Trends from Practitioner Performance Advice’s support of the management of exclusions in England

This Insights publication features NHS Resolution’s Practitioner Performance Advice service’s (Advice) annual analysis of trends in the exclusions of practitioners, drawing upon our unique perspective on exclusions of NHS doctors and dentists working within secondary care. This publication represents our annual commitment to share learning and provide guidance to inform decisions around exclusion.

Exclusion is designed as a temporary measure to remove a practitioner from their usual place of work until the nature and cause of a performance concern is understood and while an investigation is carried out. Maintaining High Professional Standards in the Modern NHS (MHPS), which is mandatory for non-foundation trusts and has been adopted by many foundation trusts, acknowledges that there are circumstances where exclusion may be necessary to either:

• protect the interests of patients or other staff, and/or
• assist the investigative process where there is a clear risk that the practitioner’s presence would impede the gathering of evidence.

We analysed 468 episodes of formal exclusion that commenced in the financial years (FY) 2019/20 to 2023/24 in England, where Advice was contacted to advise on individual episodes of exclusion.

Key headlines

• The number of exclusions per year has remained broadly consistent over the reporting period. Over the reporting period there was an average of 93.6 episodes per financial year.
• The duration of exclusions decreased over this reporting period. At the end of FY 2023/24 the average duration of ongoing exclusions was 5.5 months, compared with 7.8 months at the beginning of FY 2022/2023.
• Eighty percent of exclusion episodes which ended during this reporting period were under six months in duration. MHPS states that normally there should be a maximum limit of six months exclusion except for those cases involving criminal investigations.
• Consistent with previous years’ analysis, groups of doctors and dentists who are statistically more likely to be excluded are male, aged 65 and over or from Asian or Asian British, Black or Black British or Mixed ethnic groups.
• This year we have included analysis around place of qualification and found those who qualified outside the UK and European Economic Area (EEA) were statistically more likely to be excluded.
• Specialty and Specialist (SAS) grade doctors and doctors working in the specialties of obstetrics and gynaecology, emergency medicine, or surgery are statistically more likely to be excluded.
• For exclusion episodes which began and concluded between 2019/20 to 2023/24, 29% of practitioners returned to clinical practice on a restricted basis, with 18% returning to unrestricted practice. In 30% of episodes the exclusion ended when the practitioner left the organisation and 23% concluded for a different reason, including the practitioner’s move from exclusion to sick leave.

Key actions for managers of performance concerns

• To contact Advice when considering excluding a practitioner’s practice. Our team of experienced Advisers can offer impartial and objective advice to provide assurance that exclusion is used appropriately, proportionately and fairly in the NHS and the independent sector. 
• To adopt the use of our exclusions decisions flowchart and additional resources to support best practice when documenting and managing exclusions.
• To ensure ongoing exclusions are reviewed at least every four weeks to consider whether the reasons for the exclusion remain valid and to understand and address any delays in the investigation. This review should also incorporate a meeting with the practitioner to inform them of progress and any delays.
• To ensure that your designated board member is informed of all exclusions of practitioners and provided with regular updates on progress.
• If you are responsible for the management/oversight of concerns about individual clinicians at a secondary care trust, you can request your Advice organisational activity report (OAR). This service helps to identify patterns and issues in cases where performance concerns have arisen, including exclusion cases, and provides insight to strengthen local performance management and improve frontline understanding of the causes of concerns. You can discuss your report with your organisation’s Link Adviser who will provide an independent view on your report, drawing on their experience and expertise in performance management.

Five years of exclusion episodes in England (2019/20 – 2023/24)

• 468 total number of formal exclusion episodes

• 93.6 average number of formal exclusion episodes per financial year

• 97% of exclusion episodes involved doctors

• 3% of exclusion episodes involved dentists

Groups more likely to be excluded

Consistent with previous years’ analysis the following groups of practitioners were more likely to be excluded than would be expected given the population of doctors and dentists:

The groups described were found to be significantly more likely to be excluded using appropriate statistical tests. Where the likelihood of exclusion is expressed numerically this is based upon the overall population of doctors and dentists and adjusted for the relative size of individual groups within the overall population.

*Gender
Male practitioners were 5.1 times more likely to be excluded.

**Age
Younger practitioners were less likely to be excluded and older doctors more likely to be excluded, with the 65 and older age band 1.9 times more likely to be excluded.

***Ethnicity
Practitioners from ethnic minority groups were more likely to be excluded than white practitioners. Practitioners from Asian/Asian British and Mixed Ethnicity groups were both 1.6 times more likely to be excluded. Practitioners from Black/Black British group were 1.4 times more likely to be excluded.

****Place of qualification
Practitioners who qualified outside of the UK and EEA were 2 times more likely to be excluded.

*****Grade
SAS doctors/dentists practitioners were 1.6 times more likely to be excluded.

******Specialty
Obstetrics & Gynaecology, Emergency Medicine and Surgery were the three speciality groups from which doctors were most likely to be excluded.

Redressing disproportionate rates of disciplinary action between practitioners from ethnic minority groups and white staff across the healthcare system is essential to fostering a just system that supports staff to learn from incidents. Advice is committed to supporting the fair management and resolution of concerns through our range of services and the ‘Just and learning culture charter’ included in our publication Being fair 2¹.

Healthcare employers are also encouraged to review our research into the lived experience of ethnic minority and international medical graduate (IMG) practitioners² who are the subject of performance concerns referred to us and consider the findings and resources in the context of their own processes for the fair management of performance concerns and building positive organisational culture. Our engagement with healthcare partners on this research identified a number of activities relevant to our equality, diversity and inclusion (EDI) work that complement the objective of a better and fairer experience for ethnic minority and IMG practitioners who are the subject of performance concerns.

In collaboration with NHS England’s Professional Standards Team, we have also developed, a comprehensive framework for employers to identify the key considerations to promote fairness, proportionality and consistency in their decision making when managing and resolving performance concerns for all practitioners. 

The costs of exclusion to the practitioner and healthcare service are significant. The disproportionate use of formal procedures in certain cohorts of practitioners³ and the profound impact on practitioners that are subject to these procedures means that all national bodies with a leadership role in resolving performance concerns are advocating local informal resolution first.

Our expert view on informal resolution⁴ makes clear that such an approach is rooted in planned, thoughtful and documented engagement by the employer with the practitioner, to share concerns and explore the practitioner’s perspective. When performed with an engaged, reflective practitioner and with documented discussions and outcomes, an informal approach can resolve even the most significant concerns. This approach should not, however, ignore that patient safety is paramount and that exclusion can be necessary and the most appropriate measure to take.

Contacting Advice as early as possible to discuss concerns with your Link Adviser can support you in deciding the most appropriate way to manage a case and guide you in how to clearly document the rationale behind your decision. Our decisions flowchart is a valuable tool to ensure compliance with good practice when deciding whether exclusion is necessary and in communicating with the practitioner.

Trends in exclusions from financial years 2019/20 to 2023/24

Figure 1: Number of exclusion episodes (FYs 2019/20 to 2023/24)

Figure 1 shows number of exclusion episodes which commenced in England for each financial year (2019/20-2023/24).

* Includes exclusion episodes which commenced 2019/20-2023/24 for cases first opened with Advice in the same reporting period.

** Includes exclusion episodes which commenced 2019/20-2023/24, for cases which opened before the reporting period.

Figure 2: Number of exclusions comparative to Advice cases (FYs 2019-20 to 2023-24)

Figure 2 shows number of exclusion episodes commenced in comparison to the number of Advice cases received each financial year (2019/20 to 2023/24).

Figure 3: Rate of exclusions comparative to workforce (FYs 2019/20 to 2023/24)

Figure 3 shows financial year breakdown for rate of exclusion episode per 1,000 doctors and dentists (considering yearly workforce variation).

The number of exclusion episodes has remained broadly consistent across each financial year of the reporting period. Considered alongside the number of cases received each year which relate to practitioners working in secondary care, the number of exclusions do not appear to have a direct association with the number of cases received by Advice.

Figure 4: Outcomes for exclusions (FYs 2019/20 to 2023/24)

Figure 4 shows percentage breakdown from outcomes for all 447 exclusion episodes which concluded between 2019/20 – 2023/24 (and commenced in the same period). These outcomes relate to individual episodes of exclusion and are mutually exclusive. 

Figure 5: Exclusions which ended with return to practice (FYs 2019/20 to 2023/24) 

Figure 5 shows percentage breakdown from exclusions outcomes for all 208 exclusion episodes which concluded between 2019/20 – 2023/24 (and commenced in the same period) and ended with the practitioner returning to practice. These outcomes relate to individual episodes of exclusion and are mutually exclusive. 

Figure 6: Exclusions which ended with no return to practice (FYs 2019/20 to 2023/24) 

Figure 6 shows percentage breakdown from exclusions outcomes for all 137 exclusion episodes which concluded between 2019/20 – 2023/24 (and commenced in the same period) and ended with the practitioner not returning to practice. These outcomes relate to individual episodes of exclusion and are mutually exclusive. 

Figure 7: Outcome of exclusion episodes (percentages by financial year) FYs 2019-20 to 2023-24

Figure 7 shows percentage breakdown of outcomes in each financial year for all 447 exclusion episodes which concluded between 2019/20 – 2023/24 (and commenced in the same period). These outcomes relate to individual episodes of exclusion and are mutually exclusive. 

