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When doctors don’t perform

April 27, 2007

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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

Engagement of doctors in hospital management with high quality formal management and business training

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20 comments

  1. Business standards: Work hard, See lots of patients and generate revenue for the Trust or practice you work in.

    Huh? generate revenue for the Trust or practice you work in.

    That GP who has just been done because he was generating revenue for his practice by prescribing expensive drugs to non–existent patients, and re-selling them?

    For sure, there should be a level of commitment from any emplotyee – and the higher the pay the more commitment one should expect.

    But generating income for the Trust or practice.
    Sure that’s the first thing Addenbrookes worked out. How much can we make from hip replacements and heart surgery – so all the effort and money is going there

    Hundreds of millions – partly to meet demand
    But partly because they are the darling treatments in today’s (Blairs) world.
    Oh and of course Cancer Treatment, we want to be the ‘world’ leader in heart surgery & cancer treatment says the chief Executive – the Trust’s Mantra.

    Now don’t get me wrong, I’m all for that.
    But of course we have little time (and less money) to look at how we can improve other services.

    The word patient was not mentioned once by Mary Archer – I doubt she kbnows what they are. The focus is glossy magazine like talk of hundreds of millions, and becoming a World leader offering services to attract paying patients from All Over the World.

    Oh and if we have any free time we” treat local nhs patients – crumbs from the table. Sure the bigger the feast, the more left overs – but crumbs and leftovers all the same.

    Clinic 8 could improve its services by 100% without costing a penny more, just by changing the culture the department has developed, and by appointing as head of department someone with a ‘vision’ of how to improve services – to replace the head consultant who has been sitting on his past ‘laurels’ for far too long. Because he is the ‘top’ (meaning only) surgeon for the region dealing with hair lips and cleft palate – the rest of the department just processes patients, offering ever lower standards of treatment – and he has lost any contact with reality.
    Why are the patients teeth in such a bad way – because Cambridge Dentists haven’t been doing their job (though they’ve clearly generated revenues for their private practices).

    And then blame the patients. Over half the appointments are MISSED. Now I wonder why

    And the Consultant complains that half the patients are being referred to him, for things that should be treated by dentists – Really?
    And whose fault is that – The Patients?
    or the dentists who do not want to take on work which may have ‘costly’ complications – refer them to hospital.
    Whether it is because the dentists are unab;e, unqualified or unskilled to do the work, or unwilling to do the work, because they would rather do non-time coonsuming dentistry for high fees, ie wham bam thank you mam – than dentistry which requires attention and second or third visits which they may not be able to charge for …

    And yet if just four of those dentist were working at addenbrookes under my supervision (scrutiny) we could not only double the nhs patients we treat, but double the standards of surgery & patient satisfaction.


  2. Now, I’ll be happy to look over your work-place
    And check out what improvements can be made, for a small consultancy fee.

    You tell me what significant improvements can be made thru higher costs, and I’ll tell you what significant improvements can be made in work practices, services & therapy.

    So what do you say Mens Sana, or are you the type of Consultant – who thinks you know best
    Yet fail to realise that your ‘specific’ skills and experience seriously inhibit your view of how things may or can be improved – looking at things from another point of view.

    In fact Mens Sana, if I can have Lola and the roller for the weekend, I’ll do the Consultancy for free

    (not the lambo, I appreciate that you are possibly too attached to the lambo to let the lambo, not even to your wife)


  3. 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

    Engagement of doctors in hospital management with high quality formal management and business training

    And someone to watch over them, to make sure they don’t get lost too far up their own rear ends.


  4. “Business standards: Work hard, See lots of patients and generate revenue for the Trust or practice you work in”.

    1. What about seeing less patients and treating them like human beings instead of fodder for the pharma companies?

    “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”.

    2. What about accepting that NHS medicine isn’t right for all patients. What about prescribing alternative rememdies to patients?


  5. Hi Jeremy Jacobs,
    one can ‘meditate’ on a broken bone
    but it will ‘heal’ crooked unless
    someone sets (pins) or casts the fracture first.

    All treatments should be demonstrably ‘relevant’
    But I agree a lot of pharmacy has even less proof to substantiate its claims than some alternative remedies

    They just have more hard hitting ‘Consultants’ and ‘Lawyers’ to substantiste their often exagerated or even false claims – and an unacceptably high list of toxic side-effects.

