National Clinical Assessment Service Research Articles

Paediatric NHS 111 Clinical Assessment Services pilot: an observational study

ObjectiveTo determine the feasibility and impact of having paediatric clinicians working in the Clinical Assessment Services (CAS) within NHS 111, a national telephone advice service.DesignObservational study.SettingSix NHS 111 providers across...

What is happening to clinical negligence claims in the NHS?

The National Health Service Litigation Authority (NHSLA) was rebranded as National Health Service Resolution, or NHSR, on 03 April 2017. The stated aim of the rebranding process, according to the National Health Executive (NHE),1 is to combine the three operating arms of NHSLA, the National Clinical Assessment Service, and the Family Health Service Appeals Unit in order “to assist the NHS to resolve litigation concerns fairly, as well as share lessons learnt to improve clinical practice and preserve resources for patient care.” The NHE document points out that “Central to the change is the need for trusts across the country to learn from litigation cases and share experiences.” What then can we learn from the latest report on clinical negligence claims in the NHS, published this year by NHSR?2 During the last year, 17 338 claims were settled. In 67.8% (11 759) of those claims, resolution was achieved without issue of formal court proceedings. Damages were paid in 5226 cases (30.1%), and no damages were paid in 6533 cases (37.7%). In the former group, one assumes that the evidence for liability was clear, with compensation being paid for commercial or other reasons. Formal court proceedings were issued in 5498 claims (31.5%), with 4400 (25.4%) resulting in damages being paid and 1058 (6.1%) resulting in no damages. It is interesting that, of the 17 338 settled claims, only 121 (0.7%) ended up in court, with 49 (0.3%) resulting in payment of damages and 72 (0.4%) successfully defended. The projected expenditure for settlement of negligence claims in 2017/18 is £1.95 billion, representing a 17.5% increase compared with that of 2016/17. This latest increase does not take into account the effect of the change in the discount rate from 2.5% to -0.75% in March 2017.3 This affects the value placed on future losses …

Understanding Doctors' Performance

This book is a scholarly and concise review of the evidence so far. This shows a disturbing picture of committed professionals experiencing disproportionate stress and failure in a hostile workplace. The book is short, well written and authoritative. Many chapters are a model of the painstaking evaluation of evidence. Particularly useful are those on stress and depression (including some reference to organisational causes), the psychological factors linked to performance and the account of workload, sleep loss and shift work. Perhaps not surprisingly in a first edition, it has not ventured into detailed consideration about the defects in training and organisation that have produced such a challenging workplace and poor record of caring for the vulnerable employee. There is evidence that working for the NHS carries a higher risk of personal stress and failure than other British institutions and that depression and suicide are uncomfortably common especially in women. This is of particular concern at a time when the feminisation of the work-force proceeds apace and our dependence on women in medicine is growing and irreversible. It is perhaps most worrying that the book leaves us with the clear impression that a profession that should be most focused on the care of others has developed a culture in which the way that doctors treat their colleagues leaves so much room for improvement. There are serious concerns here about the nature of true professionalism because of the well-documented prevalence of interpersonal disputes, ineffective team-working, bullying and harassment. Recent work by the General Medical Council, royal colleges, the National Clinical Assessment Service and deaneries has shown that the general levels of skill and understanding required by consultant surgeons, trainers and trusts are worryingly low. There are serious implications here for patient safety not only because of individual failure but because those failures put vulnerable patients at even greater risk. Since the events at Bristol more than a decade ago, much has been learned about doctors' performance but much less about the causes and opportunities for improvement. Like other industries, about 6% of the work-force will show significant performance concerns in any one year but health professionals are particularly at risk because of the sensitivity of their work, the variety of problems they face and the poor standard of support in the NHS today. Repeatedly, the key features of dysfunctional NHS practice are brought into focus. These include the illusion of independent practice and the inappropriate dependence on trainees to provide the service. We should be concerned that, after many years of training, surgical consultants often lack the skills to develop effective team-working and leadership. Overall, therefore, the book raises more questions than it answers. Perhaps the most important of these is why so little of the effort that has been directed to exposing poor performance and its management has been redirected to improving the chaotic and arbitrary environment in which so many doctors have to work. This book is strong on symptoms. I hope that the next edition will also look at the underlying political and organisational causes and the opportunities for improvement.

Defining insight: a challenge that matters.

