senior health professional’s perceptions of variations in medical practice: a qualitative and...

Senior health professional's perceptions of variationsin medical practice: a qualitative and quantitative study

Allen Hutchinson,1 Aileen McIntosh,1 Melanie Williams2 & Rosaline S Barbour3

Summary Following the introduction of the UK Gen-

eral Medical Council's regulations on the handling of

poor medical performance, an interview and survey

study was carried out among senior health professionals

in the National Health Service (NHS). The aims of the

study were to explore the respondents' perceptions of

poor medical performance and to seek their experience

of handling poorly performing doctors. Sixteen inter-

views were held face to face, followed by 28 telephone

interviews. Subsequently, using similar questions to

those in the interview schedule, a survey was carried out

among senior health professionals across the NHS.

Interview results identi®ed a number of barriers to

resolving poor performance, such as the unwillingness

of some doctors to seeek advice and the protective

culture which prevented complaints being made against

doctors. Survey respondents had high standards by

which they judged poor performance, but they were

more hesitant about considering poor consultation

skills as being of the same signi®cance as poor technical

skills. However, problems with communication skills

were the most frequently reported type of poor per-

formance. The new arrangements for handling NHS

doctors whose performance is perceived to be poor have

much to do to overcome the barriers to effective action

expressed by the respondents in this study.

Keywords Doctors, NHS, performance

Medical Education 2001;35(Suppl. 1):45±51

Introduction

The 8-year period covering the introduction and imple-

mentation of the General Medical Council's (GMC's)

Performance Procedures1 has seen considerable changes

affecting the self-regulation of British doctors.

Criticism of the way in which the medical profession

has handled the poor performance of doctors initially

centred on the organizational capacity of the National

Health Service (NHS) to manage the problem. The

quasi-regulatory, locally managed means of handling

poor performance (known as the `three wise men' sys-

tem) was criticized by Rosenthal2 as being ineffective and

frustrating for patients and NHS staff alike. Concerned

commentators such as Donaldson3 began to identify

features of poor performance and this research was

supported by international reviews,4 which demon-

strated that the problem was faced by many developed

health care systems, whatever their funding basis.

Following the introduction of Performance Proce-

dures of the GMC, which came into force in July

1997, a number of surveys were undertaken among

NHS professionals with the aim of informing decision

makers about perceptions of poor practice and poss-

ible means of addressing clinical variation. Thus,

McManus and colleagues5 asked a random sample of

doctors about their views of the criteria in Good

Medical Practice6 (the GMC's basic guidance on

professional practice). In a survey of the methods that

health authorities use to `assist doctors whose

performance gives cause for concern', Rotherham and

colleagues7 gathered information by questionnaire and

interview about the criteria that health authorities

might use to identify General Practitioners (GPs) who

may be under-performing. The authors used the re-

sults to make suggestions about the systems, which

might be put in place to prevent the development of

poor performance and to avoid the need to refer a

poorly performing GP to the GMC.

The importance of these studies was underlined by

a series of serious incidents in the NHS, occurring

after the introduction of the GMC Performance

1School of Health and Related Research, University of Shef®eld2Department of Health Sciences, University of York3Department of General Practice, University of Glasgow

Correspondence: Professor A. Hutchinson, School of Health and Related

Research, University of Shef®eld, Regent Court, 30 Regent Street,

Shef®eld S1 4DA, UK, E-mail: allen.hutchinson@shef®eld.ac.uk

Original article

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35(Suppl. 1):45±51 45

Procedures,8 which subsequently led to proposals

for reducing adverse events in the NHS9 and to the

introduction of systems for reviewing the practice of

individuals and institutions.10

The study reported here examined the perceptions

and views of senior health professionals, both medical

and non-medical, on what they saw as being poor

performance, and of their experience of handling poorly

performing doctors. Commissioned by the GMC in

1997, the research was undertaken in the period

immediately after the introduction of the Performance

Procedures.

Methods

Research approach

This study was undertaken in three stages. First, a

number of semistructured interviews were undertaken

to gain insight into variation in clinical performance

and to develop an interview schedule for the main

quantitative study. Second, a limited number of struc-

tured telephone interviews were undertaken following a

short pilot study, to gather further views and validate/

triangulate the ®rst phase. The data collected here were

both quantitative and qualitative. Third, a national

postal survey was undertaken.