    Alas the abuses of a ‘free’ market economy in the pursuit of government funds and prescription drug fees


  6. JJ

    1) I agree that this is where the internal market skews healthcare away from the patient and towards the business. This is one of the most undesirable aspects of the whole thing, and is what I meant by business standards coming into conflict with ethical and professional standards.

    The main way we should get round that is by giving people a real choice of where to go. If people are treated like fodder on one place and humans in another, and they have the choice, where do you think they will go? I think that the fact that patients still have no real choice over their doctors or where they are treated is one of the worst aspects of the entire system. It would not be tolerated in most countries, and is only allowed here because people perceive it as “free”.

    2) Alternative remedies are fine, and have their place. For some people they can provide real benefits. Of that I have no doubt. On the other hand the world is full of charlatans (even some in the medical profession)trying to profit from people’s distress and fear. The trouble with alternative medicines is that there is no real evidence for what works and what doesn’t, and I don’t think it is my role to practice in that world.

    I am happy to point patients towards places where they can get information on alternative medicines and let them make up their own minds. But that isn’t really an issue of standards, its a debate about the way we practice medicine, which is a whole different can of worms


  7. So what do you say Mens Sana, or are you the type of Consultant – who thinks you know best
    Yet fail to realise that your ’specific’ skills and experience seriously inhibit your view of how things may or can be improved – looking at things from another point of view

    I think we all think we know best, Q9, even dare I say it you. You say yourself that you want someone with vision to improve clinic 8. Presumably someone who knows best?. But I am also the sort of consultant who tries to listen to what his patients are telling him and I most emphatically do not believe that I am always right. Do you?


  8. Mens Sana, Tunnel Vision
    I am referring to those instances when people get caught in old habits … and set in their ways.
    I’m sure your department has seen many changes and presumably for the best in the last 50 years
    But you’ll be surprised what ‘obvious’ possible improvements an outsider can see – there is always that blind spot if one is too close to the subject matter.
    I would not presume to think I know better or best, however I would presume to be able to observe with a ‘critical’ eye – and offer suggestions, which may well have been considered and are in the pipeline or have been dismissed, or could perhaps be adopted.

    Paper doesn’t improve things, but it is a necessary evil to transmit information and a means to standardize treatments.
    But of course as Jeremy Jacobs points out – the system should be two way – and accept feedback from doctors and consultants on their local or personal methods, treatment & surgical techniques.

    After all a BMW mechanic will not accept a directive from head office – if it is counter to what he knows is best practice – but head office will most likely have a team of ‘engineers’ to verify or dismiss his claim.

    That clearly is what is often missing between the government and the people on the coal face. But the BMA is not always best at self-regulating or demanding higher standards from their own club members


  9. Starting from the begining
    What should a doctor be concerened with
    Costs, nhs or foundation trust directives, PCTs?
    or PATIENT NEEDS.

    The chicken and the egg?

    What makes an operation cost £30,000
    so ten operations worth £300,000 ???
    and twenty operations £600,000 ???

    How about we start at 20 operations worth £200,000
    then a single operations ‘real’ cost would be £10,000

    Torchwood


  10. Q9. Re your 10.35: agree wholeheartedly

    Re your 10.49: In theory of course the cost of everything is illusory. There is no reason why people should be rich or poor. In the old NHS pre Ken Clark, we didn’t knw the cost of anything and it was fine.

    But in the world we are in today, things have a cost and have to be paid for. I will be happy if you can change the world, but I am trying to live in the one we have


  11. Hi Mens Sana,
    it is that very point I’m trying to address:

    Business standards: Work hard, See lots of patients and generate revenue for the Trust or practice you work in.

    Instead of saying – right what are the cost of having a cancer treatment department …
    and how many patients can we treat (and cure when possible) COSTS & Pricing will skew the efforts of the whole team, guiding which treatments, options or preferences the Trust has – not the ‘patient’ demand.

    Isn’t that partly your criticism of PCTs & NICE.

    The same with heart surgery.
    Instead of organising the team to work efficiently to provide the best service and treat more patients. The focus will prioritise how much the department can bill the NHS or private health insurance.