Insight is a fundamental consideration in the maintenance and improvement of performance. What is required is a definition that can be used consistently along with an understanding of the dynamic nature of insight, and therefore its potential for improvement. The work presented is a review of contemporary literature about insight, self-awareness and emotional intelligence, and experience from the National Clinical Assessment Service (NCAS) in the assessment of 300 doctors with performance problems. This work has led to the construction of a working definition of insight that incorporates reflection, emotional intelligence, self-awareness and motivation. The validity and utility of this definition was tested using data from NCAS's growing experience. The assessment of insight in NCAS performance assessments has involved the use of information from a variety of sources, including psychometric profiling, multisource feedback and self-assessment. This has been corroborated with findings from clinical performance assessment and the outcomes of remediation plans. A definition of insight is offered that is greater than just self-awareness, and that involves emotional intelligence and motivation. The use of this broad definition is of fundamental importance in the production of educational and development programmes at all levels.

A retrospective study of cognitive function in doctors and dentists with suspected performance problems: an unsuspected but significant concern.

SummaryObjectiveTo examine the performance assessments and cognitive function of practitioners referred to the National Clinical Assessment Service (NCAS).DesignRetrospective observational study.SettingPractitioners referred to NCAS for performance assessment due to suspected performance problems.ParticipantsOne hundred and nine practitioners over the age of 45 years referred to NCAS between 1 September 2008 and 30 June 2012.Main outcome measuresReasons for referral of practitioners and their characteristics; details of their assessments including screening for cognition using Addenbrooke's Cognitive Examination Revised (ACE-R); outcome of the process.ResultsReasons for referral included ‘clinical difficulties’ and ‘governance or safety issues’. Eighty-seven practitioners scored above 88 on ACE-R. Twenty-two were found to have an ACE-R score of ≤88. On further assessment, 14 of these 22 practitioners were found to have cognitive impairment. The majority of all practitioners were found to be performing below the expected level of practice for someone at their grade and specialty. Of those scoring ≤88 on the screening, only seven continued in clinical practice.ConclusionsA high proportion of practitioners scoring poorly on ACE-R were found to have cognitive impairment following detailed neuropsychological testing, the youngest aged 46 years. Many were working in isolation. Nearly all practitioners scoring poorly on ACE-R were international medical graduates; reasons for this are unclear. Performance assessment results showed persisting failings in the practitioners' record keeping and in their assessment of patients. Our findings highlight the need for increased vigilance and training of responsible officers to recognise performance problems and emphasise the importance of comprehensive assessment.

Only five in 1000 doctors prompt performance concerns

Just five in every 1000 NHS doctors prompt concerns about their performance that are sufficient to warrant outside help, analysis of 11 years of data has indicated.1 However, doctors who are in the late stages of their career are six times more likely to be referred for remedial help than those at earlier stages, the analysis shows. The findings, published in BMJ Quality & Safety , are based on analysis of referrals of NHS doctors in England by employing organisations and by doctors themselves to the National Clinical Assessment Service (NCAS). The data cover the period from April 2001, when NCAS was established, to March 2012. Over the 11 years, 6179 doctors …

Identification of poor performance in a national medical workforce over 11 years: an observational study

BackgroundPoorly performing doctors are a source of harm but do not commonly feature in discussions of patient safety. Few countries have national mechanisms to deal with these doctors; most opt...

GP suspensions fell in England in 2011-12

The number of general practitioners suspended from work in England because of concerns about their professional practice almost halved last year, but the time they spent away from work while suspended rose, new figures from the National Clinical Assessment Service (NCAS) show.1 Forty five GPs were suspended from work in the NHS in 2011-12 (down from 84 the previous year), equivalent to around one GP for every 900 in the workforce. A similar fall in GP suspensions …

GMC and NCAS agree responsibilities for their advisers ahead of revalidation

The General Medical Council (GMC) and the National Clinical Assessment Service (NCAS) have agreed a set of five joint principles in a bid to clarify their respective roles for dealing with doctors with performance concerns. The principles, which are set out in a memorandum of understanding, are intended to govern the relationship between NCAS …

