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

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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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12 Scene Setting

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• Systems for responding to these failures not fit for purposeo Outdated, unwieldy and bureaucratico Excessively legalistic, adversarial and court-like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)

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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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12 Looking forward

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