DOCTORS, POWER AND THEIR PERFORMANCE

1. DOCTORS, POWER AND THEIR PERFORMANCE October 2012 Professor Alastair Scotland OBE FRCS FRCP FRCGP FFPH

2. Overview • Setting the scene • Doctors, power and their practice – why is this important? • When things go wrong – learning from experience • The governance gap in UK health care – and the response • What did we learn? How did we do? • Where are we now? Where do we need to go? • Looking forward – using experience • Predicting, preventing and identifying dysfunctional practice • And if we do – what are the chances of success in managing it?

3. Scene Setting Doctors, power and their practice

4. Doctors and power – the background • All practising doctors are, by definition, in positions of power • In the doctor-patient relationship • In the clinical team • In the organisation and the wider health economy • In the population they serve • All practising doctors are ascribed positions of power • In law • In the way health services are structured • In the attitude of patients and society • The nature of medical regulation underpins and enhances this power gradient • The stewardship of an obscure science and technology • The lack of accessibility and practicability of a relevant legal code

5. Doctors and power – the consequence • The consequence of these power gradients is the need for a contract • Between the profession and society • Between individual practitioners and those they work with • Contracts are about creating an equal relationship • And when things go wrong … • Matters can closely reflect and enhance apparently inappropriate power gradients • And everyone suffers

6. When things go wrong Learning from experience

7. The governance challenge • Medical scandals • Was poor performance tolerated more than it should have been? • Repeated common features in service and individual failures • Was health care in the UK 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 • Systems for responding to these failures not fit for purpose • Outdated, unwieldy and bureaucratic • Excessively legalistic, adversarial and court-like • Media response focused on blame • Difficult or impossible to separate out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-one’s fault

8. The response – a three phase approach to reform • Moving accountability centre stage, underpinned by new central governance bodies • System governance – CHI-HCC-CQC / QIS-HIS / RQIA / HIW, NICE, NPSA, NHSLA, CSCI etc • Professional governance – CHRE, NCAA-NCAS • Modernising employment and HR practice • Contracts of employment and for provision of service • Education, training and career structures • Disciplinary and other professional governance systems for employed and contracted practitioners • Reforming professional regulation for all clinical staff groups • Trust, Assurance and Safety, responsible officers, revalidation etc

9. BUT – how the quality arena can feel National Quality Board Public Health England PROMs NHSLA Medical Education England Other Regulators CHRE ADASS Performance Management Audit Commission GMC LAA Staff Revalidation Quality observatories RIEPs NHS Constitution GSCC NHS Commissioning Board NMC Responsible officers 3rd Sector NPSA CQC DH E&D Human rights NICE Commissioning groups Health care providers DCLG CAA SCIE JSNA Quality Framework Professional accreditation JIPs Quality Accounts NHS Choices Improvement Agencies Personalisation NCAS Political landscape (PAC, HSC)

10. Tackling the governance challenge – what happened? • Modern health care is high-impact, highly effective, highly demanding – and high-risk • Pattern of response to perceived failures in governance • Creation of regulatory or quasi-regulatory ALBs as one-off actions • When expected improvement does not occur – reconfiguring or abolition with little analysis of cause • Why? • Quality landscape busy and fragmented • Lack of recognition that modern health care is a team effort – not just the ‘sum of the parts’ • Tendency to public sector ‘organisational snobbery’ – working only with ‘equals or seniors’ • Unless duty of co-operation and duty of candour are explicit, they cannot be relied on

11. So what is needed? • Simpler regulatory landscape with clear rules, audited for use • Bespoke regulation distinct from the law or market forces should exist only where justified • Creating ‘knee-jerk’ regulatory structures devalues market operation and makes a mockery of the law • Regulatory and governance support structures must reflect the reality of day-to-day practice and service delivery • Or the contract between society and the service or profession will not function properly • For example – do we need ten regulatory bodies for health professions? • A properly integrated approach to regulation and governance • Legally-binding duty of co-operation across all agencies in regulation and governance support • ‘Blind’ to the status of the agencies involved • Include an explicit duty of ‘pro-active’ candour

12. Looking forward Using experience

13. The performance triangle Work Context Clinical Knowledge & Skills Health Behaviour Adapted from Jacques et al, Québèc

14. The evidence – the size of the problem Sources: Donaldson (1994), GMC (2011), NCAS (2011) • International evidence • c1.0 – 1.5% of any population of doctors get into difficulty each year sufficient to require outside help • UK experience reflects international experience • UK experience • NCAS [practising population] • One doctor in 200 referred each year (c1,000) • From 3 in 4 NHS organisations • GMC [registered population] • c3% of registered numbers referred each year (c7,000) • 84% closed, referred back or no action taken • 16% have some finding or action taken (c1150) • Total broadly reflects the published figures worldwide

15. The evidence – demography Source: NCAS (2011) • NCAS has regularly published the most detailed evidence • Certain groups more likely to be referred • Older • Consultants – and career grades more generally • Men • In secondary care, non-white doctors qualifying outside the UK • Much more likely for single-handed than in practices of 4 or more • Certain specialties more – or less – likely to be referred • Psychiatry group, Obstetrics & Gynaecology and General Practice significantly more likely to be referred than by chance • Anaesthetics, General Medicine group and Public & Community Health significantly less likely to be referred than by chance

16. The evidence – findings Source: NCAS (2005, 2010) • NCAS’ experience in assessing practitioners • 82% had five or more major areas of deficit across four domains • 94% had significant difficulty arising from their behavioural approach • 88% had major challenges arising from their working environment • What was found was often at variance with referred concerns

17. Behavioural factors – strengths becoming weaknesses Source: Hogan and Hogan (1997, 2001); King (2008)

18. Behavioural factors – findings can be counterintuitive Source: King (2007, 2009)

19. Behavioural factors – summary findings Source: King (2007) Patient-focused to the exclusion of wider considerations Diligent to the point of perfectionism Confrontation-averse Poor influencers Low self-awareness Receptive to ideas BUT resistant to changing their own ways of working

20. What predicts the likelihood of change? Source: King (2008) • Do they have the ‘key’ personality traits to support change? • Are they stable enough? • Can they persevere? • Do they have insight? • Are they psychologically minded? • Can they reflect on their behaviour and learn from their experience? • Do they want / intend to change? • Have they a history of successful change attempts? • What will motivate them to change? • What kind of environment will they be working in? • What support is available? • What are the contextual factors that may influence their behaviour?

21. Review • Dysfunctional practice • Rare – but high in its impact on patients and the wider health team • The evidence is building on what contributes to it • Consistent across jurisdictions • Disruptive behaviour is a significant element – including, in extreme cases, abuse of inherent professional power • The UK’s experience to tackling this governance challenge • Repeated creation, abolition and recreation of external agencies • Focus shift from failing practitioners to failing organisations / systems • What we need into the future • Simpler regulatory landscape with clear rules, audited for use • Better integration across regulation and governance support • More sensitive and specific systems to support front-line governance in moving up stream

22. DOCTORS, POWER AND THEIR PERFORMANCE October 2012 Professor Alastair Scotland OBE FRCS FRCP FRCGP FFPH