National Clinical Assessment Service to join NHS Litigation Authority

The National Clinical Assessment Service (NCAS), which works with NHS organisations to resolve concerns about doctors’ performance, is to join the NHS Litigation Authority, the Department of Health has announced. The service will become an operating division of the authority from April next year, when its agreed one year hosting by the National Institute for Health and Clinical Excellence comes to an end. BMJ Careers understands that several options were considered but that the NHS Litigation Authority was deemed the most appropriate location for the service, which had previously …

Guidance is published on dealing with concerns about a doctor’s behaviour

The National Clinical Assessment Service (NCAS) has published new best practice guidance to help NHS organisations deal effectively with concerns about a doctor’s behaviour. NCAS advises healthcare managers and NHS organisations on how to deal locally with concerns about the performance of doctors, dentists, and pharmacists. More than half (57%) of the 3000 cases referred to it between December 2007 and October 2010 had some type of behaviour or conduct …

Which clinical errors lead to referral of paediatricians to the national clinical assessment service?

Aim To determine which clinical errors lead to the referral of paediatricians to the National Clinical Assessment Service (NCAS). This information could result in improvements in medical training and to fewer errors being made. Methods Data for the 10 year period from 1/4/01-31/3/11 was analysed. Every referral is summarised in the first letter from the NCAS adviser to the referrer. These letters were examined. Referrals are broadly classified into clinical, behavioural and health issues relating to the medical practitioner. Clinical referrals can be general, relating to general deficiencies in knowledge and skills, or specific and concerned with a critical incident. Specific clinical referrals were identified and analysed. Results There were 259 paediatric cases in this period. There were 110 (42%) clinical concerns in the 259 cases. In 47 (43%) of the 110 cases these were general concerns. There were therefore 63 cases where specific clinical concerns had led to the referral. In 16 (25%) of the 63 cases a patient had died. The clinical incidents that led to referral to NCAS were: prescribing errors 13, diagnosis other than child protection cases 12, management of child protection cases 10, diagnosis in child protection cases 9, treatment incidents 7, difficulties with transfer of a patient to another unit 6, poor resuscitation 4 and slow response to an emergency 2. Over half, 56%, of clinical concerns related to a consultant paediatrician. Conclusion This analysis reveals some different errors to those in other studies of paediatric litigation and complaints. Mistakes in child protection cases were the commonest reason for referral to NCAS. Prescribing errors were the second commonest cause. Difficulties in the diagnosis and treatment of a range of different conditions accounted for the next biggest group of referrals. Interestingly, problems with the transfer of patients to other units were a further cause for referrals as was inadequate resuscitation. This study helps highlight areas of paediatrics, such as child protection and prescribing, where training needs to be improved in order to improve patient safety.

Fall in suspensions of GPs could be due to disorder during reforms

The number of GPs who were suspended from work fell in the first half of 2011-12 for the first time in England since 2005, possibly as a result of less vigilant monitoring of performance in primary care during implementation of the government’s changes to the NHS, the National Clinical Assessment Service has said. A total of 24 new suspensions were initiated between April and September 2011, down from 42 in the same period in 2010 and 43 from April to September …

Which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service?

The aim of this study was to determine which clinical errors lead to the referral of UK paediatricians to the National Clinical Assessment Service (NCAS). Data for the 10-year period from 1 April 2001 to 31 March 2011 were analysed. Referrals are classified into clinical, behavioural and health related. Clinical referrals can be general, relating to general deficiencies in knowledge and skills, or specific and concerned with a critical incident. Specific clinical referrals were analysed. There were 259 paediatric cases in this period. There were 110 (42 %) clinical concerns in the 259 cases. In 47 of the 110 cases, these were general concerns. There were 63 cases where specific clinical concerns had led to the referral. These were: diagnosis and management of child protection cases, 19; prescribing errors, 13; diagnosis other than child protection cases, 12; treatment incidents, 7; difficulties with transfer of a patient to another unit, 6; poor resuscitation, 4; and slow response to an emergency, 2. In 16 of the cases, the patient died. This analysis reveals some different errors to those in other studies of paediatric litigation and complaints. Mistakes in child protection cases were the commonest reason for referral to NCAS. Prescribing errors were the second commonest cause. Difficulties in the diagnosis and treatment of a range of different conditions accounted for the next biggest group of referrals. This study helps highlight areas of paediatrics, such as child protection and prescribing, where training needs to be improved in order to improve patient safety.

Dysfunctional doctors – will revalidation help?

