Managing Dental Underperformance. The Role of Local Performance Schemes and the National Clinical Assessment Service

Transcription

1 Managing Dental Underperformance The Role of Local Performance Schemes and the National Clinical Assessment Service

2 National Patient Safety Agency Managing Dental Underperformance 1 The issue of underperforming dental professionals and how to deal with them is an important one. Dealing with concerns aro u n d performance can often be challenging for both the practitioner, and their employing authority. This advice booklet is intended to o ffer guidance to Primary Care Organisations (PCOs), such as Primary Care Trusts and Local Health Boards, on how local performance schemes and the National Clinical Assessment Service (NCAS) can be of help in managing these concern s. What is Underperformance? Underperformance is usually defined as performance that: places patients at risk; fails to meet accepted and re q u i red standards; and/or departs from what is considered normal practice. Indicators of underperformance may include: poor skills in clinical care; poor organisational and managerial skills in the delivery of healthcare ; knowledge, skills and attitudes that are below expected standards; a lack of clinical competence; behavioural problems; regular indicators of performance issues (such as a relatively high number of patient complaints or contract monitoring) over a period of time.

3 2 Managing Dental Underperformance National Patient Safety Agency The Importance of Local Performance Schemes Local performance schemes can help with the initial investigation into the reported concern and help resolve relatively straightforward difficulties by providing additional training and/or local support, for example mentoring. In the last decade several legal and advisory frameworks such as the Medical (Professional Performance) Act (1995) and T h e Management of Doctors with Problems (Department of Health, 1997) recommended the creation of local pro c e d u res to deal with underperforming practitioners, before possible referral to the regulatory authority. A number of schemes for doctors were established as a result. The first Practitioner Advice and Support Scheme (PASS) for dentists was established in East Lancashire in Since then, a number of local schemes have been cre a t e d with the support of PCOs and Local Dental Committees (LDCs) to help deal with underperformance in dental pro f e s s i o n a l s. Although PCOs have responsibility for dealing with underperformance by health professionals as part of their risk management strategies and clinical governance frameworks, relatively few have local arrangements in place. Local performance schemes for dentists are normally set up under the auspices of the PCO and the LDC. Their composition, pro c e d u re s and policies should be agreed formally and the constitution published locally through the PCO and LDC. The General Dental C o u n c i l s (GDC) guidance on local practitioner advice and support schemes is useful for anyone involved in setting up or running a local performance scheme for dental pro f e s s i o n a l s. 1 F u r t h e r practical guidance that compliments this is also available from the British Dental Association (BDA). 2 1 Guide to Local Practitioner Advice and Support Schemes. General Dental Council. April Available at: 2 BDA Advice Note 34: Practitioner Advice and Support Schemes Guidance on establishing a local scheme. British Dental Association. July 2005

4 National Patient Safety Agency Managing Dental Underperformance 3 The Work of Local Performance Schemes The aim of a local performance scheme is to protect patients t h rou gh the early detection of poor performance in a dentist, and to support dentists by providing them with skilled support and guidance to help them improve their performance. A referral can come from the practitioner themselves, a colleague, a Dental Practice Adviser, a friend, or another authority if a complaint has been made. A case could be anything from a dentist in need of temporary support whilst they work toward s sorting out a short term problem, to deeper problems concern i n g clinical, professional, managerial or financial underperformance. The scheme will carry out a local investigation of re f e r re d practitioners to identify the possible causes of underperformance. This will range from discussions with the dentist, to undertaking practice visits and observing the way the dentist, their team and the arrangements in the practice work. The local scheme will suggest options available to underperforming dentists, which may include appropriate training courses for the practitioner, the support of the PCO or a local educational establishment, or a referral to occupational health services or a suitable support gro u p if the problem is linked to a health issue. The dentist should agre e to be helped by the scheme and comply with its recommendations. In general, local schemes can be of most help in investigating the n a t u re of a diff i c u l t y. Where the difficulty may be re s o l v e d relatively simply with additional training and local support, for example by observing another practitioner s clinical skills, local intervention would be the pre f e r red route. However, if the p roblem is only one part of a more serious underlying issue, then the scheme is obliged to refer the case on to one or more re l e v a n t organisations, which may include NCAS.

5 4 Managing Dental Underperformance National Patient Safety Agency The Role of the National Clinical Assessment Service Referral to NCAS is appropriate when a local investigation has failed to resolve an issue or where the difficulty is complex and involves, for example, both clinical and behavioural concerns. The National Clinical Assessment Authority (NCAA) was established on 1 April 2001 following recommendations made in the Chief Medical Officer's report, Supporting Doctors, Protecting Patients (November 1999) and Assuring the Quality of Medical Practice: Implementing Supporting Doctors, Protecting Patients (January 2001). On 1 April 2005, following the government review of NHS arm s length bodies, the functions of the NCAA transferred to the National Clinical Assessment Service (NCAS), a newly established division within the National Patient Safety Agency (NPSA). NCAS provides a service to support the NHS in dealing with doctors and dentists whose performance gives cause for concern. It provides advice about local handling of cases and, where n e c e s s a r y, can carry out clinical performance assessments to clarify a reas of concern and make recommendations on how diff i c u l t i e s may be resolved. The NCAS assessment process involves trained medical/dental and lay assessors. Once an objective assessment has been carried out, NCAS will advise on the appropriate course of action. However, NCAS does not take over the role of the e m p l o y e r, nor does it function as a regulator; it is established as an advisory body and the NHS employer organisation re m a i n s responsible for resolving the problem once NCAS has produced its assessment. In general, NCAS can be of most help where local investigation has been undertaken, and local resolution has been attempted but failed. In addition, where the local investigation has shown the performance issue to be complex and involving a number of aspects, for example both clinical and behavioural concern s, referral to NCAS would be the pre f e r red ro u t e.

