A definition of underperformance

There is no unchallengeable definition of the term 'underperforming doctor'. Indeed, seeking to determine whether an individual doctor is underperforming has kept legions of barristers in gainful employment at General Medical Council (GMC) Fitness to Practise panels for years.

Nevertheless, some sort of working definition is useful for individual doctors, employing authorities and for patients.

As a rule of thumb, an underperforming doctor is one who persistently fails to comply with the standards identified in the the GMC Handbook Good Medical Practice (GMP).¹

The most significant word in the above paragraph is 'persistently'. Since we are all human and we all have our off days it is impossible to comply with all the GMC standards all the time. The definition of an underperforming doctor must therefore capture the sense that such a doctor has a tendency to underperform on numerous occasions.

Experts providing reports to GMC screeners are asked a) whether the doctor's performance was of a standard that could be expected of a reasonably competent medical practitioner and b) whether any such deficiency was serious. The term 'reasonably competent' is itself difficult to define but is meant to emphasise that a doctor's performance should be judged against that of an average GP as they go about their daily business rather than that of an MRCGP examination candidate. 'Seriousness' again is a variable feast but is meant to encapsulate both the degree of deviation from acceptable standards and the harm that such deviation might bring to patients.

The Royal College of General Practitioners (RCGP) has expanded these issues further in its document Good Medical Practice for General Practitioners. This seeks to interpret how GMP applies to the everyday work of a GP. Using the GMP standards as its basis, it defines the characteristics of an exemplary GP, an excellent GP, a poor GP and an unacceptable GP.²

The duties of a doctor registered with the GMC¹

GMP identifies these as follows:

"Patients must be able to trust doctors with their lives and health. To justify that trust you must show respect for human life and you must:
• Make the care of your patient your first concern.
• Protect and promote the health of patients and the public.
• Provide a good standard of practice and care.
• Keep your professional knowledge and skills up to date.
• Recognise and work within the limits of your competence.
• Work with colleagues in the ways that best serve patients' interests.
• Treat patients as individuals and respect their dignity.
• Treat patients politely and considerately.
• Respect patients' right to confidentiality.
• Work in partnership with patients.
• Listen to patients and respond to their concerns and preferences.
• Give patients the information they want or need in a way they can understand.
• Respect patients' right to reach decisions with you about their treatment and care.
• Support patients in caring for themselves to improve and maintain their health.
• Be honest and open and act with integrity.
• Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.
• Never discriminate unfairly against patients or colleagues.
• Never abuse your patients' trust in you or the public's trust in the profession.
• You are personally accountable for your professional practice and must always be prepared to justify your decisions and actions."

Monitoring performance

The monitoring of performance can and should take place at many levels from the individual to the profession as a whole.

A very basic but important level is the individual clinician. Individual monitoring can be as simple as five minutes of self-reflection, mulling over the patients seen that session, over a cup of coffee. More formal methods such as the 'patient's unmet needs' (PUNs) and 'doctor's educational needs' (DENs) logs, individual audits and personal development plans (PDPs) are all tried and tested methods of gaining evidence suitable for external review.

At practice level, significant event analysis/serious untoward incident reporting³, discussion of near misses and informal exchange between members of the primary care team all create an environment in which the monitoring of professional standards should flourish. It was this very lack of inter-professional exchange which allowed Shipman to continue undetected for so long.⁴

Primary care organisations have had a limited role to play in the monitoring of individual practitioners but they are currently one of the bodies to whom the whistle-blower may first turn.⁵ Some, in the past, have attempted to draw up local standards of performance in conjunction with local medical committees. They are of course still the organisations which drive the appraisal process and the local clinical governance agenda and are the level at which Responsible Officers are intended to operate (see 'Revalidation', below). How all this will translate into the brave new world of primary care commissioning has yet to be determined.

Revalidation

This is the highest level of performance monitoring and is intended to apply to the profession as a whole. Originally envisaged as a two-stage process of reaccreditation and relicensing, the whole has been subsumed into the revalidation agenda. The GMC is committed to introduce the process in 2012 but there have been many hiccups along the way. For more information, see separate article Revalidation - Current State of Play.

The causes of a doctor to underperform cover a range of very different problems - for example:

• Personal:
  • Poor training for general practice.
  • Lack of continuing education.
  • Isolation from colleagues.
  • Physical health problems.
  • Mental health problems, including alcohol and drug abuse.
  • Stress related to work or to domestic situations.
  • Low morale.
  • Burnout.
  • Excessive workload.
• Practice:
  • Poor practice infrastructure.
  • Poor relationships within the practice.
  • Poor premises and facilities.
  • Financial pressures.
  • Inadequate staffing levels.

There is also a clear link between the health and wellbeing of a doctor with the organisation in which they work.⁶

Underperformance of a colleague

When a colleague underperforms, a judgement needs to be made in the same way as any other judgement made in general practice. A range of options should be considered and the risks and benefits of each evaluated. The least 'invasive' action would be a quiet chat with the person involved. They may have a perfectly reasonable explanation for their actions or they may be able to identify a system failure requiring a change of protocol which would affect the whole practice. The colleague may welcome an opportunity to 'offload'; or may see the approach as an unwarranted intrusion on their private and professional life.

Other options - which should be considered if there is the slightest risk to patient safety - would include approaching other members of the practice team (e.g. the practice manager or the senior partner), reporting the matter to the primary care organisation or contacting the GMC.

This situation is never easy and an unwarranted accusation unsupported by evidence may result in a counter-allegation which may result in the whistle-blower themselves getting into trouble. This is why, before embarking on any of these options, a call to one's medical defence organisation would be a wise move.

Document references

1. Good Medical Practice, General Medical Council; (website updated annually)
2. Good Medical Practice for General Practitioners, Royal College of General Practitioners (RCGP), July 2008
3. McKay J, Bradley N, Lough M, et al; A review of significant events analysed in general practice: implications for the BMC Fam Pract. 2009 Sep 1;10:61. [abstract]
4. The Shipman Inquiry; The Shipman Inquiry official site
5. Cox SJ, Holden JD; Presentation and outcome of clinical poor performance in one health district over Br J Gen Pract. 2009 May;59(562):344-8. [abstract]
6. Cohen D, Rhydderch M; Measuring a doctor's performance: personality, health and well-being. Occupational Medicine 2006 56(7):438-440.

Internet and further reading

• Revalidation prompts surge in referrals of underperforming doctors; BMJ Careers January 2011

Acknowledgements