Guidance

Introduction

General Practitioners spend much time helping and supporting patients through their many physical and mental health problems – but who looks after and supports GPs? Many will have great support from family and friends, but occasionally may need more. If you realise that you are struggling, remember that you are not alone, nor are you the first to have experienced this.

In a recent survey, one in eight GPs had sought help from pastoral or wellbeing services within the past year. Over 90% of GPs identified workload as a major factor. This has led to many older doctors leaving the profession earlier than they intended and is also deterring younger GP trainees from joining the profession.

GPs may self-identify that they need help, or this thought might come from a work colleague, family and/or friends, or it may be part of the discussion during appraisal. The important factor is identifying that there is an issue and being willing to seek help.

The LMC are often contacted by GPs who need help. Very few are aware of the range of support that is available or how to access this help.

Most GPs will not reach the end of their career without facing a complaint. This is stressful for all involved but can be helped if the process is understood.

There are many different bodies that may be involved in the journey of a complaint.

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Health and Wellbeing: Burnout

If the constant stress of work and life is leaving you feeling disillusioned, helpless and worn out then you may be suffering from burnout.

Burnout is a state of emotional, mental and physical exhaustion caused by excessive demands and prolonged stress. It leaves you feeling increasingly helpless, hopeless, cynical and resentful. Life loses its meaning and you may feel you have nothing left to give. On the BMA website is a link to a questionnaire to rate your risk of burnout  Are you in danger of burn out?

Research into burnout suggests that GPs are at risk. A Dutch study suggested that 40% of GPs were experiencing high levels of burnout, and a recent study by Pulse amongst UK GPs showed that 50% were experiencing symptoms suggestive of burnout.

Here are some common signs that you might be experiencing burnout:

  • Exhaustion: mental, physical or emotional, or all three.
  • Neglecting your needs, no time or energy for anything else other than work.
  • Lack of motivation: not feeling enthusiastic about anything anymore.
  • Frustration, cynicism, or other negative emotions – these become overwhelming.
  • Slipping job performance: tasks building up, complaints increasing.
  • Interpersonal problems at home and at work: more conflicts, withdrawal from colleagues and isolating yourself.
  • Not taking care of yourself: developing unhealthy coping strategies, drinking more alcohol, eating too much, junk-food, smoking more, having affairs, self- medication.
  • Being pre-occupied with work, even when not at work.
  • Generally decreased satisfaction in everything you do.
  • Health problems, digestive issues, heart disease, depression.
  • Depersonalisation: losing contact with yourself, no longer seeing yourself as valuable and losing track of personal needs. Your view of life narrows to the present time and life turns to a series of mechanical functions or tasks that are not to be enjoyed, but just completed.

If you are a hard-working idealist or a perfectionist, investing high energy, emotion and commitment to your role, your risk is even greater.

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Stages of Burnout

There are several different models, but the stages are similar:

Honeymoon Period. . .

  • High energy, good satisfaction from trying to solve problems and make changes, you find the job interesting most of the time.

Fuel starting to run low. . .

  • Gradual onset of frustration, tiredness, and loss of interest. Distancing yourself from colleagues and patients, become more cynical.
  • Denial of emerging problems – blame increasing problems on time pressure and all the work you have to do.
  • More mistakes.
  • Physical symptoms increase fatigue, sleep disturbances.
  • Escape activities such as drinking or eating too much, smoking, buying things.

Towards a crisis. . .

  • Symptoms and dissatisfaction with the job dominate all areas of life.
  • Wanting to be alone, rejecting help, lots of anger and inability to relax.
  • You start thinking of extreme measures to escape – moving, resigning, divorce or even suicide.

Apathy. . .

  • Energy is very depleted, and symptoms get worse.
  • CRISIS
Preventing Burnout

There are lots of tips, books, and websites out there with plenty of advice. Most involve some of the following and spending some time reflecting on how you can avoid burnout is never wasted, even if you don’t currently feel it applies to you.