Face-to-face interviews

The interview approach was deemed to be the most

appropriate method of identifying the issues to be

covered in the postal survey. Following a literature

review and assessment of current knowledge in this

area, an interview schedule was developed. Purposive

sampling was used to select a range of participants that

would satisfy the spread of experiences that were likely

to be found nationwide.11 In some instances partici-

pants held dual roles and this helped to cover the issues

from several viewpoints. Participants comprised senior

health service professionals involved in complaints,

disciplinary procedures, education or retraining for

doctors, including; directors of public health, GP

medical advisers, NHS complaints managers, medical

directors of hospital trusts, local medical committee

medical secretaries (the of®cers of the statutory body

representing GPs in the NHS) and chief of®cers from

the community health councils. Sixteen respondents

were interviewed from the Northern and Yorkshire and

Trent NHS regions of England. All interviews were

fully transcribed.

Themes, categories and subcategories were identi®ed

from the analysis of the interviews.12 Following this

analysis a structured telephone interview schedule was

developed and piloted with six senior NHS staff, for use

in the second stage of the study.

Telephone interviews

Twenty-eight structured telephone interviews were

undertaken in order to further explore themes and

issues that arose from the initial interviews, and to

provide a means of triangulation. This phase of the

study was UK-wide, using random quota sampling

in four of the eight English health regions, Northern

Ireland, Wales and Scotland, to provide coverage of a

range of roles and types of hospital trusts.

All but the ®rst three interviewees were sent an

interview schedule. Additional notes were taken,

interviews were tape recorded and used to clarify points

in the analysis. Descriptive statistics were used in the

analysis and themes, subthemes and coding categories

were applied to the responses given to the open-ended

questions. This provided a basis for the development of

the national postal questionnaire.

Postal survey

All UK health authorities/boards and local medical

committees (LMCs) were included in the survey,

together with a random sample of »50% of hospital

trusts and »50% of community health councils

(CHCs). Participants in the interviews (both face to

face and telephone) were excluded, as were those in

health authorities in the north-west NHS region, who

had been involved in developing management guidance

on handling poorly performing GPs. In all 949 ques-

tionnaires were distributed.

Results

The ®ndings presented here are from the structured

telephone interviews and the postal questionnaires.

Findings from structured telephone interviews

When respondents discussed poor performance they

appeared to use two distinct de®nitions.

· The ®rst was the GMC de®nition, that is, poor

performance suf®cient to call into question a doc-

tor's registration, expressed through failure to meet

the requirements in Good Medical Practice.6

· The second could be called the `iceberg effect': that

is, poor performance that does not meet the GMC

de®nition but might be classed as `giving cause for

Ó Blackwell Science Ltd MEDICAL EDUCATION 2001;35(Suppl. 1):45±51

Senior health professional's perceptions · A Hutchinson et al.46

concern'.7 This might be quite a broad spectrum of

situations that are dif®cult to classify without dis-

crete examples, but where there are expressions of

concern among health professionals, patients or their

representatives over aspects of a doctor's practice

over a period of time.

Another aspect that made de®ning poor performance

problematic for respondents was the distinction

between public and professional de®nitions of poor

performance, particularly in terms of where the

boundaries of poor performance were in relation to

other aspects of clinical practice and performance, such

as clinical decision making. For example, there can be

differences of perception if a particular clinical decision,

recognized to be of reasonable quality by colleagues,

leads to different (especially poorer) outcomes than

expected. A CHC chief of®cer explained that `to a lay

person a clinical decision may be poor performance,

but it isn't'.

Similarly, the issue of consistency in terms of criteria

for poor performance could also be problematic. Many of

the medically quali®ed respondents discussed a key

distinction: `there's a difference between making mis-

takes and poor performance'. While there is a recognition

that mistakes are always possible in clinical practice,9

poor performance usually involves a pattern of events.

Thus, the boundaries of poor performance are not

always clear to all of those involved, which can cause

problems in the subsequent management of the issue.

Types of poor performance

The 28 interview respondents were asked to comment

directly on ®ve areas of poor performance, manner and

attitude, communication, prescribing and diagnosis.

Interview responses re¯ected high standards in rela-

tion to professional performance. Respondents were

asked `how important' did they think the ®ve

performance areas were, in relation to its impact on

general patterns of professional performance. The

majority of respondents (23 of 28) answered `very

important' or `quite important' for the performance

areas they had encountered. However, there were some

notable exceptions with four of the remaining ®ve

respondents holding different views. In addition, two

respondents applied mitigating factors to the mainten-

ance of high professional standards. A CHC chief

of®cer stated that ìn a very deprived area with high

morbidity problems, GPs have to be skilled in all areas'.

