Title: Remediating doctors’ performance to restore patient safety: A realist review
Funder: Department of Health and Social Care

Abstract: Introduction Tackling underperformance in doctors has been at the centre of recent regulatory reform. Introduced as a statutory requirement in 2012, medical revalidation is the process whereby all UK doctors demonstrate to the regulator (the General Medical Council (GMC)) that they are fit to practise through submitting evidence every five years from their annual performance appraisal.(1) Early evidence suggests that revalidation is helping to identify poor performance(2, 3) and healthcare organisations have a statutory responsibility to ensure that remediation is available for these doctors.(4) While patients should, rightly, expect doctors who are incompetent to be stopped from practising; the wider issue that is more difficult to address is doctors who underperform. For these doctors, the accepted appropriate course of action is remediation, i.e. remedying the underperformance through reskilling or rehabilitation, and wherever possible returning the doctor to safe practice. Yet the evidence base for remediation remains exceptionally poor. The most recent systematic review, by Cleland and colleagues in 2013, found that the existing body of literature on remediation gave, “no insight into what types of extra support work, or how much extra teaching is critical, in terms of developing learning”. Aim To identify why, how, in what contexts, for whom and to what extent remediation works for practising doctors, to support patient safety. Objectives 1. To conduct a realist review to understand how interventions to remediate doctors produce their effects. 2. To provide recommendations on tailoring, implementation and design strategies to improve remediation interventions for doctors. Methods Remediation is a complex intervention and realist reviews have been established as an appropriate method of evidence synthesis to explore such complexity. Underpinning a realist enquiry is the generative model of causality, which holds that to infer a causal outcome between any two events requires an understanding of the “causal mechanisms that connect them and the context in which relationships occur”.(5) Remediation activities take place against the background of a range of contexts (e.g. broad political context, regional setting, participant characteristics, etc.), some of which will affect the outcomes. Mechanisms are the way in which an activity’s resources or opportunities interact with the reasoning of individuals and lead to outcomes such as changes in behaviour.(6) By developing and testing a model of how remediation works (a programme theory), the realist review will uncover the underlying mechanisms at work in remediation activity and the contexts that determine how these mechanisms operate to produce desired or undesired outcomes. This study will be conducted with stakeholder input, including the NHS’s advisory and remediation service, NCAS. Outputs The outputs of this study will be: 1) a firm evidence base, including evidence of best practice, that can be used to guide and shape remediation practice in NHS organisations and in particular the development of NCAS remediation and professional support services; 2) the establishment of a professional collaboration with NCAS and other stakeholders for future remediation research; 3) the basis for further empirical research using a full realist evaluation for which we will seek additional funding upon completion of the review.

Lay abstract: The human cost of a failing doctor is difficult to measure but it is estimated that nearly 12,000 patients die in England each year as a result of preventable medical errors. All of us, as patients, expect our doctors to be competent. If they are not, we expect the doctors to be stopped from practising. The General Medical Council has powers to do this. However, there is a wider problem that is more difficult to address: doctors who underperform. For this group of doctors, they do not need to stop practising but, to keep patients safe, they need help. This could be through retraining in a certain area, or perhaps addressing underlying physical or mental health problems. Bringing a doctor’s performance back up to an acceptable standard is called remediation. It is thought that, at some point in their careers, around 18,000 doctors fall below the standards that are expected of them. It is only fair that they be given the opportunity to improve their performance. Also, there is a shortage of doctors in the NHS and a fully trained doctor will have cost the taxpayer around £500,000 to train. Therefore, the success of a remediation programme in improving the performance of an underperforming doctor is important for patient safety and for workforce planning in the NHS. Remediation covers a range of interventions aimed at improving doctor performance, from a ‘quiet word in the ear’ to more formalised training programmes. Yet it is widely recognised that we do not know enough about whether and how these remediation programmes work. The aim of this study is, therefore, to identify not just which kinds of remediation programme work, but also why, how and for whom they work. To answer these questions, we shall use a method of examining existing evidence known as a ‘realist review’. A realist review works by building a model, known as a ‘programme theory’, that will show how remediation should work and why in some situations it does not. This model is then tested and retested using data from the literature so that the final product is a best-fit theory that can be used to guide policy and practice. Throughout the process of the review, we shall involve a stakeholder group made up of those professionals involved in delivering remediation for doctors, as well as representatives from patient groups. This will provide expert input to help develop the findings and make sure that they are relevant to developing policy and practice in the NHS. The findings of the review will be circulated and publicised by writing articles in internationally recognised journals and through delivering conference papers and workshops. Importantly, the research will be conducted in collaboration with the National Clinical Assessment Service (NCAS), an NHS body that assesses doctor performance and assists with remediation planning. The review will contribute to the ongoing development and evaluation of NCAS’s advice, guidance and assessment services on remediation and will, therefore, shape the conduct of remediation programmes for practising doctors in NHS organisations.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE