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DOCTORS, POWER AND THEIR PERFORMANCE
October 2012Professor Alastair Scotland OBE FRCS FRCP FRCGP FFPH
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Overview
• Setting the sceneo Doctors, power and their practice – why is this important?
• When things go wrong – learning from experienceo The governance gap in UK health care – and the responseo What did we learn? How did we do?o Where are we now? Where do we need to go?
• Looking forward – using experienceo Predicting, preventing and identifying dysfunctional practiceo And if we do – what are the chances of success in managing it?
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Doctors, power and their practice
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Doctors and power – the background
• All practising doctors are, by definition, in positions of powero In the doctor-patient relationshipo In the clinical teamo In the organisation and the wider health economyo In the population they serve
• All practising doctors are ascribed positions of powero In lawo In the way health services are structuredo In the attitude of patients and society
• The nature of medical regulation underpins and enhances this power gradiento The stewardship of an obscure science and technologyo The lack of accessibility and practicability of a relevant legal code
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Doctors and power – the consequence
• The consequence of these power gradients is the need for a contracto Between the profession and societyo Between individual practitioners and those they work with
• Contracts are about creating an equal relationship• And when things go wrong …
o Matters can closely reflect and enhance apparently inappropriate power gradients
o And everyone suffers
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12 When things go wrong
Learning from experience
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The governance challenge
• Medical scandalso Was poor performance tolerated more than it should have been?
• Repeated common features in service and individual failureso Was health care in the UK able to learn from its own mistakes?
• Systems for responding to these failures not fit for purposeo Outdated, unwieldy and bureaucratico Excessively legalistic, adversarial and court-like
• Media response focused on blameo Difficult or impossible to separate out individual failure, system failure
and untoward incidents which were no-one’s fault
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The response – a three phase approach to reform
• Moving accountability centre stage, underpinned by new central governance bodieso System governance – CHI-HCC-CQC / QIS-HIS / RQIA / HIW, NICE,
NPSA, NHSLA, CSCI etco Professional governance – CHRE, NCAA-NCAS
• Modernising employment and HR practiceo Contracts of employment and for provision of serviceo Education, training and career structureso Disciplinary and other professional governance systems for employed
and contracted practitioners
• Reforming professional regulation for all clinical staff groupso Trust, Assurance and Safety, responsible officers, revalidation etc
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BUT – how the quality arena can feel
CQC
Performance Management
NHS Constitution
Professional accreditation
Personalisation
Quality Accounts
Quality Framework
National Quality Board
Other Regulators
NHSLA
3rd Sector NPSA
Audit Commission
NICE
Improvement Agencies
PROMs
GSCCRIEPs
ADASS
NMC
GMC
Human rights E&D
DCLG
Political landscape (PAC, HSC)
DH
CAA JSNA
Quality observatories
Commissioning groups
Revalidation
NHS Choices
Staff
SCIEHealth care providers
JIPs
LAA
CHRE
NCAS
Responsible officersNHS Commissioning Board
Public Health England
Medical Education England
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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 governanceo Creation of regulatory or quasi-regulatory ALBs as one-off actionso When expected improvement does not occur – reconfiguring or
abolition with little analysis of cause
• Why?o Quality landscape busy and fragmentedo Lack of recognition that modern health care is a team effort – not just
the ‘sum of the parts’o Tendency to public sector ‘organisational snobbery’ – working only
with ‘equals or seniors’o Unless duty of co-operation and duty of candour are explicit, they
cannot be relied on
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So what is needed?