A medical director of a mental health trust that

frequently relied on locum support quali®ed his

remarks, saying that àll are serious but we have to be

realistic. Availability is a factor, do we have no doctor or

do we have a doctor who'll do?'

Respondents were asked whether a consistent and

serious error in any one of the ®ve performance areas

would constitute poor performance. Seventeen of the

28 respondents were less certain about de®ning the

consultation skills of manner and attitude, and

communication as poor performance. This is despite

the ®ndings that problems with consultation skills

of manner and attitude, and communication were fre-

quently encountered by respondents. A health

authority complaints manager stated that communica-

tion was `the basis of most of the complaints that come

through', identifying consultation skills as the most

frequently encountered type of poor performance. A

number of comments were made to explain this hesit-

ancy. It was felt to be more dif®cult to demonstrate

serious and consistent errors in manner and attitude,

and communication. For example, a hospital medical

director considered these areas `more vague and harder

to demonstrate' than technical skills. An LMC chair

stated that errors in consultation skills òught to' be

considered poor performance but `whether they do or

not remains to be seen'. Respondents were equally

hesitant about triggering a local investigation or refer-

ring errors in consultation skills to the GMC.

Handling poor performance

Formal mechanisms

Interview respondents were asked whether, in the last

two years, they had used the formal mechanisms listed

in Table 1 to handle poor performance.

Overall the use of formal mechanisms was not very

common. Only two of the 28 respondents (both med-

ical directors) had held discussions with the appropriate

royal college regarding a poorly performing doctor and

one respondent (LMC secretary and locum GP) had

used the educational route and talked to the regional

adviser in general practice.

A quarter of the respondents (one non-medical and

six medical) had never used any of the formal

mechanisms upon which they were asked to com-

ment. A CHC chief of®cer felt unable to respond,

Table 1 Respondents were asked if they had used any of these

mechanisms

(1) Informal discussion (2) Work shifting

(3) Diverting patient ¯ow (4) Assigning easier cases

(5) Exporting the problem (6) Additional education and training

(7) `Three wise men' (8) Informal involvement of LMC

Senior health professional's perceptions · A Hutchinson et al. 47


being currently in the middle of procedures that might

or might not result in the use of formal procedures.

He said that things were at the stage where ìt's

somebody's perception ¼ it's not proved yet that that

is the case'.

The ability to use the formal mechanisms could also

be compromised if the ®nding from one GP medical

adviser were widespread; he claimed Ì don't know what

they are'.

Informal mechanisms

The use of informal mechanisms were cited more fre-

quently than were formal routes. The most frequently

used informal mechanisms were àn informal discus-

sion' and `providing additional education or retraining'.

Nineteen respondents had used these methods on at

least one occasion over the previous two years (see

Table 2). Early retirement was also an option that was

considered.

Barriers to resolving poor performance

Respondents identi®ed a number of barriers that

potentially prevented the successful handling and

resolution of poor performance. These barriers are

complex and interlinked, and demonstrate that some of

the informal and formal mechanisms for handling poor

performers may actually act as barriers to resolving

performance issues. In particular these include the

following.

Willingness of the doctor involved to seek advice

One respondent (GP principal, LMC chair and GP

Tutor) suggested that achieving a positive outcome was

often dependent on the attitude of the doctor con-

cerned. This respondent suggested that an unsatisfac-

tory outcome frequently occurred because, in terms of

attitude, Ìf they don't accept there is a problem, no

amount of education or retraining will make any

difference'. A GP medical adviser suggested that formal

and informal mechanisms could not address `person-

ality problems' and a Director of Public Health (DPH)

stated that, when handling poor performers `for

personality type problems, there's not a lot you can do

¼ you can't retrain for manner and attitude'. These

comments suggest that some poorly performing doctors

will not be open to the prospect of remedial action or

retraining, and that their poor performance is likely to

continue, despite efforts to address it.

Professional etiquette and changing medical culture

A reluctance of doctors to criticise their peers. A

medical director discussed the dif®culties of reporting

colleagues and the perception of `whistle-blowing' and

a DPH suggested that ìt's almost impossible to make a

complaint against a doctor'. One respondent demon-

strated defensiveness: ìt's us against the world and we

close ranks to protect each other'. However, a trust

medical director suggested that the culture was slowly

changing and doctors were more able to accept

reporting poor practice as a professional responsibility.