    It is walking away from we are doctors, and we must earn money for the trust or private institution – and if we have any ‘free’ time we’ll see charity cases.
    Since when is a £90 billion NHS a charity case.

    The same occurs with IVY League Universities, and Cambridge – or Blairite cum Thatcherite HE
    They cater for paying customers, sure up to 60% of patients may be on scholarships – but that is because they cannot fill those places with paying students too

    Imagine if you had a £90 billion nhs which only catered for paying patients – Those who can pay £10,000 up front will be refunded half the fee, whilst those who cannot pay up front will be denied a referral for treatment.
    Ironic? but that is the way it is heading
    Slowly but surely once you are on a slippery slope, you knoe you are in for the fall – except those patients who are prejudiced against are still too few (or know no better, and have no voice).

    If dentistry is the model health care aims to follow
    The net result is 30% (the poorest 30%) receiving poor late & inadequate dentistry, and in some cases barbaric surgery
    Whilst the 70% who need no serious dentistry, or who can afford to pay for corrective & ‘cosmetic’ dentistry – are happy (sort of) with services, and remain blissfully unaware, of the true and painful plight of the rest.
    But of course if they cannot pay – they have no SAY!

    The Medical Profession & Hospitals (Whether NHS or Foundation Trusts) should not seek to provide answers to justify their actions, but seek answers to provide the treatment for All patients regardless of ability to PAY.

    And it is possible in the Real World
    But, clearly some are hellbent on making it impossible


  12. You know what Q9, we see every patient referred to us in the hospital within 2 weeks of referral, usually within 1 week. We give them the best treatment we can, though sometimes there may be slightly better treatments that the government wont let us provide. At the moment we can do nothing about that except shout about it and complain at every level, which we do. We do this within our budget, and none of these patients pays a penny to us (except of course through their taxes). These are ALL NHS patients. Private patients are not treated in the same institution, and only form a tiny minority (maybe 5%) of the total of our workload. The consultants do not get paid by the NHS for the small amount of time they spend seeing thir private patients. For that the Trust wants to charge the PCT what it costs to deliver the service. What is your problem with that?


  13. Hi Mens Sana, you are really unaware of what is going on – or don’t want to face the truth.

    Clinic 8 Addenbrookes hospital complains that dentists are referring patients to hospital who should be treated by dentists.
    So the hospital tells dentists NOT to refer patients, or to refer them somewhere else – if Addenbrookes doesn’t want them why should another Trust?.

    Dentists unwilling or unable to treat these patients, are referring them to the hospital because they are unable to treat the patient or can’t afford(?) to treat the patient.

    And then Clinic 8 Addenbrookes complains that half the patients who are booked miss their appointments.
    Incidentally this is NOT why they don’t want dentists to refer patients – This is just to place the blame on a patient. Sure it is time wasting, sure it is not convenient (for the hospital or Consultant) but you spend three sleepless nights with chronic pain, then succumb to ‘blissful’ slumber and miss an appointment

    Why cannot the patient still go in for treatment even if he wakes up late on the day of his apppointment.
    In an imperfect world we demand(?) the patient be perfect.

    I REPEAT I criticise things that are in the REAL world

    I sure hope that cancer patients are treated more sympathetically than dental patients – but it would be naive to think that the sympathy of some Consultants and nurses – extends right across the board.

    Tell me where you work, and I’ll pop in and visit.
    I’m sure I’ll find no fault, but because I sense I can like you – I’ll be happy to offer any suggestions which may be helpful and are possible in the REALworld

    I deliberately point out where all this privatisation and foundation hospitals is leading to. It is the slippery slope that has left 30% of patients with late, inadequate and often incompetent (unchecked) or second rate dentistry – nhs dentistry is viewed as an act of ‘charity’ (albeit paid by the nhs) – and nhs patients are viewed as undesirable, unwanted, unprofitable patients for most dental practices.
    Now that is as clear as water – and it is a fact.

    Michelle Tempest is campaigning to save the NHS in 24 hours and ‘save’ doctors jobs
    She should first be campaigning to keep the NHS free at the point of delivery – then she’d really have my full support and undivided attention.