  • Give yourself planned time for a relaxing ritual. This might be doing gentle stretches, meditating, writing a journal, reading, listening to music etc. The key is to do it mindfully, with your whole attention.
  • Eat healthily, exercise and get enough sleep.
  • Set boundaries.
  • Take a daily break from technology, “disconnect from an overly connected world”.
  • Do something creative and choose activities that have nothing to do with work or achievement.
  • Learn how to manage stress – you may need help with this.

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Recovering from Burnout

If it’s too late, and after reading this it is clear to you that you need help, then you need to take your burnout very seriously. You can’t push through burnout and serious harm may come to you and your family if you do.

Step 1. . .        SLOW DOWN

You need to force yourself to slow down or take a break. Give yourself time to rest, reflect and heal.

Step 2. . .        GET SUPPORT

You need help. Share your true feelings, stop trying to deny the situation and talk to another person. Consider seeing your GP, contact the NHS GP Health Service – Practitioner Health at NHS Practitioner Health for confidential mental health and addiction support or BMA Wellbeing Support service at Your wellbeing (bma.org.uk) Contact the LMC gpsupport@wessexlmcs.org.uk

Step 3. . .        RE-EVALUATE

Burnout is a sign that something isn’t working in your life. Your task is to find out what and put it right. You may need help to do this.

Step 4. . .        TAKE TIME OFF

If burnout seems inevitable then you might need to take a complete break from work.

Take a holiday, ask for leave of absence, take a sabbatical or you might need to take sick leave. Unless you take a break, you will not be able to find the solutions.

Doctors are often very poor at managing their health and wellbeing, constantly putting work first and the traditional culture in medicine is that of needing to always be strong and not show vulnerability. They worry what others will think if they “confess” to having problems and of course if they do, may have to speak to a colleague who knows them professionally as well as being their patient. However, t is really important to put fears and inhibitions to one side and trust the professional judgements and decisions of others. The strong person is the one who recognises the problems and decides to act positively to get a better life.

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Practitioner Health

NHS Practitioner Health is a free, confidential NHS primary care mental health and addiction service with expertise in treating health & care professionals.

Practitioner Health is a self-referral service for doctors and for other staff where accessing care confidentially is difficult. The act of self-referral is key as this acknowledges recognition of need, preparedness to trust the service and willingness to engage in treatment.

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Other Sources of Health Support

email wellbeingsupport@bma.org.uk

Telephone: 0330 123 1245

  • Action on Addictionlinks to advice and treatment, including rehabilitation for alcohol and drug misuse. 
  • Sick Doctors Trustsupport and help for doctors, dentists and medical students concerned about their use of drugs or alcohol.

Telephone: 0370 444 5163

Confidential peer support network for doctors and medical students with concerns about their mental health.

The group aims to provide support to any medical professional or dentist facing suspension, exclusion, investigation of complaints and/or allegations of professional misconduct, through peer support.

DocHealth is a confidential, not for profit, psychotherapeutic consultation service for all doctors.

Telephone: 0207 383 6533

Help ranges from financial assistance in the form of grants and loans to a telephone befriending scheme for those who may be isolated and in need of support

Telephone: 0208 540 9194

  • Tea & Empathy Facebook group. A national, informal, peer-to-peer support network aiming to foster a compassionate and supportive atmosphere throughout the NHS.

Telephone: 116 123 (free)

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Occupational Health Services

The NHS England (South) contract for Occupational Health services for GP and Dental clinics covers NHS England regions South East, South Central, Wessex & South East areas.

The service provides: –

  • A comprehensive Occupational Health service to all GPs, Dentists, Ophthalmic/Optometry practices and Pharmacies.
  • Needlestick Injury (NSI) advice and support to NHS GPs, Dentists, Pharmacists and healthcare workers, including trainees – telephone 033 3344 9089.
  • The ability for practices to purchase Occupational Health services for their clinical and non-clinical staff at preferential rates.
  • Clearance services for clinical practitioners wishing to join the National Performers List (self-funded) – telephone 033 3344 9089.

The service provides all clinics with an easy-to-use online portal for Occupational Health services including referring staff and managing cases referred.

To register for the service and to find out what information practices need to provide as part of the registration process, go to Heales clinic registration portal.