• Simpler regulatory landscape with clear rules, audited for useo 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 lawo 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 governanceo Legally-binding duty of co-operation across all agencies in regulation
and governance supporto ‘Blind’ to the status of the agencies involvedo Include an explicit duty of ‘pro-active’ candour
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Using experience
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The performance triangle
Work Context
Health
Clinical Knowledge &
Skills
Behaviour
Adapted from Jacques et al, Québèc
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The evidence – the size of the problem
• International evidenceo c1.0 – 1.5% of any population of doctors get into difficulty each year
sufficient to require outside helpo UK experience reflects international experience
• UK experienceo NCAS [practising population]
One doctor in 200 referred each year (c1,000) From 3 in 4 NHS organisations
o 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
Sources: Donaldson (1994), GMC (2011), NCAS (2011)
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The evidence – demography
• NCAS has regularly published the most detailed evidence• Certain groups more likely to be referred
o Oldero Consultants – and career grades more generallyo Meno In secondary care, non-white doctors qualifying outside the UKo Much more likely for single-handed than in practices of 4 or more
• Certain specialties more – or less – likely to be referredo Psychiatry group, Obstetrics & Gynaecology and General Practice
significantly more likely to be referred than by chanceo Anaesthetics, General Medicine group and Public & Community
Health significantly less likely to be referred than by chance
Source: NCAS (2011)
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The evidence – findings
• NCAS’ experience in assessing practitionerso 82% had five or more major areas of deficit across four domainso 94% had significant difficulty arising from their behavioural approacho 88% had major challenges arising from their working environment
• What was found was often at variance with referred concerns
Domain Notified at referral Found at assessment
Clinical skills 54% 82%
Governance and safety 35% 48%
Behaviour – conduct 33%
Behaviour – other than conduct 29% 94%
Health 24% 28%
Organisational 11% 88%
Source: NCAS (2005, 2010)
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Behavioural factors – strengths becoming weaknessesSTRENGTH
Enthusiastic
Shrewd
Careful
Independent
Focused
Confident
Charming
Vivacious
Imaginative
Diligent
Dutiful
DYSFUNCTIONAL BEHAVIOUR
Volatile
Mistrustful
Cautious
Detached
Passive-Aggressive
Arrogant
Manipulative
Dramatic
Eccentric
Perfectionist
Dependent
Moving away from others
Moving against others
Moving towards others
Source: Hogan and Hogan (1997, 2001); King (2008)
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Behavioural factors – findings can be counterintuitiveWHAT WAS EXPECTED
More emotionally reactive
More introverted
Less open
Less agreeable
Less conscientious
More arrogant
Unmotivated
Stressed
Low self-awareness
Weak influencing and leadership skills
WHAT WAS FOUND
Somewhat more reactive
More introverted
Less open
Much MORE agreeable
Similar to the working population
More perfectionist and more dependent
MotivatedResilient (based on US norms) – but Stressed (based on UK working pop)
Low self-awareness
Weak influencing and leadership skills
Source: King (2007, 2009)
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Behavioural factors – summary findings
• 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
Source: King (2007)
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What predicts the likelihood of change?
• Do they have the ‘key’ personality traits to support change?o Are they stable enough? o Can they persevere?
• Do they have insight?o Are they psychologically minded?o Can they reflect on their behaviour and learn from their experience?
• Do they want / intend to change?o Have they a history of successful change attempts?o What will motivate them to change?
• What kind of environment will they be working in?o What support is available?o What are the contextual factors that may influence their behaviour?
Source: King (2008)
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Review
• Dysfunctional practiceo Rare – but high in its impact on patients and the wider health team
• The evidence is building on what contributes to ito Consistent across jurisdictionso Disruptive behaviour is a significant element – including, in extreme
cases, abuse of inherent professional power
• The UK’s experience to tackling this governance challengeo Repeated creation, abolition and recreation of external agencieso Focus shift from failing practitioners to failing organisations / systems
• What we need into the futureo Simpler regulatory landscape with clear rules, audited for useo Better integration across regulation and governance supporto More sensitive and specific systems to support front-line governance
in moving up stream
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DOCTORS, POWER AND THEIR PERFORMANCE
October 2012Professor Alastair Scotland OBE FRCS FRCP FRCGP FFPH
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