Analysis and commentary from Practitioner Performance Advice’s support of the management of exclusions in England

This Insight publication highlights the unique perspective of NHS Resolution’s Practitioner Performance Advice (the Advice Service) on exclusions of NHS doctors and dentists in secondary care. We are pleased to publish our fourth edition of this annual analysis as part of our 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 are understood and actions taken to resolve them. We analysed 509 episodes of formal exclusion that commenced in England from April 2020 to March 2025, where the Advice Service was contacted to advise on individual episodes of exclusion.

Key headlines

• The highest number of exclusions commenced in financial year (FY) 2024/25 (131 episodes) though the proportion of exclusions in relation to the number of Advice Service cases involving secondary care practitioners was broadly consistent with previous years.  
• The duration of exclusions continued to decrease over reporting period. At the end of FY 2024/25 the average duration of ongoing exclusions was 2.4 months, less than half the average duration in FY 2020/21 (5.2 months).
• Over 80% of the exclusion episodes which ended during this reporting period were under six months in duration. Maintaining High Professional Standards in the Modern NHS (MHPS) states that normally there should be a maximum limit of six months’ exclusion except for those cases involving criminal investigations.
• Consistent with our previous analysis, groups of doctors and dentists who are statistically more likely to be excluded are: male, aged 65 and over, from Asian or Asian British, Black or Black British or Mixed ethnic groups, or who qualified outside the UK and European Economic Area (EEA).
• Specialty/Associate specialist doctors and doctors working in obstetrics and gynaecology, emergency medicine, or surgery remain statistically more likely to be excluded.
• In 47% of episodes the exclusion ended with practitioners returning to either the full scope of their clinical practice or under some restriction. Practitioners did not return to their employing organisation in 31% of episodes. In the remaining 22% episodes concluded for a different reason, including the practitioner’s move from exclusion to sick leave.
• Since FY 2020/21 there has been an annual increase in the proportion of exclusions where the reported concern relates to sexual misconduct. FY 2024/25 saw the highest proportion of exclusions related to sexual misconduct concerns (36% of all exclusions), an increase from 28% in FY 2020/21.

Key actions for managers of performance concerns

• Consider the findings of our analysis and how the experience of managing exclusion cases in your organisation compares to the national picture.  
• Contact the Advice Service when considering the exclusion or restriction of a practitioner’s practice. Our Advisers offer impartial and objective advice, and can provide assurance that exclusion is used appropriately, proportionately and fairly in the NHS and the independent sector. 
• Use our exclusions decisions flowchart and additional resources to complement local organisational policies and support best practice when considering, managing and documenting exclusions.
• Review ongoing exclusions before the end of each four-week period to consider whether the rationale for exclusion remains valid, consider alternative options 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 with the investigation and any delays. It is best practice to document decision making, including rationale.
• Ensure that your designated board member is informed of, and regularly updated on, doctors and dentists from your organisations who have been excluded from clinical practice and the outcome of any four-weekly reviews. 
• Consider using our Principles and Framework to promote fairness, proportionality and consistency in decision making. This framework can be adapted for use at your own organisation when managing and resolving performance concerns, including cases involving exclusion.
• Request your organisation’s Practitioner Performance Advice organisational activity report (OAR) if you are responsible for the management or oversight of concerns about individual clinicians. This service helps to identify patterns and issues in cases where performance concerns have arisen, including exclusion cases, and provides comparison of your case profile alongside that of similar sized organisations. 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.

Exclusion episodes from FYs 2020/21 to 2024/25

Practitioner demographics

We analysed the personal characteristics of the practitioners in our exclusion cases against the NHS workforce of secondary care doctors and dentists in England aiming to understand if any groups are overrepresented and, if so, to what extent.

Our analysis looks back at exclusions which commenced during the previous full five financial year period and is intended to provide a snapshot of our exclusions data for that period. This approach was adopted in our previous two Insight publications focusing on exclusions and as such there is overlap in the reporting periods. For this reason we have not provided any comparative statistical analysis with previous Insight publications although, where relevant, we have included commentary on any notable similarities or differences in data over the reporting period covered, i.e. FYs 2020/21 to 2024/25).

The groups described below were found to be significantly more likely to be excluded using appropriate statistical tests. The rates of exclusion stated are based upon the overall population of doctors and dentists and adjusted for the relative size of individual groups within the overall population. Where likelihood of exclusion is expressed numerically, it reflects the odds of a particular group being excluded compared to their representation in the overall NHS doctor and dentist population. For example, male practitioners are estimated to be 5.8 times more likely/higher odds to be excluded than expected, given their representation in the population.

*Trust grade doctors were found to have a higher rate of exclusion than Speciality/Associate Specialist doctors. It is difficult to determine the statistical accuracy of this as we recognise the term ‘trust grade’ can be used to define doctors working in different roles. Additionally trust grade doctors are not explicitly categorised in NHS digital workforce data in the same way that consultant, speciality/associate specialist and training grade doctors are. We therefore include this as a point of observation with a note of caution as to accuracy, based on these factors. 

