Introduction

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The General Medical Council's performance procedures were introduced in the summer of 1997.¹ These new procedures give the GMC, for the first time, the power to discipline doctors whose performance is found to be seriously deficient. If doctors are found to be underperforming, the GMC now has the power to suspend the doctors' registration and make the lifting of this suspension conditional on a period of retraining.² There are, however, a number of uncertainties around these new procedures, not least the scale of the problem and the type of retraining that will be required.

In an effort to quantify the size of the problem in general practice in the Northern Deanery and identify the areas in which training may be required in the future, I carried out a postal survey of interested parties.

	Methods

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In early 1988 I conducted a postal survey of the three groups perceived to be interested in general practice in the Northern Deanery: NHS commissioners, represented by the seven directors of primary care at the relevant health authorities; general practitioners, represented by the seven secretaries of local medical committees; and patients, represented by the 14 chief officers of community health councils. The response rate was excellent, with 100% responses from the directors of primary care and the secretaries of local medical committees and 11/14 responses from the secretaries of community health councils to the first request for information. The response from the community health councils rose to 13/14 after one reminder.

I used standard development methods for the questionnaire, including piloting to ensure clarity, question structure, and time to complete.³ The first series of questions related to whether responders had referred or were planning to refer general practitioners to the GMC under the procedures for seriously deficient performance. The respondents were also asked to identify the areas in which these doctors were perceived to be underperforming. The development of this part of the questionnaire was based on views obtained during unstructured interviews with a sample population of general practitioners and health authority directors of primary care. The facility to add further areas of concern was allowed, as was further free comment.

Respondents were then asked to gauge how many doctors in their area needed help with their performance but not at such a level as to require referral; they were asked to indicate the size of the population of underperforming doctors by circling a range. A further question asked them to identify areas that they perceived to be problematic in this population of doctors; they were able to identify more than one area.

Respondents were asked what methods, either formal or informal, were used to identify underperforming doctors. In the final question respondents were asked to identify up to three deficiencies in the current systems relating to the identification and management of poorly performing doctors, and these were analysed with standard qualitative analysis techniques.⁴

	Results

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Referral of doctors to the GMC
The seven health authorities had already referred five doctors under the new GMC procedures and were also considering referral in five further cases. The community health councils had referred six doctors and were considering the case of five others. The local medical committees had not referred any doctors but were considering the cases of two. It is impossible to say from the data if there was overlap of referral between organisations, but the numbers involved, while small, are not insignificant. The total number of general practitioners in the Northern Deanery is 1633.⁵

View larger version (16K): [in this window] [in a new window]   Fig 1.    Respondents' estimates of the number of local general practitioners in need of help for underperformance

Doctors needing help with their performance
Figure 1 shows the respondents' estimates of the number of doctors who were in need of help with their performance but not at such a level as to require referral, and figure 2 shows the respondents' areas of concern about these underperforming doctors. The areas of concern identified were similar to those listed for the doctors who had been referred to the GMC or considered for referral. The health authorities and local medical committees were also concerned about the doctors' prescribing, and to a lesser degree health authorities about referrals. Concerns about management (which was not defined in the questionnaire) were common, especially among the patients' representatives.

View larger version (23K): [in this window] [in a new window]   Fig 2.    Respondents' perceptions of areas of concern in the population of underperforming doctors

Methods used to identify underperforming doctors
Health authorities listed many different formal mechanisms for identifying underperforming doctors, including targets, practice inspections, input from the pharmaceutical advisor, and a number of quality systems such as King's Fund organisational audit,⁶ the Royal College of General Practitioners fellowship by assessment,⁷ and a local health authority practice accreditation scheme. Two health authorities also used the complaints mechanisms. Of the 13 community health councils that responded, six used the complaints mechanisms to identify underperforming doctors, and this was the only formal mechanism used by the councils. The local medical committees had no formal mechanisms other than one being involved with the local practice accreditation scheme.

Sources of help for underperforming doctors
The questionnaire offered respondents a choice of organisations that might provide help to underperforming doctors, and table 2 shows their responses. They were able to identify more than one source of help. One community health council thought that the GMC itself should be a source of help to such doctors.

Perceived deficiencies in present system
Figure 3 lists the deficiencies in the present system that respondents identified. The health authorities felt limited by their lack of power, had problems identifying underperforming doctors, and were limited by doctors' loyalty to colleagues. They also identified problems with resources, including time. The local medical committees saw the main problem as identification of underperforming doctors but also noted doctor loyalty as a problem. The community health councils, however, did not see identification as a problem but saw the major problems to be doctors' professional loyalty, their lack of accountability to the health service, and the lack of patients' and health authorities' power in these situations.

View larger version (24K): [in this window] [in a new window]   Fig 3.    Respondents' choices of deficiencies in current system of dealing with underperforming doctors

	Discussion

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The purpose of the performance procedures is to protect the public from doctors providing seriously deficient care, and the profession has a responsibility to help with this. It is also important to recognise that some doctors may need help to enable them to avoid being drawn into these procedures. It is unclear whether mechanisms exist at present to identify these doctors. Preventive help rather than punitive action should surely be the aim in the long term.

The results of this small survey seem to point to a small but significant number of doctors being referred under the performance procedures and a larger pool of doctors who may fall into this system if action is not taken to help them. The areas of concern cited were, however, only perceptions. There were few, if any, formal mechanisms being used for the routine assessment of performance of doctors in practice, and the tools used would seem to be crude measures of performance. It seems unlikely that poorly performing doctors would involve themselves in activities such as the King's Fund organisational audit or the Royal College of General Practitioners fellowship by assessment, both of which require a high level of commitment. Formal targets or practice inspections will provide, at best, crude measures of performance. Complaints will identify poor performance, but perhaps too late in a doctor's career.

A variety of methods have been put forward to assess clinical competence for the purpose of re-certification.⁸ Southgate and Jolly, from the United Kingdom, recommend information sources such as practice logs, patterns of referral and prescribing, and direct observation, whereas Hays, from Australia, proposes practice audit, external audit, standardised patients, and direct observation by trained assessors.⁸ In our survey the health authorities were using some of the external audit data that they held, such as targets and prescribing. There does not seem, as yet, to be any mechanism to assess and use data relating to day to day practice. The NHS Executive have recently proposed a national framework for assessing performance.⁹ This does not, however, seem real or relevant to everyday practice. Is an admission rate for severe ear, nose, and throat infection a true indicator of management of acute care in primary care? It may well be that developments such as the Royal College of General Practitioners clinical practice evaluation programme (CPEP)¹⁰ will help in this area.

Our survey also seemed to identify deficiencies in the NHS systems for bringing about change in underperforming doctors. The medical profession clearly has a major responsibility in overcoming its natural reticence in "blowing the whistle" on seriously underperforming colleagues. It also needs to recognise its responsibility to help doctors whose performance is slipping to rectify their problems before these threaten their ability to practice to an acceptable level. The GMC and the medical profession must either reassure the public that present systems are able to protect them or else review the existing systems in the light of experience and make changes to increase the public's confidence.