N.B. the service provided by NHS England is for GPs only. As employers GP practices have a responsibility to ensure their staff can access occupational health services as necessary. Heales and other occupational health providers offer such a service, which would need to be funded by the practice.

The service commissioned by NHS England in the South will provide:

  • Occupational Health advice via the portal, telephone, e-mail and post
  • COVID-19 general advice, return to work assessment or in-work assessment (including review of COVID-19 tests)
  • Management referral for short-term or long-term sickness absence or concerns over performance related to a health issue.
  • Health Surveillance (for example nightworker assessments, vaccination boosters etc.)
  • Ill-health retirement under the NHS, Local Government or private pension scheme
  • Needlestick/Sharps telephone support line
  • Pre-employment screening (including any required vaccination/immunisation)
  • For further information see the Heales brochure

Locum GPs on the performers list can access services directly via nhsengland@heales.com or on 033 3344 9089.

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Appraisals

Your appraisal is an annual opportunity to reflect with a trained appraiser.

Whether you are starting to spot the warning signs of burn-out or are aware of issues that you want to sort out, helpful discussions may well start at your annual appraisal.

Information for appraisals in the South West – BSW and Dorset – GP Appraisals and Revalidation.

Email: england.gpappraisalswd@nhs.net

Information for appraisals in the South East – HIOW –  NHS England South East » Appraisal and Revalidation

Email –  england.hiow-appraisals@nhs.net

Appraisers are either practising or recently retired GPs who have a clear understanding and experience of the pressures of modern-day general practice. They have additional skills in coaching and mentorship and can encourage and motivate doctors to reflect on their personal health and work-life balance and make changes where necessary. They can also act as a resource and signpost doctors towards appropriate sources of help and professional support.

When documenting discussions that have taken place, GPs should be aware that the appraisal documents and summary are as confidential as medical records.

Therefore, they can be seen by other professionals working in the revalidation process, such as the RO and their team. Additionally, they may be subject to a request to disclose, just as clinical notes can be. It is therefore important that not only does the documentation not include patient or colleague identifiable information but also that you may wish to reflect on the level of detail recorded about any deeply personal thoughts or conversations that you have with your appraiser.

Wessex Appraisal Service have a section offering support and advice re appraisal and revalidation or professional concerns on their website.

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Complaints

Medicine is not an exact science and GPs are expected to manage risk and clinical uncertainty daily. It is not surprising when occasionally, despite best efforts, things do not always turn out as expected. In addition, the culture in the UK has changed with people becoming far more willing to complain if they do not get what they want.

With all these factors it is unlikely a GP will get through their career without having a complaint made against them. This is very stressful whether there are grounds for a complaint or not.

Complaints made to the practice, can be investigated locally and are mainly resolved amicably – if not they may be taken to the Ombudsman. Sometimes the complaint may be made directly to the ICB (previously was to NHS England) or the GMC. A GP or the practice may seek help from the LMC, the BMA (if you are a member) or Defence Organisation to help with the process. The LMC can offer an individual GP personal help and support.

Remember reflection about all complaints made against a GP as an individual need to be included in your annual appraisal, in a non-identifiable way. The aim is to ensure that you can explore, in protected time, what lessons you have learned and any changes you have made as a result, and to process the impact of the complaint on you and your work. Even if there was nothing that you could have done differently, this can be an important part of letting go and moving on.

A complaint that is made to the practice will often be dealt with by the practice. Most practices handle complaints very well. Remember what most people who have made a complaint want is that:

  • It is taken seriously.
  • Their concerns are addressed, and an explanation is provided by the practice.
  • The practice or individual apologises (you can say that you are sorry that this has happened, without admitting responsibility).
  • That this doesn’t happen to someone else – that the issues will be discussed within the practice team, and this will help in preventing this happening to another patient in the future.

Patients can also contact the ICB (previously was to NHS England) directly as the contract holder. If a patient makes a complaint to the ICB directly then the complaints team will contact the practice and share the concerns. They will seek the practice’s views and explanation. All complaints will then be reviewed by the Performance Team and may result in them being discussed in a Performance Advisory Group (see below).