Age and gender

For exclusions which commenced from April 2020 to March 2025 we observed a higher rate of exclusion for male practitioners than female practitioners, with male practitioners 5.8 times more likely to be excluded.
 
The rate of exclusion for practitioners increased with each advancing age group. Practitioners who were aged 65 and over were 2.2 times more likely to be excluded.

These findings echo our analysis of Advice Service cases which found that male doctors and dentists and those aged 65 and over are statistically more likely to be discussed with us¹.

Ethnicity and place of qualification

Practitioners from a mixed ethnic group were 1.4 times more likely to be excluded, followed by Black/Black British (1.3 times more likely) and Asian/Asian British practitioners (1.1 times more likely).

Practitioners who qualified outside the UK and EEA were 2.1 times more likely to be excluded.

Grade and specialty

Associate specialist/specialty doctors were 1.5 times more likely to be excluded. Consultants were the next most likely to be excluded (1.3 times more likely).
 
Practitioners specialising in emergency medicine were 1.8 times more likely to be excluded. The next most likely to be excluded were practitioners working in obstetrics and gynaecology and surgery (both 1.5 times more likely).
 
We recognise that ethnic minority and IMG practitioners are disproportionately impacted by formal disciplinary processes as discussed in Fair to Refer published by the GMC² and other work from the NHS³. Please also see our publication on the lived experience of ethnic minority and IMG practitioners who had cases with our service⁴.
 
Any decision to exclude is a challenging judgement which seeks to ensure patients and staff are protected from harm, or a risk of harm, whilst the practitioner is treated fairly. Although not a formal disciplinary action, exclusion can inevitably impact how practitioners perceive themselves and are perceived by others. The absence of a colleague can also have a profound effect on a service in terms of both performance and cost and impact wider than just the main employer if the doctor works across the health system.
 
Contacting the Advice Service as early as possible to discuss concerns with your Link Adviser can support you in deciding the most appropriate way to manage cases. Our decisions flowchart is also a valuable tool to ensure compliance with good practice when deciding whether exclusion is necessary.
 
We recently published Principles and a Framework to promote fairness, proportionality and consistency in decision making⁵ when managing and resolving performance concerns. The framework includes a dedicated section for promoting equity and proportionality when making decisions about exclusion. It provides key prompts to guide decision-makers, including the need to provide clear and documented rationale for the decision to exclude, consideration of the proportionality of exclusion in response to the risk to patient/public safety and any alternatives which have been considered and discounted.

Number of exclusions

Figure 1: Number of exclusions in comparison to the total number of Advice cases (FYs 2020/21 to 2024/25)

Figure 1 shows the number of exclusions which commenced each FY from 2020/21 to 2024/25, in comparison to the number of secondary care cases.

Figure 2: Number of exclusions in comparison to the total number of Advice cases – percentages by financial year (FYs 2020/21 to 2024/25)

Figure 2 shows the number of exclusions which commenced each FY from 2020/21 to 2024/25, as the percentage of the total number of Advice cases.

The number of exclusion episodes has remained broadly consistent from April 2020 to March 2025, however FY 2024/25 saw the highest number of exclusion episodes during this period (131). As a proportion of Advice Service cases, the percentage of cases involving exclusion varies across each FY, accounting for between 14% to 21% of the total number of cases involving secondary care practitioners. 

Exclusion end reasons

Figure 3: Exclusion end reasons (FYs 2020/21 to 2024/25)

Figure 3 shows percentage breakdown for exclusion end reasons for all 460 exclusions which concluded between 2020/21 to 2024/25 (and commenced in the same period). These relate to individual episodes of exclusion and are mutually exclusive.

Figure 4: Exclusions end reasons – percentages by financial year (FYs 2020/21 to 2024/25)

Figure 4 shows percentage breakdown for exclusion end reasons in each FY for all 460 exclusions which concluded between 2020/21 to 2024/25 (and commenced in the same period). These relate to individual episodes of exclusion and are mutually exclusive.

For exclusion episodes concluded during the reporting period, around half of practitioners returned to clinical practice. In each of the five previous FYs (2020 to 2025) between 42% and 53% of practitioners returned to clinical practice, either on a restricted or unrestricted basis. For the 31% of exclusion episodes which ended in the practitioner not returning to clinical practice, half of these were due to dismissal. 

Duration of exclusions

Figure 5: Duration of exclusion episodes at end (FYs 2020/21 to 2024/25)

Figure 5 shows breakdown of duration of exclusions at end for all 461 episodes which commenced in 2020/21 to 2024/25 in England and ended in the reporting period

Table shows the mean and median average duration of exclusion episodes which commenced in 2020/21 to 2024/25 in England and ended in the reporting period.

Most exclusions which ended during the reporting period did so within six months or less (79%), six months being the normal maximum limit for exclusion under MHPS. Eight percent of exclusions took longer than 12 months to conclude and 43% of these cases involved criminal investigations, which can lead to prolonged exclusions until police investigations are concluded.