  14. Star post, mens sana I agree with pretty much everything you say. The only thing I would add is that in other professions, there are lots of levels of sanction against people performing badly under any of your three headings, starting from the mild ticking-off from the boss, proceeding through written warnings, then through leaving the organisation in various ways including summary dismissal and ending up with the equivalent of getting struck off. It appears to me that for doctors there is not nearly enough at the lower levels of sanction and then a sudden leap to the possibility of getting struck off. I think your GMC-replacement needs to consider carefully what kind of doctors’ sins it is going to have oversight of. I think there are probably quite a few that would be better dealt with by the employing organisation.

    I also agree about the engagement of consultants in hospital management. Of course, you would have to be willing to pay higher management salaries to attract the consultants in specialties with the possibility of big private practices. In every other profession, the top managers tend to be people who formerly practiced as professionals and they have to paid enough to motivate them to stop.

    There are a l,ot of interesting parallels between hospital doctors and fund managers; I won’t clutter up this comments box now, but I could write a small book on how to manage, and involve in the management of the business, very clever people with a strong professional ethos and the technical skills which the business sells.


  15. Thanks Potentilla

    To be fair I believe that the Trusts do have various degrees of sanction open to them: Its just that they are not often applied, partly because doctors feel it is very stigmatising to be singled out for poor perforamnce (because it never happens!), so Trust management finds it difficult to involve peers in the process.

    Re your last point: I suspect you are right. It would be a pleasure to be cluttered up with something pertinent to the thread!


  16. Test


  17. Ho ho – I had the same thought re your last sentence.

    You’re right of course about both the trusts having sanctions available, and about why the sanctions are seldom used. I have a certain amount of inside knowledge on the latter as you may know, and it is certainly the case that quite severe cases of underperformance, due in some cases to alcohol and controlled substances, are not dealt with in as timely and thorough a way as they should be because of the reluctance of professional colleagues, even medical directors, to be involved in any way. This is (to be honest) completely crackers and would not happen in any other profession.

    I don’t have time for the small book right now (the sun is out!) but I will just say that I think the key to controlling fund managers tends to be (a) to have an ex-fund manager now working as a full-time manager (ie NOT managing money, the equivalent of seeing patients) in charge of them (and of course it has to be someone who had a reasonably successful career as a fund manager, not a star necessarily, but certainly not a failure) and (b) to have at least a good proportion of the rest of the senior management be strong-minded and preferably high-calibre people (otherwise they will get eaten for breakfast).

    And you have to be willing to sack them occasionally if they get out of hand, even the ones who are turning in good investment performance if they do something outstandingly stupid or wrong in some other way (the common ones would be deliberately ignoring rules which are there to prevent errors, or something like sexual harassment or racism). I remember once being involved, for instance, with the summary dismissal of a very senior management consultant for forging his boss’s signature on an expense claim, even though there was not a shadow of a doubt that the expenses were all entirely proper ones.

    I guess the problem with both (a) and (b) is that they are visibly expensive in the short term, even if they might save money over the long haul.

    Incidentally I have just been reading a book with some interesting things to say about medical errors; Pauline Chen “Final Exam” (she’s a surgeon). Also Atul Gawande “Complications” is good. Do UK hospitals have “mortality and morbidity” conferences too?


  18. Mens Sana,

    Do you know how other countries apply terms and conditions/promotion to their medical staff, surely this has been addressed by others, are you aware of improvements that can be ‘imported’ as better practice from these countries, France, Germany, USA etc??


  19. This is an exellent post, it is so great to have sites like this written by professionals. I don’t suppose consultants are interested in being trained in business, they simply want to get on with their job. I agree you need non-medics on your regulatory committee, otherwise they will lack transparency. Renewable contracts would certainly focus the mind and weed out those whose work is not up to standard.


  20. Thanks Ellee. There are of course lots of consultants who just want to get on with their job, but there are also many who have an interest in the business side (as there are GPs). I think they are very frustrated with the lack of business training-the best we usually get is a 2 or 3 day course in NHS (Mickey mouse) economics and management, and are a huge untapped resource

    I suspect there are not too many who share my view of contracts: (Turkeys, Christmas…)

    Mark most countries have doctors who are either self-employed or who are employed by local hospitals. I don’t know if such a thing as national terms and conditions exist in many other places (maybe Canada and Australasia?). Clearly sharing best practice from elsewhere is sensible, but actually what is needed is a change in mindset.



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