Structural issues in terms of organizations also helped

limit what could be achieved in terms of addressing

poor performance. A medical director (and consultant

doctor) discussed the problems of staff rotation which

meant that problems were often exported rather than

addressed:

some of my problems have been with doctors in their

®rst or second job who've had coping problems at

medical school and it hasn't been addressed at that

stage ¼ in terms of numbers for me, that has actually

been an issue ¼ they're on 6-month contracts so

there's a real risk that the problem ¼ is just exported

rather than dealt with ¼

Dissatisfaction with current mechanisms

A number of the respondents felt that the mechanisms

as a whole for handling poor performance were not

satisfactory. One respondent (LMC secretary and GP)

made the comment that the current approaches to the

management of poorly performing doctors are `not

very good ¼ things are swept under the carpet'. A

DPH suggested that `we have ways of tackling doctors

who are perceived to be inadequate which we've had

for a very long time and they don't work very well ¼because ¼ it's very dif®cult to prove a doctor is

inadequate'. An assistant director of clinical and

professional performance described the complaints

procedure as `protracted, rather bureaucratic and not

Table 2 Number of interview respondents (medical) who had

used speci®c informal mechanisms to handle a poorly performing

doctor during 1996±98

Yes No

Informal discussion 19 9

Work-shifting 7 21

Diverting patient ¯ow 4 24

Assigning easier cases 6 22

Exporting the problem 5 23

Three wise men 8 20

Informal involvement of LMC 3 25

Additional education or retraining 15 13



terribly effective', while a medical director considered

it `hadn't been much use in handling poorly per-

forming doctors'. A DPH said that `none were

resolved to my satisfaction'. A CHC chief of®cer

stated that contacting the GMC was a `hopeless

experience' and that, from a patient perspective, no

satisfactory outcome was achieved.

The postal questionnaire study

An overall 48% response rate meant 457 questionnaires

were available for analysis. Sixty-eight per cent of

respondents were clinicians of whom 72% were provi-

ding regular care for patients, across the whole range of

specialities and general practice. In some health

authorities/boards and trusts there were responses from

more than one type of health professional, but there

were no signi®cant differences between responses from

different types of respondent within institution type.

The overall response rate of institutions was 68%.

Response rates by institution that gave at least one

response were: health authorities/boards 75%, trusts

69%, LMCs 71% and CHCs 56%. Results are dis-

played from the four types of institution, as they each

have different aspects of poor performance as their

priority (Tables 3±5).

Perceptions of poor performance

Respondents were asked whether, in their opinion, a

consistent and serious error in any one of ®ve areas of

clinical practice would constitute poor performance

(Table 3). Almost all respondents stated de®nitely yes

or yes when considering prescribing, diagnosis and

outcome. However, respondents were less certain

about clearly de®ning consultation skills of manner and

attitude, and communication as poor performance,

despite stating that these are the most frequently

encountered performance problems (Table 4). It may

be that the variation in rates of encountering

performance problems is partly determined by roles,

for example the role of the community health council

as patient advocate.

Management of doctors with serious and consistent

errors of performance

Respondents were asked: should a consistent and ser-

ious error in any of a number of areas (listed in

Table 2) trigger a local investigation? and if that local

investigation fails to resolve poor performance, should

referral under the GMC Performance Procedures be

considered?

Table 3 Percentage of respondents who considered that a consistent and serious error in areas of clinical practice may constitute poor

performance, strati®ed by employing organization

Manner and

attitude (%)

Communication

(%)

Prescribing

(%)

Diagnosis

(%)

Management

and outcome (%)

Health authority (n � 134) 75 82 95 98 98

Trust (n � 182) 81 89 98 98 98

Community health council (n � 67) 88 91 97 98 97

Local medical committee (n � 73) 66 88 96 99 97

Table 4 Number of respondents who

encountered speci®c performance

problems in the last two years, in general

practice and hospital practice, ranked by

frequency of experience of problem

(percentages in parentheses)

General practice Hospital practice

HA

(n � 134)

CHC

(n � 67)

LMC

(n � 73)

HA

(n � 134)

CHC

(n � 67)

Trust

(n � 182)

Manner and attitude 119 (89) 63 (94) 63 (86) 58 (43) 65 (97) 167 (92)

Communication 110 (82) 63 (94) 54 (74) 58 (43) 65 (97) 166 (91)

Diagnosis 92 (69) 59 (88) 48 (66) 35 (26) 60 (90) 91 (50)

Prescribing 96 (72) 47 (70) 45 (62) 42 (31) 38 (57) 71 (39)

Management and

outcome

98 (73) 52 (78) 44 (60) 47 (35) 61 (91) 129 (71)

HA ± health authority, CHC ± community health council, LMC ± local medical com-

mittees.