6 National Patient Safety Agency Managing Dental Underperformance 5 How Local Performance Schemes and NCAS Work To g e t h e r W h e rever possible, dentists whose performance gives cause for c o n c e rn should be given local help and support to improve their s t a n d a rd of care. Informal chats with a dentist suspected of underperformance, with little or no monitoring or follow-up, do not ensure that the causes of underperformance are identified and the support given is appropriate. Formal local pro c e d u res for dealing with performance issues, such as those carried out by a local performance scheme, are encouraged to provide consistency in aims, constitution, working methods and protocols. The majority of performance concerns encountered with dental p rofessionals will probably be resolved this way. NCAS can be of assistance if local schemes fail to re s o l v e performance issues, or when it has been deemed that the issues a re complex and persistent. NCAS can offer an in-depth assessment for clinicians in diff i c u l t y, which is often beyond the remit of most local performance schemes. This assessment pro c e s s evaluates clinical, health-related and behavioural aspects of a p r a c t i t i o n e r s performance within the context of their working e n v i ronment, which may prove invaluable in identifying underlying causes of underperformance. Often, NCAS and local performance schemes may be working on a case simultaneously, and there may be situations where liaison between the scheme and NCAS may be appropriate in identifying and resolving the causes of underperformance. In summary, both local performance schemes and NCAS can be of help in resolving performance issues with dental professionals, and should be re g a rde d as integral to PCO s clinical governance and quality assurance frameworks.

7 6 Managing Dental Underperformance National Patient Safety Agency Local Performance Scheme Flow Chart Presenting concern If the concern involves serious misconduct or fitness to practise, consider immediate referral to the General Dental Council Does the PCO have a local performance scheme in place? No Yes Does the concern regarding the practioner appear to warrant immediate suspension from the PCO dental list? Yes No Refer the case to the local performance scheme (consulting NCAS at this point may also be useful) Refer the case to NCAS Local performance scheme NCAS No Local support and advice provided Can the local performance scheme resolve the concern? Yes Consider setting up a local performance scheme within your PCO Action-planning and possible assessment Close case

8 National Patient Safety Agency Managing Dental Underperformance 7 Questions and Answers for Primary Care Organisations Q : What are indicators of poor performance in a dental practitioner? A: Indicators can be varied. It may be a serious isolated incident that p rompts a referral to either the local performance scheme or to NCAS, or it may be a number of less obvious indicators. Things like the frequency and number of patient complaints is important, but so is softer information such as negative reports from other s t a ff within the practice or from PCT dental staff, such as the Dental Practice Adviser. Q: Who should I consult before making a referral to either a local performance scheme or to NCAS? A : If at all possible, speak to someone at the PCO, Trust or Local Health Board who is responsible in some way for dentistry. This may be the Dental Practice Adviser, the Consultant in Dental Public Health or the Clinical Director for Dental Services. They can be used to sound out your ideas and concerns, and may be able to o ffer advice (if you need it) on whether the practitioner should be re f e r red locally, to NCAS or to both. You should find that most c o n c e rns will be resolved by the local performance scheme, with a smaller number requiring direct NCAS involvement. Q: Can I make a referral to the local performance scheme and to NCAS at the same time? A: Yes. NCAS are happy to accept referrals at any time, irre s p e c t i v e of if a local performance scheme has been informed. It may be that a local performance scheme resolves the problem before NCAS gets fully involved, but if an issue turns out to be persistent or difficult to resolve locally, informing NCAS early on in the investigation may be advantageous.

9 8 Managing Dental Underperformance National Patient Safety Agency Q: What if a practitioner fails to cooperate with either a local performance scheme and/or NCAS? A : The Healthcare Commission re q u i res that all PCOs use clinical g o v e rnance frameworks and strategies to help ensure that clinical s t a n d a rds are maintained and improved. If a practitioner fails to cooperate with moves to improve clinical standards, they may be subject to disciplinary action, which may eventually lead to their suspension from the PCO s dental performers list. Q: The local performance scheme in my area is keen on undertaking their own assessments for referred practitioners. How does an NCAS assessment differ from a local assessment? A : Some schemes may wish to undertake assessments of re f e r re d practitioners, but these will probably be quite basic and be more akin to fact finding exercises. In contrast, an NCAS assessment is an in-depth process that aims to investigate not just clinical performance, but also the practitioner s health and behaviour in addition to the environment in which they work. Even if the local scheme is working hard to resolve the issues, NCAS should ideally be monitoring the pro g ress of the case and would be able to p rovide an in-depth assessment if it eventually becomes necessary. It would be rare for a local scheme to have access to the bro a d expertise available at NCAS, or to deal with the number of cases locally which allow that expertise to develop. Q : Should I contact the General Dental Council about my c o n c e rns, and can I do this at the same time as involving a local performance scheme and/or NCAS? A: If there are serious concerns about the fitness to practise of a dental practitioner, the General Dental Council (GDC) should be informed as soon as possible. This may be because there are serious concerns about ill health, the practitioner has been convicted of a criminal offence or they may have committed serious professional misconduct. As part of their duty to pro t e c t the public, the GDC has the power to take action restricting or removing a practitioner s practise rights if they fall seriously short of the high standards expected. It would also be worth involving a local performance scheme and/or NCAS at the same time, as practitioners may be in need of support and assistance following any GDC involvement.

10 w w w. n c a s. n h s. u k National Clinical Assessment Service Market To w e r s 1 Nine Elms Lane L o n d o n SW8 5NQ T F J A N 0 6 National Patient Safety Agency Copyright and other intellectual property rights in this material belong to the NPSA and all rights are reserved. The NPSA authorises healthcare organisations to re p roduce this material for educational and non-commercial use.