Title: Optimising the delivery of existing professional support programmes for doctors: A participatory co-design and realist evaluation approach (RESTORE 2)
Funder: Department of Health and Social Care

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 mistakes in their treatment. As patients, we expect our doctors to be competent. If they are not, we expect them to be stopped from practising. However, there is a wider problem that is more difficult to fix. It is estimated that at any one time, around 6% (approx. 9,400) of hospital doctors in England may be underperforming. While they do not need to stop practising, they do need help to improve their work to keep patients safe. Returning a doctors’ performance to an acceptable standard is called remediation or professional support. We have decided to use the term professional support in our study as the term remediation is viewed negatively by doctors and NHS staff._x000D_ _x000D_ Professional support covers a range of activities from a ‘quiet word in the ear’ to more formal training. However, we do not know enough about how the different approaches to professional support work in the NHS. This could result in professional support being conducted ineffectively, wasting doctors’ time and taxpayers’ money, and still leaving patients at risk of medical mistakes. Professional support is also important for workforce planning. The NHS has a shortage of doctors and a fully trained doctor costs the taxpayer around £500k to train. Thus, doctors should be given all the support that they need to improve their performance, or we might lose them completely from the workforce._x000D_ _x000D_ We recently completed a project funded by the NHS to look at different types of professional support programmes. We wanted to find out which ones work, why and how they work, and for whom. This ‘RESTORE 1’ project looked at papers written across the world and produced recommendations giving practical advice to make professional support programmes better. For example, we recommended that doctors should be involved in planning what steps they need to take to improve the way they work so that they feel some ownership of the process. This will help them feel more motivated to change their behaviour to become better and safer doctors. _x000D_ _x000D_ In RESTORE 2, we will work with professional support teams at five NHS sites in the UK. Together with those teams, we will look at the recommendations from RESTORE 1 and identify what changes each would need to make to improve their local programme. The professional support team at each NHS site will then implement the changes, after which we will evaluate the modified programmes. Our study will produce two outputs that will be valuable and useful to the NHS:_x000D_ 1) a detailed understanding of how, why, for whom, in what context and to what extent professional support programmes work in NHS settings, and _x000D_ 2) an NHS-specific toolkit, that will enable any NHS professional support programme to improve the support services that it provides for underperforming doctors. By optimising professional support interventions for doctors, patient safety will be improved. _x000D_ _x000D_ The study will be assisted by two groups – one of patients and members of the public, the other of doctors and professional support staff. These groups will help us ensure that our findings make sense, and are relevant and useful to the people who have to implement them. They will also help us to spread the word about our work to a wide range of audiences. The findings of the study will be publicised within the NHS by providing professional support teams with user-friendly materials, and will be made available to academic audiences via journal publications and conferences.

Lay abstract: Background_x000D_ The safety of patients is at risk if a doctor is performing below expected standards. Remediation, or professional support (the term we are now using due to the negative connotation associated with the former term), is a set of interventions used globally to address doctors’ underperformance, whether this is identified externally or self-perceived. The successful professional support of doctors has a direct impact on patient safety and the retention of doctors in the workforce. Recognising the importance of this topic, the NIHR HS&DR funded our research team to complete a realist review of the remediation literature (RESTORE 1). The aim of this review was to understand what kinds of remediation programme work, why, how and for whom. To address this aim we developed a programme theory of how remediation interventions produce their effects. The review found that remediation interventions work when they develop doctors’ insight and motivation, and reinforce behaviour change. But, our review also identified significant knowledge gaps. Most studies were from North America: few focused on the UK NHS setting. There was also a lack of detailed high-quality data to effectively test the programme theory and, in particular, the potential contextual impacts on intervention effectiveness. While acknowledging these limitations, we developed a series of recommendations based on our programme theory of how the remediation of doctors produces its effects for those working to deliver remediation programmes._x000D_ _x000D_ Research Question_x000D_ How do we optimise the delivery of existing professional support programmes for doctors in the NHS through the use of evidence-based recommendations?_x000D_ _x000D_ Objectives_x000D_ 1. To use a participatory co-design approach to help NHS organisations incorporate evidence-based recommendations to optimise the delivery of existing professional support _x000D_ interventions for doctors_x000D_ 2. To use a realist approach to evaluate and learn from the use and impact of these recommendations on professional support interventions before and after implementation_x000D_ 3. To develop:_x000D_ a. NHS-specific recommendations for the optimisation of professional support programmes _x000D_ b.an ‘implementation toolkit’ for professional support programme leads in the NHS to improve their professional support programmes based on the NHS-specific recommendations._x000D_ _x000D_ Methods_x000D_ This project will use participatory research and realist evaluation approaches to generate primary data across five NHS Sites. The five sites were purposively sampled to involve specific groups of doctors including primary/secondary care, trainees and consultant/GP/SAS doctors. The research will involve three work packages (WPs). WP1 will involve working with each site to optimise the delivery of their existing professional support programme based on the RESTORE 1 ‘recommendations’ using observation and the development of an action plan. WP2 will involve a realist evaluation of the implemented action plan via semi-structured interviews. WP3 will use workshops to develop an ‘implementation toolkit’ containing NHS-specific recommendations to improve professional support programmes in the NHS. _x000D_ _x000D_ Timelines for delivery_x000D_ 30 months starting in July 2021. _x000D_ _x000D_ Anticipated impact and dissemination_x000D_ The study will directly improve the delivery of five professional support programmes in the UK. It will test and refine the programme theory of how professional support works and thereby provide more in-depth ‘recommendations’ for NHS professional support programmes. The findings will be disseminated via our links with stakeholders, a final report, high-impact peer-reviewed publications, presentations at key stakeholder meetings, and via conferences.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE