Just five in every 1000 NHS doctors -- less than 1% of the workforce -- prompt concerns about their performance every year, sufficient to warrant the need for outside help, indicates an analysis of 11 years of data, published in BMJ Quality & Safety.
But doctors in the late stages of their career are six times more likely to be referred for remedial help, the figures show.
The findings are based on a detailed analysis of referrals of NHS doctors by employing organizations -- and in 3% of cases, the doctors themselves -- to the National Clinical Assessment Service (NCAS) between April 2001, when NCAS was set up in England, and March 2012.
Unlike the professional regulator, the General Medical Council, NCAS does not seek to determine whether doctors are fit to practise, but to find out if they are able to do the job(s) they are employed to do.
Over the 11 years, 6179 doctors from all specialties and types of employment were referred to NCAS, and while the annual rate fluctuated to some extent in the first few years after NCAS was set up, the annual rate worked out at five referrals per 1000 working doctors.
Based on eight years of data (5271 doctors), to exclude the fluctuations of the first three start-up years, the figures consistently showed that doctors who qualified overseas and male doctors were more than twice as likely to be referred to the service.
And doctors in the late stages of their career were almost six times as likely to be referred as those in the early stages.
The specialties prompting the highest rates of concern were psychiatry and obstetrics and gynacology.
Doctors working in these specialties were more than 3.5 times as likely to be referred as those working in the specialties with the lowest referral rates -- public health, cancer, and general medicine.
"Top level" concerns included clinical difficulties, such as poor diagnostic and treatment decisions; governance/safety issues; behavioural problems, such as aggression; misconduct, such as financial irregularities and inappropriate sexual behaviour; health problems, including drug and alcohol misuse; work environment, such as inability to cope with work pressures; and personal issues, such as marital break-down and bereavement.
The figures indicated that the type of top level concern varied with age among the 3467 doctors for whom information on the type of concern was available.
Clinical difficulties were significantly more common among doctors in mid and late career than those at the start of their careers, while misconduct issues were significantly more common in early career than in mid or late career.
The authors confirm that their findings back those of other studies, but caution against overly simplistic explanations. The arguments advanced for the gender divide in referrals -- that women are better at apologizing or are better communicators -- was not entirely consistent with their findings, for example.
Misconduct was more common among men, but behavioural issues were more common among women, the figures showed.
And while the real possibility of racial discrimination needs to be borne in mind for doctors who qualify overseas, non-white doctors who qualify in the UK do not seem to be at greater risk of referral, the figures indicate.
But nearly a third of doctors referred to NCAS had a health problem, which is often a strong reason for poor performance, say the authors. "Greater attention must be paid by organizations towards the mental well-being of their staff," they urge.
- L. J. Donaldson, S. S. Panesar, P. A. McAvoy, D. M. Scarrott. Identification of poor performance in a national medical workforce over 11 years: an observational study. BMJ Quality & Safety, 2013; DOI: 10.1136/bmjqs-2013-002054
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