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Support from the LMC

The LMC have many people who can help and support GPs, including Medical Directors and experienced managers. To get in touch please contact the LMC Office either by email office@wessexlmcs.org.uk or by phone 023 8025 3874. When calling you don’t need to share the detailed reason for the call if you do not wish to. Simply ask for a conversation. Support is provided free of charge.

Counselling and Peer Support Through The BMA

The BMA wellbeing support services are open to all doctors and medical students. They’re confidential and free of charge. Call 0330 123 1245 and you will have the choice of speaking to a counsellor or taking the details of a doctor who you can contact for peer support.

Counselling

Their counselling service is staffed by professional telephone counsellors, 24 hours a day, seven days a week. All counsellors are members of the British Association for Counselling and Psychotherapy and are bound by strict codes of confidentiality and ethical practice.

You can talk to them over the phone or by video. Ongoing counselling is available, and you can arrange regular appointments. Having spoken to a counsellor, you can request to speak to that person again. It can be more helpful to speak to the same counsellor each time, giving you continuity of care and providing you with more effective support.

The counsellors are there to help you deal with a variety of issues. By seeking constructive help, you may identify ways of addressing the root causes of your concerns and develop strategies to reduce the impact of the consequences.

Peer Support

Their peer support service offers doctors and medical students in distress or difficulty the choice of speaking in confidence to another doctor. It’s confidential peer support with an emotional focus.

Ask to speak to a doctor and you will be given the details of one of their team, who are experienced in supporting colleagues. You can arrange ongoing conversations at mutually convenient times.

Their peer support doctors can provide reflective space, working with you to gain insight into your problems. They can signpost, if appropriate, to other sources of support.

Their doctors do not provide diagnoses or treatment, this is not an emergency service.

Contact Information

Access counselling (24 hours a day, seven days a week) and peer support on 0330 123 1245.

Please see their dedicated webpage to these services:

https://www.bma.org.uk/advice-and-support/your-wellbeing#wellbeing-support-services

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The Doctor Support Service

If you have a complaint that goes to the GMC there is a dedicated support service for this. This is called the Doctor Support Service. It is available to all doctors. It is there for anyone with a complaint at the GMC or if you are at risk of having your licence withdrawn.

They offer up to 6 hours of telephone support. Additionally, they can offer face to face support on the first day of a hearing and orientation visits if you would find this helpful.

Please see their webpage for further details:

https://www.bma.org.uk/advice-and-support/your-wellbeing/wellbeing-support-services/gmc-investigation-support-doctor-support-service.

The Doctors Support Group

(DSG) aims to provide support and assistance to any medical professional or dentist facing suspension, exclusion, investigation of complaints and/or allegations of professional misconduct

Website: The Doctors Support Group – https://doctorssupportgroup.com/

Practitioner Health Programme

Can offer support in dealing with the stress and psychological consequences of complaints and NHSEI / GMC performance procedures

https://www.practitionerhealth.nhs.uk/.

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Wessex LMCs GP Support

A core part of the role of Wessex LMCs is pastoral support. The LMC offers one to one support for GPs and Practice Managers who might face a range of challenges from problems in the practice, health issues, personal problems at home, and include performance issues, either developing, or established, in terms of performance procedures with the ICB or GMC. These processes can be extremely stressful, and GPs need to know that they can turn to us for confidential support whatever the problem.

With this in mind we have established the Wessex LMCs GP Support

Like everyone, GPs go through times in life of significant change, unhappiness, or difficulty. The LMC’s vision is to support and represent GPs both in distress but also to reach their full potential to allow General Practice to thrive. The team at the office provide an element of pastoral support but we also wish to provide a menu of options to allow extra tailored support.

Journey for support:

  • Individual makes contact via email or telephone to the LMC office
  • Call/email treated with complete confidentiality
  • Chat arranged with a Medical Director (GP in the LMC office)
  • Individualised advice and support given with suggestions of potential other avenues of support

Enquiries

To discuss whether GP Support is right for you simply email the LMC at: gpsupport@wessexlmcs.org.uk.  Alternatively, contact the office on: Tel. 023 8025 3874 and ask for ‘Wessex GP Support’ to arrange for a discussion with a Medical Director at a mutually convenient time.