In over 40% of exclusions which concluded during the whole reporting period the practitioner returned to work (restricted or unrestricted) following exclusion. This has remained consistent across each of the five previous full financial years. In 2021/22, when we saw the highest number of exclusions during the reporting period, we also saw the highest proportion of practitioners returning to practice following exclusion. For over a quarter of all exclusions during the reporting period which ended with the practitioner’s return to work, they did so on a restricted basis.

Figure 8: Duration of exclusion episodes at end (FYs 2019/20 to 2023/24)

Figure 8 shows breakdown of duration of exclusion episodes at end for all 447 episodes which commenced in 2019/20 – 2023/24 in England and ended in the reporting period.

Figure 9: Average duration of ongoing exclusion episodes (by bi-monthly reporting periods)

Figure 9 shows bi-monthly breakdown of mean and median duration of ongoing exclusion episodes in England since April 2022 (when this data began being recorded).

Most exclusions which ended during the reporting period did so within six months or less, six months being the normal maximum limit for exclusion under MHPS. The average length of exclusions decreased over the reporting period. At the same time, it should be noted that a fifth of all exclusions which ended during this period exceeded the six-month limit, with 5% of all exclusions total taking 18 months or more to conclude. Forty percent of these exclusions involved criminal investigations, which can lead to prolonged exclusions until police investigations are concluded.

Our Insights on themes of our work during the COVID-19 pandemic also noted the delay this caused to investigations and hearings. Advice is committed to working with healthcare organisations to support the timely resolution of exclusion episodes. We regularly review with employers whether exclusion is still warranted or whether the risks can be mitigated in other ways. We particularly encourage employers to contact their Link Adviser before excluding a practitioner. They can help explore alternatives to exclusion.

Learning and resources from Advice to support best practice

Organisational knowledge of investigation processes and awareness of best practice can be key in managing exclusions and investigations. Advice has several educational offerings to aid healthcare organisations in this, including case studies that allow participants to explore good practice when considering exclusions. Our learning resources include an exclusions case studies – learning pack which we have used extensively with medical directors, HR staff and responsible officers and can be used in local CPD sessions.

We encourage organisations to incorporate our fairness and proportionality framework as a documented part of local case management. This framework may also provide a helpful tool to inform engagement and discussion with Advice. Alongside this framework we have also developed fictional case studies to illustrate how case management may be positively influenced by adopting the framework and to encourage discussion about how the framework could work in local contexts.

We also provide a number of training courses including Understanding and using MHPS (Maintaining High Professional Standards) effectively, Case Investigator, and Case Manager, as well as Compassionate Conversations, which is currently in phase two of its development prior to national launch. We are also preparing to launch a new workshop Board Level Assurance For Resolving Performance Concerns, this training covers both the Board’s responsibilities for assurance of performance concerns as well as specifically the role of the designated board member in performance management cases.

What should healthcare organisations do next?

We invite healthcare organisations to consider the findings of this Insight and how you engage with Advice with regards to the following:

• Do you contact Advice when considering exclusion? Whether exclusion is being considered or not, there is no threshold for contacting us, nor any restriction on contacting Advice in only those cases where formal procedures are invoked. For more information on formal and informal case management, please see our Expert View Insight from Sally Pearson, our Responsible Officer and HPAN Lead at NHS Resolution.
• Has your organisation adopted the exclusion resources made available by Advice to support best practice in the consideration and ongoing management of exclusions?  
• Could your organisation benefit from the training courses provided by Advice to improve the knowledge and skills required to manage exclusions and investigations?
• If you are interested in discussing your organisational activity report to reflect on themes and trends in your cases over time, please contact us at: nhsr.casesupport@nhs.net.

Our Insights publications share analysis and research which draw on our in-depth experience providing expert, impartial advice and interventions to healthcare organisations. By sharing these publications, we aim to support the healthcare system to better understand, manage and resolve concerns about doctors, dentists or pharmacists. All past reports are available from our Insights page.

If you are interested in hearing more about our research and Insights programme, please get in touch with us at nhsr.adviceresearchandevaluation@nhs.net.

If you’d like to learn more about our work and the services we offer, please visit our dedicated Practitioner Performance Advice webpages. Our Education service offers training courses to provide healthcare organisations with the knowledge and skills to identify and manage performance concerns locally.

Footnotes

¹ Being fair 2: Promoting a person-centred workplace that is compassionate, safe and fair (NHS Resolution, 2023).

² An exploration of the experiences of ethnic minority practitioners and International Medical Graduates of the management of concerns about their medical practice (NHS Resolution, 2024).

³ Equality, diversity and inclusion Targets, progress and priorities for 2024 (GMC, 2024).

⁴ Informal First – the value of informal resolution and how Advice can support you (NHS Resolution, 2024).