Results here showed a similar pattern to those

regarding perceptions of poor performance questions,

with reference to the relative importance attached to

speci®c areas of practice. For example, respondents in

51% of health authorities and 41% of trusts said prob-

ably yes to considering whether to trigger a local

investigation for manner and attitude while respondents

in 76% of health authorities and 83% of trusts said

de®nitely yes when considering clinical management and

outcome.

With regard to situations which involved the referral

of unresolved performance problems to the GMC, a

similar pattern emerged. Respondents demonstrated

more reservations about referring serious and consis-

tent errors in relation to the consultation skills of

manner and attitude and of communication than they

did with regard to referring technical skills.

Types of performance problems encountered

The most frequently encountered performance prob-

lems were related to consultation skills (Table 4).

Health authority and CHC respondents answered this

question less frequently in regard to hospital practice,

as the problem of poor performance is usually a matter

for the trust.

Experience of handling poorly performing doctors

Respondents were asked whether they had used any

formal or informal mechanisms (see Table 1) to handle a

poorly performing doctor over the preceding two years.

Formal mechanisms

About half of the institutions had used complaints or

disciplinary procedures in relation to a doctor in the

preceding two years. In addition, 55% of health

authorities, 43% of CHCs, 40% of LMCs and 19% of

trusts had referred to the GMC Health Procedures or

to Conduct Procedures on at least one occasion in that

time (Table 5).

Informal mechanisms

Informal discussion was one of the most frequently

used informal methods, as was providing additional

education and training and work shifting (Table 5).

Conclusion

The results from this study present the context of

perceptions about good practice in the NHS, and some

of the deviations from it, at the time when the GMC's

Performance Procedures were introduced.

Although accurate retrospective quanti®cation was

not possible to the extent of the potential performance

problems faced by the respondents, they clearly

considered that they were likely to see more related to

communication skills than to technical skills. Yet many

of the respondents clearly felt uneasy about classifying

persistent dif®culties with communication as meriting

calling a doctor's registration into question (one out-

come of referral to the GMC).

Perhaps this hesitancy re¯ects a concern over the

possible levels of what might be classed as poor

performance, for at any one time more than one de®-

nition may be in operation. The number (and propor-

tion) of doctors performing so poorly as to call into

question their GMC registration is widely perceived to

be small. However, there may be larger numbers of

doctors whose performance `gives cause for concern',

the term used by Rotherham and colleagues7 to

describe doctors who might be perceived to be failing

but for whom support might prove bene®cial. Within

the NHS there are now new structures being put in

place to identify and assess such doctors through clin-

ical governance arrangements and the National Clinical

Assessment Authority.12

Respondents' hesitation to classify inadequate

communication skills as poor performance may also be

related to their perception that interventions aimed at

improving doctors' attitudes and manner are likely to

have only limited success. New mechanisms will have to

address some of the dissatisfactions about the formal and

informal mechanisms that have until recently been used

to handle poor performance. Both clinical and non-

clinical respondents voiced concerns about the inad-

equate process and outcomes of current methods of

handling poor performance, or performance which gives

cause for concern, pointing out that what may be

regarded by some as a `successful outcome' does not

necessarily mean that the procedures work well. How-

ever, it may be that the high expectations of the

respondents area factor in their feelingsofdissatisfaction.

Table 5 Proportions of survey respondents who had used speci®c

informal mechanisms to handle a poorly performing doctor during

1996±98

Health authority

(n � 134)

Trust

(n � 182)

LMC

(n � 73)

Informal discussion 89% 90% 82%

Additional education 50% 51% 23%

Work shifting 43% 49% 41%

Three wise men 32% 25% 32%

Diverting patients 18%



Three main barriers to managing poor performance

were identi®ed. First there was a view that remedial

action is unlikely to successfully address a poor attitude

towards professional performance. Second, that

professional etiquette makes it very dif®cult for doctors

to criticize their peers. Third, that existing handling

mechanisms and procedures, such as staff rotation, can

make it dif®cult to resolve successfully poor perform-

ance; there is a real danger that the problem is simply

exported.

The new arrangements for handling doctors in the

NHS whose performance is perceived to be poor have

much to do to overcome the barriers perceived by the

respondents in this study.

Acknowledgements

Our thanks are due to all those who responded to our

requests for help with interviews and with question-

naires and to the GMC for funding support.

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