHS bodies
• At any one time, one NHS organisation in two is
  working with us
• We are used equally, regardless of organisational
  star rating
• We get self referrals as well as referrals from
  organisations
• Our overlap with professional regulators is now
  very small
• Cases are being referred earlier two thirds of
  NCAS cases lt1 year old in 2005/06, compared with
  two thirds gt1 year old in 2002/03
• Suspensions and exclusions
• Estimated direct cost per case 188k so worth
  saving!
• New cases alternative to exclusion offered in
  gt80
• Long-term cases prevalence reduced by two
  thirds
• All disciplinary cases 30 capability / 70
  discipline

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Overview of NCAS First Five Years 2

• Age
• GPs gt60 eight times more likely to be referred
  than at 35-39
• Consultants gt60 three times more likely to be
  referred than at 35-39
• Gender
• Referrals of women GPs less than half what we
  would expect by age
• Referrals of women hospital community doctors a
  third lower than we would expect
• Ethnicity and place of qualification
• More non-white referrals than would be expected
  from the workforce but also more referrals of
  doctors qualified outside the UK
• Likelihood of referral highest in non-white
  non-UK qualified doctors

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What Does NCAS Bring to Support Cases?

• Referring bodies are looking for
• Diagnostic help with clinical and behavioural
  concerns (28)
• Help and support to local handling of cases
  (72), including disciplinary / regulatory /
  criminal issues, health concerns, and support to
  local remediation
• NCAS can bring
• Guidance and direction to local use of
  performance, disciplinary and regulatory
  procedures
• Expert advice on guidance, regulations and
  legislation
• Facilitation and brokering within and between
  organisations and agencies, especially in
  contingency and action planning

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Review of a Sample of Fifty NCAS Support Cases

• In 46, there was one area of presenting concern
  only, and in 26 there were three or more areas
  of concern
• Clinical presenting concerns in 70, including
• Consultation skills and clinical decision-making
• Record keeping and prescribing
• Behavioural presenting concerns in 78, split
  equally between allegations of specific conduct
  incidents and general behavioural issues
• Health concerns in 30, including mental illness,
  substance misuse and cognitive impairment
• Organisational issues in 14, including
  particularly workload and relationship issues

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NCAS Assessment

• Purpose
• Clarify areas of concern, understand what is
  leading to them, and make recommendations on how
  they may be resolved
• Challenge to NCAS
• Create a developmental model in an adversarial
  environment
• Credible with sponsors, partners and users
• Able to withstand legal challenge
• Affordable and practicable
• Components
• Uses recognised methods modified for NCAS purpose
• 10 tools with triangulation of evidence
• Holistic not only clinical
• Recommendations underpinned by educational
  expertise

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The Performance Triangle Our Take on the
Canadian Model
Work Context
Clinical Capability
Behaviour
Health
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Review of First Fifty NCAS Assessment Cases

• Concerns are usually in more than one area,
  whether clinical or not gt40/50 had more than 5
  areas of significant concern at assessment
• Clinical concerns in 41 out of 50, including
• Clinical knowledge
• Clinical decision-making (including making a
  diagnosis)
• Record keeping, guidelines, policies and
  procedures
• Non clinical concerns include
• Behaviour (47) eg communication, leadership,
  general behaviour
• Education / training / continuing professional
  development (24)
• Health (14) eg physical or mental illness,
  cognitive impairment
• Organisational issues (44) eg workload, team
  functioning

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Future Developments Responding to a Changing
Environment

• Developing our service and responding to demand
• Other sectors private healthcare
• Other professions how our approach might be
  extended
• A broader range of assessment models
• Clinical teams
• Modular approaches
• Contracting with UK General Dental Council to
  provide its performance assessments
• Responding to the political context
• Other funding models self-funding for part or
  all of our work
• Reviews by Parliament and by Government
  Departments
• Inquiries Shipman, Ayling, Neale, KerrHaslam
• UK professional regulation reviews

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So What? How does NCAS fill The Governance
Gap?
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What Have We Contributed?

• Oiling the wheels
• Partnership and support to systems at all levels
  of professional regulation self, team,
  organisational and national
• Getting behind the concern
• Wide publication of NHS learning about the nature
  of performance concerns and how they may be
  resolved
• A menu of responses
• Enabled a broader-based and more flexible
  approach across the UK in dealing with concerns
  at professional performance
• The trusted third party
• Brought independent, objective and even-handed
  support to resolving performance disputes from
  within the health care system

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v
What Have We Achieved?

• Stick to the knitting
• Kept our focus on what we were asked to do, set
  clear goals and achieved them, particularly
• Reducing inappropriate suspension and exclusion
• Ensuring rapid responses to unacceptable
  performance
• A holistic approach
• Built one of the largest case series on the
  impact of behaviour on performance and of
  performance on behaviour
• Influence versus power
• NCAS has no regulatory powers but our advice
  tends to be taken!
• And we think we oiled the wheels
• That helps all the key agencies work more
  effectively together

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What have we Learned?

• Everything on these slides and more plus
• Stay small and do what needs to be done
  nationally
• Concentration of expertise and economies of scale
• Concerns are uncommon, so a large practitioner
  population is required (c140,000)
• Share experience and expertise
• There is much common ground to be shared between
  health care professions in managing performance
• Build evaluation and learning from Day One
• A young organisation has a great opportunity
  and a driven need to build a strong culture of
  evaluation and research from the start

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The 21st Century Challenge Safer Patients
Safer Practitioners
Secrecy, Blame and Injury or Openness,
Forgiveness and Safety? Professor Donald M
Berwick European Patient Safety Summit 30
November 2005
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FILLING THE GOVERNANCE GAP Five Years
Experience of Promoting Confidence in Doctors
and Dentists IAMRA 2006 Wellington, New
Zealand Professor Alastair Scotland FRCS FRCP FFPH