DOCTORS, POWER AND THEIR PERFORMANCE
October 2012
Professor Alastair Scotland OBE FRCS FRCP FRCGP FFPH
Overview
• Setting the scene
o
Doctors, power and their practice – why is this important?
• When things go wrong – learning from experience
o
o
o
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
o
o
Predicting, preventing and identifying dysfunctional practice
And if we do – what are the chances of success in managing it?
Scene Setting
Doctors, power and their practice
Doctors and power – the background
• All practising doctors are, by definition, in positions of power
o
o
o
o
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
o
o
o
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
o
o
The stewardship of an obscure science and technology
The lack of accessibility and practicability of a relevant legal code
Doctors and power – the consequence
• The consequence of these power gradients is the need for a
contract
o
o
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 …
o
o
Matters can closely reflect and enhance apparently inappropriate
power gradients
And everyone suffers
When things go wrong
Learning from experience
The governance challenge
• Medical scandals
o
Was poor performance tolerated more than it should have been?
• Repeated common features in service and individual failures
o
Was health care in the UK able to learn from its own mistakes?
• Systems for responding to these failures not fit for purpose
o
o
Outdated, unwieldy and bureaucratic
Excessively legalistic, adversarial and court-like
• Media response focused on blame
o
Difficult or impossible to separate out individual failure, system failure
and untoward incidents which were no-one’s fault
The response – a three phase approach to reform
• Moving accountability centre stage, underpinned by new
central governance bodies
o
o
System governance – CHI-HCC-CQC / QIS-HIS / RQIA / HIW, NICE,
NPSA, NHSLA, CSCI etc
Professional governance – CHRE, NCAA-NCAS
• Modernising employment and HR practice
o
o
o
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
o
Trust, Assurance and Safety, responsible officers, revalidation etc
BUT – how the quality arena can feel
National Quality Board NHSLA
Other Regulators
ADASS
Audit Commission
LAA
RIEPs
Public Health England
Medical Education England
PROMs
CHRE
Performance Management
Staff
Quality observatories
NHS Commissioning Board
NMC
rd
CQC
E&D 3 Sector NPSA
NICE Commissioning groups
DH
Revalidation
NHS Constitution
GMC
GSCC
Responsible officers
Human rights
Health care providers
DCLG
CAA
SCIE
JSNA
Quality Framework
Professional accreditation
JIPs Quality Accounts
NHS Choices
Improvement Agencies
Personalisation Political landscape (PAC, HSC)
NCAS
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
o
o
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?
o
o
o
o
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
So what is needed?
• Simpler regulatory landscape with clear rules, audited for use
o
Bespoke regulation distinct from the law or market forces should exist
only where justified

o
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
o
o
o
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
Looking forward
Using experience
The performance triangle
Work
Context
Clinical
Knowledge &
Skills
Health
Adapted from Jacques et al, Québèc
Behaviour
The evidence – the size of the problem
• International evidence
o
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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
o
NCAS [practising population]


o
One doctor in 200 referred each year (c1,000)
From 3 in 4 NHS organisations
GMC [registered population]


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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)
The evidence – demography
• NCAS has regularly published the most detailed evidence
• Certain groups more likely to be referred
o
o
o
o
o
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
o
o
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
Source: NCAS (2011)
The evidence – findings
• NCAS’ experience in assessing practitioners
o
o
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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
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)
Behavioural factors – strengths becoming weaknesses
STRENGTH
DYSFUNCTIONAL BEHAVIOUR
Enthusiastic
Volatile
Shrewd
Mistrustful
Careful
Moving away
from others
Cautious
Independent
Detached
Focused
Passive-Aggressive
Confident
Arrogant
Charming
Vivacious
Moving against
others
Imaginative
Diligent
Dutiful
Manipulative
Dramatic
Eccentric
Moving towards
others
Source: Hogan and Hogan (1997, 2001); King (2008)
Perfectionist
Dependent
Behavioural factors – findings can be counterintuitive
WHAT WAS EXPECTED
WHAT WAS FOUND
More emotionally reactive
Somewhat more reactive
More introverted
More introverted
Less open
Less open
Less agreeable
Much MORE agreeable
Less conscientious
Similar to the working population
More arrogant
More perfectionist and more dependent
Unmotivated
Motivated
Stressed
Resilient (based on US norms) – but
Stressed (based on UK working pop)
Low self-awareness
Low self-awareness
Weak influencing and leadership skills
Weak influencing and leadership skills
Source: King (2007, 2009)
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)
What predicts the likelihood of change?
• Do they have the ‘key’ personality traits to support change?
o
o
Are they stable enough?
Can they persevere?
• Do they have insight?
o
o
Are they psychologically minded?
Can they reflect on their behaviour and learn from their experience?
• Do they want / intend to change?
o
o
Have they a history of successful change attempts?
What will motivate them to change?
• What kind of environment will they be working in?
o
o
What support is available?
What are the contextual factors that may influence their behaviour?
Source: King (2008)
Review
• Dysfunctional practice
o
Rare – but high in its impact on patients and the wider health team
• The evidence is building on what contributes to it
o
o
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
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o
Repeated creation, abolition and recreation of external agencies
Focus shift from failing practitioners to failing organisations / systems
• What we need into the future
o
o
o
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
DOCTORS, POWER AND THEIR PERFORMANCE
October 2012
Professor Alastair Scotland OBE FRCS FRCP FRCGP FFPH