Numbers of National Clinical Assessment Service referrals concerning practitioners' performance are much higher for the over-50s, especially in GPs. In 20% of cases there are concerns with diagnosis that are unlikely to be recognised by revalidation. Accurate and timely diagnosis is fundamental to patient safety, and the results of studies in which GPs were tested using mystery patients are not encouraging. We need to assess pratictioners' competencies in diagnosis throughout their careers. Plans to extend working life may require changes to the clinical responsibilities of older doctors.

Supporting doctors: the National Clinical Assessment Service

Many doctors do not know what the NCAS is—that doesn’t mean it doesn’t know them. Paul Dinsdale investigates

Factors that might undermine the validity of patient and multi-source feedback

Multi-source feedback (MSF) and patient feedback (PF) are used increasingly around the world to assess and quality-assure clinical practice. However, concerns about the evidence for their utility pertain to their ability to identify poor performance, the impact of allowing assessees to select their own assessors and the many confounders that may undermine validity. This study was conducted in conjunction with the National Clinical Assessment Service (NCAS) in the UK and used established MSF and PF instruments to assess doctors in potential difficulty. Multi-source feedback assessors were nominated by both the practitioner (Pnom) and the referring body (RBnom). Demographics were collected to elucidate any differences found. Ratings generated by MSF and PF were compared with one another and with findings of a previous study that provided a normative cohort. Using MSF, NCAS-assessed doctors scored significantly lower than the reference cohort. Nineteen (28%) NCAS-assessed doctors achieved scores that were less than satisfactory. This rose to 50% when only RBnom assessors were used. Overall, ratings awarded by RBnom assessors were significantly lower than those awarded by Pnom assessors. Collected demographics did not help to explain the difference. Only one NCAS-assessed doctor scored below average according to PF. Doctors in the NCAS-assessed group did not score significantly lower than the reference cohort in PF. Doctor assessment scores awarded by patients were significantly higher than those awarded by colleagues. Although colleagues appear to report poor performance using MSF, patients fail to report concurrent findings. This challenges the validity of PF as it is currently constructed. Scores in MSF differ significantly depending on whether they are practitioner- or third party-nominated. Previously recognised confounding factors do not help to explain this difference.

An investigation into the numbers of dentists from 19 European Economic Area (EEA) member states currently registered to work in the United Kingdom and key differences between the practise of dentistry in the UK and their member states of origin

The aim of this short communication is to highlight the numbers of non-UK EEA qualified dentists currently registered with the General Dental Council (GDC) and to present a brief overview of the systems for the provision of oral healthcare in the non-UK EEA member states identifying differences in practise. The relevant data were gathered for the National Clinical Assessment Service (NCAS) as part of a wider project. It was found that at 31 December 2010, 28% of dentists registered with the GDC had not qualified in the UK. Of these more than 6,300 were European Economic Area (EEA) dentists with non-UK qualifications. The nature of their practise varied widely from member state to member state. The implications of these findings are discussed briefly.

Sharp drop in referrals to National Clinical Assessment Service

Sharp drop in referrals to National Clinical Assessment Service

Addressing performance concerns

Aim: To assess the impact of the National Clinical Assessment Service (NCAS) on governance activity for medical and dental practitioners in Northern Ireland. Method: Telephone interviews were conducted with a purposive sample of referrers to NCAS in Northern Ireland. Results: Twenty-two referrers agreed to take part and nineteen were interviewed. Respondents held a range of positions, including senior human resources personnel, but the majority were Medical Directors or Clinical Directors. The majority of referrals were for issues related to clinical competence, although this frequently overlapped with behavioural, health and probity issues. As well as automatically-triggered referral as part of disciplinary cases, reasons for seeking input from NCAS included seeking reassurance, expertise and objective advice. In some cases, employers reached their limits with a case, and NCAS filled the ‘governance gap‘ between local and regulatory responsibility. All respondents expressed satisfaction with the service and found NCAS to be approachable, accessible and neutral. Some challenges remained in handling performance concerns. These included: achieving a balance between patient safety, service delivery and responsibility to the practitioner in question; initial contact with the practitioner; and challenges in identifying and managing performance concerns indoctors who were not located with a long-term employer (i.e. trainees and locums). Conclusion: NCAS has value as an independent non-regulatory body in addressing performance concerns, and could have a positive future role in supporting the regulatory process of revalidation