The average duration across all exclusion episodes has reduced over the reporting period. For exclusions which concluded in 2024/25, the mean average duration was half that of exclusions which ended in 2020/21. The median average duration has also reduced with exclusions ending in 2024/25 nearly a month shorter than those which concluded at the beginning of the reporting period.                   

Our Advisers are here to work with healthcare organisations to support the timely resolution of exclusion episodes. They regularly review with organisations whether exclusion is still warranted or if risks can be mitigated in other ways.

Sexual misconduct and exclusion 

In a recent Insight publication⁸ we undertook keyword match analysis to identify cases where there was a concern relating to sexual misconduct⁹. The analysis showed an increase in cases since 2019/20 which were matched to the keywords related to sexual misconduct¹⁰. We have also found that the number of exclusion cases involving a concern of sexual misconduct has increased.

Figure 6: Number of exclusion episodes relating to sexual misconduct concerns in comparison to the number of Advice cases involving sexual misconduct concerns (FYs 2020/21 to 2024/25)

Figure 6 shows the number of exclusions involving concerns of sexual misconduct which commenced each FY from 2020/21 to 2024/25, in comparison to the number of secondary care cases involving concerns of sexual misconduct.

Figure 7: Percentage of exclusion episodes relating to sexual misconduct concerns in comparison to the total number of exclusions (FYs 2020/21 to 2024/25)

Figure 7 shows the number of exclusions involving concerns of sexual misconduct which commenced each FY from 2020/21 to 2024/25, as percentage of the total number of secondary care cases involving concerns of sexual misconduct 

Since April 2020 the number of exclusions in cases involving concerns of sexual misconduct has increased each FY. In the past two FYs exclusions in sexual misconduct concern cases have represented over a third of the total number of exclusions, with 36% in 2024/25 representing the highest proportion over the reporting period. Our previous analysis found that the proportion of cases involving sexual misconduct concerns represented 20% of our total cases in 2024/25.

This increase in exclusions in such cases may reflect how organisations are responding to changes in legislation on sexual safety at work, a renewed emphasis to take all reasonable action to eradicate concerns in this area, as well as responding to refreshed regulatory standards from the GMC.

Exclusion may be necessary in certain circumstances to safeguard patients and staff, particularly when concerns involve sexual misconduct — including sexual offences, assault, harassment, or violence — which may constitute criminal acts.

Matching our analysis of all cases involving concerns of sexual misconduct, exclusion cases identified as involving a sexual misconduct concern also appear to have a longer duration then those which do not, as measured both by the median months open and mean months open.

What should healthcare organisations do next?

We invite healthcare organisations to consider the findings of this Insight publication with focus on the following:

• Review and consider the key actions for managers dealing with performance concerns at the start of this paper, including contacting the Advice Service when considering exclusion, adopting the Principles and Framework for Fairness and Proportionality and requesting your own Organisational Activity Report.

• Review and consider the exclusion resources made available by the Advice Service to complement your local policies and support best practice in the consideration and ongoing management of exclusions.

• Whether exclusion is being considered or not, there is no threshold for contacting us, nor any restriction on contacting the Advice Service for cases where formal procedures have not been 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.

• Review the management of sexual misconduct related exclusion cases. We will also be running a sexual misconduct learning event for those involved in the management of performance concerns later in the year, to share our learning and insights more widely. Please look out for further information about this opportunity on the our webpages and our Education training courses.

Our Insight 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 Insight page.

If you are interested in hearing more about our research and Insight 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.

¹ Demographics, professions and concerns: Analysis of Practitioner Performance Advice cases including a focus on sexual misconduct concerns (Practitioner Performance Advice, 2025)

² Fair to refer? (GMC, 2019)

³ Medical Workforce Race Equality Standard (MWRES) WRES indicators for the medical workforce 2020 (NHS England/Improvement, 2021)

⁴ Experiences of ethnic minority and IMG practitioners: Research to improve fairness in the management of concerns (Practitioner Performance Advice, 2024)

⁵ Principles and Framework for healthcare organisations managing performance concerns (Practitioner Performance Advice and NHS England, 2025)

⁶ To avoid potential identification of an individual exclusion episode we have provided a duration range as an alternative to the specific length of the shortest exclusion

⁷ To avoid potential identification of an individual exclusion episode we have provided a duration range as an alternative to the specific length of the longest exclusion.

⁸ Demographics, professions and concerns: Analysis of Practitioner Performance Advice cases including a focus on sexual misconduct concerns (Practitioner Performance Advice, 2025)

⁹ We acknowledge that the proportion of cases identified by matching key words does not perfectly represent the true number/proportion of sexual misconduct cases.

¹⁰ The analysis covered the FYs 2015/16 to 2024/25, but only covered cases up to 15 March 2025 in the final year of the analysis. The approach to identify sexual misconduct cases had an accuracy of 89% against cases already marked as sexual misconduct cases on our case management system for cases where sexual misconduct was identified as a concern when the case was opened. The manual review by SMEs of cases identified as involving sexual misconduct through keyword matched produced an accuracy of 89%. Our data science team has indicated that there is consistent recall across the timeframe of analysis which indicates an upward trend of cases and that the 6% increase can be considered with a reasonable degree of confidence.