NHS Resolution have collaborated with NHS England’s Professional Standards Team to develop 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 framework has been reviewed for applicability to Wales and Northern Ireland.
The framework seeks to address five key areas (“the Principles”) in case management:
- Ensuring welfare and support
- Understanding the issues
- Ensuring the practitioner is heard
- Adherence to process
- Equity and proportionality
Background
This work supports the NHS People Plan’s ambition for more people to work in a compassionate and inclusive culture. Be that through processes managed under national policies, such as Maintaining High Professional Standards in the Modern NHS/HPSS in England and Northern Ireland respectively, Upholding Professional Standards in Wales, or through local policies of employing or contracting bodies, or in managing a practitioner’s inclusion on the Performers Lists. We recognise the strategic importance of delivering fair resolution and where possible, keeping healthcare staff out of formal processes to minimise distress and cost.
It has been widely reported how different practitioner groups can be disproportionately impacted by the application of local and national policies, processes and Regulations applied in the management of performance concerns. Our related report, Being Fair 2, aims to act as a resource for organisations looking to adopt a just culture when managing incidents and supporting staff, and refers to NHS England’s Just Culture Guide for staff to assess the appropriate response when an incident occurs. The Just Culture Guide has since been replaced by NHS England’s Being fair tool: supporting staff following a patient safety incident. This new set of resources aims to encourage consistency, fairness and proportionality for all practitioner groups, regardless of demographic or background. It will though, be noted that in understanding the context in which a performance concern has arisen in order to reach a proportionate and fair outcome, professional training, background and induction is an important factor to consider.
Developing the framework
A working group was created with members from NHS England and NHS Resolution who have experience in managing and presenting cases within the NHS, representing practitioners in local disciplinary and performers lists management processes and in providing independent and expert advice. Utilising this experience, the group identified the five key areas (“the Principles”) in case management that a framework would seek to address and developed a list of key considerations within each area, rather than a checklist which risked becoming an audit tool for use at the conclusion of a case. These are equally applicable to cases managed in a primary and/or secondary care setting, irrespective of the grade, specialty or protected characteristics of the practitioner. Each section of the framework should be consulted both at the commencement of managing a performance concern, and as a case progresses. The framework was shared with key stakeholders including practitioner groups, regulators and providers and it was revised based on feedback received, recognising that the framework is not intended to be exhaustive.
Key actions and resources for healthcare organisations
We encourage organisations to use the framework as a documented part of local case management. It may be adapted for use by individual organisations and consideration should be given to how and when it is implemented, as well as how it dovetails with other local processes. However, we advise that the overall five ‘Principles’ are not changed. We envisage that the framework will be a disclosable document and should be retained within the Case Manager’s case file. It may also provide a helpful tool to inform engagement and discussion with Practitioner Performance Advice. Those managing cases should note that whilst the questions on the Framework are binary, it is anticipated that a ‘no’ or ‘unknown’ answer would lead to further investigation/inquiry and consideration of the issue in question.
Along with the principles for fairness and proportionality and the associated framework, we have 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. Links to these resources are available below.
To avoid the potential bias or inconsistency in approach to case management for differing groups of practitioners, questions relating to the context in which the issue arises are posed alongside questions relating to place of qualification and induction. The overall aim of the framework is to promote consistency and fairness in all cases, rather than it being relevant solely to specific practitioner groups.
Anticipated benefits
The overall aim of the framework is to improve the local management of performance concerns to promote fairness and proportionality in case management and decision making to ensure expeditious and proportionate resolution of concerns at the earliest possible stage.
The framework has been developed to ensure fairness, proportionality and consistency applies at all stages of the management of a local process. This goes beyond the original action which was to focus on the preliminary analysis of concerns and ensures that it promotes transparency and supports fully informed decision making at every level and can aid practitioner engagement, through their involvement in the process. We recognise that in some circumstances, practitioners may initially respond to performance concerns with defensiveness, denial or blame, and it may take time for them to provide a considered and insightful response. Organisations should ensure that concerns are managed sensitively, openly and with information provided to practitioners to allow for a considered response and to enhance engagement. Having a framework to support a fair approach to the management of cases will ensure that important stages in the process are not overlooked and that all relevant issues and circumstances are considered from the outset for every case.
We anticipate several related key benefits for organisations and practitioners using the framework and case studies, including:
- For organisations:
- Better understanding of the circumstances and context in which concerns have taken place.
- Improved adherence to policies and regulations.
- Improved confidence in decision making in the management of cases.
- For practitioners:
- Improved communication with the employer.
- Greater awareness of sources of support.
- A better understanding of the process to manage the performance concerns.
- More practitioners feeling that the management of their concerns were handled fairly.
In the long term we anticipate these benefits contributing to a reduction in disproportionality the management of performance concerns across demographics and protected characteristics, along with other actions being taken across the healthcare system.
Future Evaluation
The framework is intended to be an evolving document and therefore we have proposed that its use is promoted at this stage, in the same way as our Exclusions Resources were published, and that iterative evaluation will be undertaken to inform further development.
We commit to evaluating the use of the resource and the effectiveness of the framework in six months’ time against the anticipated benefits. We will assess use through engagement with the resources on our website and will be in contact with organisations who use the Practitioner Performance Advice service to seek feedback which will shape the further development of the resource. If you have any immediate feedback or would like to take part in the evaluation, please contact nhsr.adviceresearchandevaluation@nhs.net.
How Practitioner Performance Advice can help you
Practitioner Performance Advice can support you to review any concerns about the individual practise of doctors, dentists and pharmacists and encourage you to do so as early as possible. There is no threshold for contacting us.
Through our network of Link Advisers we provide impartial advice to help you effectively manage and resolve any concerns. Link Advisers can also guide you through the specific support we can provide through our assessment and remediation services.
Acknowledgements
The creation of the framework would not have been possible without significant input from experienced Heads of Professional Standards, Iona Neeve (NHS England South West) and Rachel Kinghorn (NHS England North East and Yorkshire).
A full list of acknowledgments is outlined on our Fairness and Proportionality resources webpage.
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