When doctors don’t performApril 27, 2007
What do we do when doctors are underperforming? Historically this was an issue of limited application, as doctors performance was not assessed, so there was no way of knowing how they compared to other doctors in the same field. Now phrases like performance management, appraisal and assessment are beginning to creep into the hospital managers’ dictionaries. Doctors are of course deeply suspicious of this: How would a mere manager (so the saying goes) be able to manage an intellectual and moral titan like me. Pah!
There are 3 major caregories of standard at issue:
Ethical standards. eg Don’t sleep with your patients.
Professional standards: Look after your patients properly and professionally, to a standard that your peers would accept is reasonable
Business standards: Work hard, See lots of patients and generate revenue for the Trust or practice you work in.
For me the interesting aspect of this is what happens when there is a conflict between two sets of standards. In essence as professional and ethical standards should be completely compatible, that means that we are looking at conflicts between business standards and professional/ethical standards. This is easily seen in practice: For instance a hospital might dictate the use of an inferior quality hip replacement to save money. This is fine and will of course happen as part of natural business practice, but when does good value become cheap tat? The doctor has a very important role here as the guardian of standards: only s/he can provide managers with the right information to make the right decision. Or as we saw on Can Gerry Robinson save the NHS?, the case of an eye surgeon who was doing an old-fashioned cataract operation that took an hour instead of 15 minutes. Clearly it is better busines for the trust for him to do more operations with the shorter procedure. It should be better for patients too, but if he is not familiar with this operation, it might be in conflict with his professional standards. This should be a fairly simple matter of continuous professional development, but if not well handled can deteriorate into an ugly stand off.
So how to regulate this.
1) We used to have a body responsible for moral, ethical and professional standards. It was called the GMC. The GMC is now, by all accounts an expensive talking shop which has made some high profile errors (see HERE and HERE, for example). It also has the problem that in cases of serious medical misconduct it is both prosecutor and judge, a problem which Dame Janet Smith alluded to in her recommendations for the GMC following Shipman. So we need to have professional regulation. People say doctors should not be allowed to regulate themselves. I’m not sure that this is right, in the same way that I believe other professional groups are probably in the best position to judge whether or not any given action is acceptable practice. It is interesting that Dame Janet, a lawyer, proposed that a lawyer should be in charge, but she may be right. There does definitely need to be at least an equal representation of non-medics on the GMC to prevent the sort of ‘there there, old chap, could have happened to anyone: See you down the club” approach to regulation. Like many of the beliefs about doctors this was largely a myth, but it needs to be seen to have been slain. In practice I think this means a new regulatory body. Lets call it the Medical Licencing Committee to adjudicate on cases which could be prosecuted by the GMC, or a new watchdog. The GMCs licensing function should be taken over by this body who would have no other role.
2) Trusts need to be more aware of the standards of their doctors. This can only be achieved by trying to develop a culture of openness in medicine. A culture where we admit our mistakes and they are made public. A culture where reviews of doctors performance can be carried out regularly, jointly by senior doctors and hospital managers. These should not be cap-doffing exercises. Neither shuld they be so exhaustive as to waste a huge amount of everybody’s time. But this is done all the time in any company you can think of. In fact I suspect it is rather hard to think of a job in which people earn over £100,000 per annum and do not have some form of serious performance review.
3) I think the career structure of hospital doctors needs to change. At the moment doctors undergo a period of training (in my case about 12 years) and are then, if they make the grade, appointed as consultants. After this there is no promotion or demotion. The pyramid is flat and extremely difficult to fall off. Sure, a few people will go on to be heads of departments or medical directors, but in general these are titular appointments which do not carry any real pay or kudos with them. The appointees are too often the last person to leave the room, or selected by Buggins’ turn rather than merit based criteria. There is thus very little management of consultants, even less management of consultants by consultants, and little incentive for consultants to become involved in management
I would favour a rather more hierarchical structure with pay progression dependent on promotion rather than time served. I also believe consultants’ contracts should be renewable 5-yearly, so that if someone was failing to deliver to the appropriate standard they could be sacked or moved sideways. In practice I doubt this would happen often, but it would focus the mind
4) The thorny issue of business practice. Consultants are inadequately trained in business, and I would make it a core part of their training, with an option for some to specialise in hospital management with an MBA programme and time spent in industries other than healthcare to foster a real understanding of commercial business practice. Only by engaging doctors will we develop sensible safe and ethical business practice, and only by engaging doctors can we set appropriate targets against which people can be measured. But we are talking about perverse incentives here: If the Trust maximises its income, all it is doing is taking money from the commissioning body which could be spent elsewhere. Nevertheless, performance-related pay could be an option for some fields, especially those where performance is easily measured.
But being involved in the business side MUST not absolve us of responsibility to act as advocates for our patients. This is the real test of our mettle
So My prescription is as follows
A new central Medical Licensing Committee to replace the GMC’s function of regulating fitness to practice
A different career structure for hospital doctors with renewable contracts and a more hierarchical structure for senior doctors
Regular and robust performance review on which career and pay progression would depend