Short abstract
Suspending a doctor for poor performance is a drastic step. It's far better to get to the problem earlier in the day, says Alastair Scotland, head of the National Clinical Assessment Authority
A switch from plastic surgery to public health—from the most hands-on specialty to one of the least—is surely not among the more common career moves in medicine. But such is the route that Alastair Scotland has followed to his present job as chief officer and medical director of the National Clinical Assessment Authority.
Figure 1.
Alastair Scotland (pictured): when employers don't follow his recommendations, he would like to know the reason why, but he doesn't want them bludgeoned into line
“If you've ever done surgery, you do miss the excitement, the hurly burly of the acute situation,” he admits. However, if part of the appeal of medicine is being able to observe the human drama at first hand, running the new authority is hardly short of drama—involving as it does advising on what to do for and about doctors in difficulty.
Perhaps even a bit too dramatic: isn't it depressing to have to deal with a passing parade of the inadequate, the incompetent, and the simply fallible from within your own profession? Scotland finds the question amusing. Far from being depressed, he says, he loves the job—it's interesting, stimulating, and exciting. And, on the Monday morning I went to see him, it's slightly chaotic: a crate had gone missing in the weekend's office move.
The crucial thing with suspension is to avoid it in the first place
The authority was set up in April 2001 with three objectives: to help hospitals and primary care trusts improve their handling of doctors with performance problems; to develop better local and national procedures for this purpose; and to assess the performance of individual doctors. Scotland describes the procedures in place until now as confrontational and legalistic. “They've often resulted in too quick a move to a disciplinary approach. And the traditional NHS disciplinary process may have been fit for the purpose when it was created, but it certainly isn't now.”
Listening to Scotland talk effusively about the authority and how he wants it to operate, I suggest that he's acting as a kind of social worker to his profession. He resists the comparison, except in one respect. “An element of the social worker's job is prevention. We're also about helping before things get to the point where there is an irremediable problem. If somebody thinks something might be wrong with the way that a doctor is getting on, then we can help guide local systems to get things back on course.”
He begins to draw a parallel of his own with public health—but then backtracks from this too. “I sometimes describe what I'm doing as a public health approach. In practice, though, it's not. It's simply a good care approach, where primary prevention is best and early identification of problems is next best. And finally, where a problem is established, you get things better.”
If somebody thinks something might be wrong with the way that a doctor is getting on, then we can help guide local systems to get things back on course
It's still difficult to predict the level that the number of cases brought to the authority each year will settle down to. But in the two years or so since the authority was set up it has handled more than 700. In that time its staff have dealt with problems ranging from the minor to the most severe—although, as Scotland points out, no case really is small. The authority is usually approached when local procedures are unable to deal with doctors who are having or creating problems. “We're rather like the tertiary level referral services in the NHS. People come to us for specialist help.”
Eighty five per cent of what we see is at consultant or principal level: people who are at the top of the profession. It's right that we should take time
So far, more than two thirds of cases have required advice only. Such advice might concern the best use of a disciplinary policy or where to get help for some particular problem. The remaining third of cases have proved more demanding, but still only about 10% have required the authority to do an assessment of its own. “That's expensive, it takes time, and it's highly specialised. Actually that's as it should be. Eighty five per cent of what we see is at consultant or principal level: people who are at the top of the profession. It's right that we should take time.”
The authority's recommendations are advisory. Would Scotland like them to be mandatory? “It's very tempting to say yes,” he admits. “In practice I don't think it's necessary.” He would like to know why an employer or primary care trust had chosen not to follow his recommendations, but he wouldn't want them bludgeoned into line. If this were to be the rule it would clearly alter the attitude of individuals or organisations consulting him. To seek advice is one thing; to know you're then obliged to follow whatever you're told is another.
The authority has drawn up what it calls “memoranda of understanding” with the four other bodies involved in setting or enforcing standards in medicine: the “quality quins,” as Scotland calls them (the others being the General Medical Council, the Commission for Health Improvement, the National Patient Safety Agency, and the National Care Standards Commission). Does medicine really need five separate bodies pursuing this agenda? Scotland thinks so, if only because their differing points of focus make it unavoidable.
Primary prevention is best, and early identification of problems is next best
One of the scandals of the NHS is the number of doctors suspended for months or even years on full pay. Scotland maintains that the authority can help—indeed has already. In 30 out of 36 cases in which trusts told the authority that they were thinking of suspending a doctor the advice of Scotland and his colleagues resulted in an alternative course of action. “The crucial thing with suspension is to avoid it in the first place,” he says. “The moment you've suspended a doctor, the harder it is to handle the situation. But we have also managed to get some doctors back to work.”
The authority is a small organisation, and Scotland hopes to keep it that way. It allows him the opportunity to be more than solely an administrator, something he clearly values.
“I spend a good quarter of my time doing case work. That's important. It keeps me abreast of what's going on.” As does searching for that missing crate.