Primary Care Team Support

Wessex LMCs has a page where GPs and Practice Managers can find resources for their whole team: Health and Wellbeing for the practice team (non-GP)

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Avenues of support include:

Coaching and Mentoring

Subtly different avenues for GPs seeking support in decision making and personal growth around career direction, or more pastoral career support. You can access these services via:

NHS England – Looking after your career offers free career coaching aimed at the primary care workforce. ‘Individual coaching is available with a skilled and experienced career coach. The aim of the service is to provide an easy to access, individually tailored coaching service that focuses on supporting you with your career choices.

If you are thinking about your career and what you want from your current role, or if you are thinking about exploring new opportunities and making some changes, investing some time with a coach can be a very helpful thing to do.

NHS England – Looking after you too  offers a coaching support service for the frontline primary care workforce. ‘Individual coaching is available with a skilled and experienced coach who will work with you to discuss any area of your wellbeing that you would like to address. They will listen, ask questions and support you to develop practical strategies to cope with your situation and stay well.’

NHS England – looking after your team  offers coaching for those leading, managing or organising teams groups or services in primary care. ‘Your coach will help you think about and plan how you work with the people you lead and manage, using approaches centred in compassionate and collaborative team leadership.

The aim is to encourage resilience in teams while supporting them to continue to deliver projects, services and high-quality care to patients. Your coach can help you to develop practical tools and methods to work with your team in whatever way is important to you.’ 

Area Leadership Academy Coaching:

Coaching and Mentoring – South East Leadership Academy (Hampshire)

Coaching & Mentoring – South West Leadership Academy (BSW & Dorset)

Dorset Primary Care Training Hub (primarycaredorset.co.uk)

RCGP offer coaching and mentoring:

Mentoring              Coaching

It is open to non-members but there is a charge.

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Counselling

Counselling is available to GPs via Practitioner Health Programme (see below) and the BMA:

BMA Counselling offer

Also available are area Wellbeing Hubs:

Practitioner Health

Provided nationally as a service separate to the NHS to support GPs with mental health concerns, stress, depression, or addiction. Free to the individual. May provide CBT, counselling after initial session with a GP within the service

https://www.practitionerhealth.nhs.uk/

Facilitated Conversations

To help address and resolve Partnership or Practice disputes/issues.

The LMC team can offer basic facilitation calls or visits to practices, but longer more complex facilitation may require professional facilitator input and we can signpost you to these services. We do not offer formal mediation services as this is a specialised area. BMA professional mediation

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Career Counselling

For those looking to change direction in Medicine or outside of Medicine signposting for career counselling.

There are schemes to help GPs carve out a career pathway tailored to their individual aspirations. The GP Career Support Hub has been created on FutureNHS to help doctors understand what options are available to them at different stages in their career.

MBTI Assessment

Where there have been personality clashes or difficulty working in teams. MBTI assessment and a coaching session that explores the individual’s preferences and their interactions with those around them can be helpful.

Specialist Mentoring

For those who are referred under Performance Procedures for mentoring support. Signposting to those who are familiar with requirements to be able to provide tailored support. (Note, those individuals requiring clinical supervision / retraining as part of performance procedures will be signposted to their local Deanery or NHS Resolution).

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Performance Procedures

All GPs want to do their best when seeing patients.

It is unlikely that a practitioner will end up in difficulties with performance procedures if they actively engage in the appraisal process, have an open and supportive practice environment, positively respond to patient concerns, observe their duty of candour and work in an environment where learning form mistakes is encouraged and shared via significant event analysis.

There are over 1,000,000 consultations per day taking place in general practice. Most are of high quality and repeated patient satisfaction surveys show that over 85% of patients rate their experience when seeing a GP as good and with nearly 50% saying it was very good. Compared with the volume of patients seen, the number of complaints a GP receives is very low.

GPs are all too aware that a serious performance issue could be referred to the GMC. Are you equally aware of the local performance procedures or what could happen if a complaint ended up with the ICB or the Ombudsman?

The local ICB has a role to protect patients, ensure services are run efficiently and effectively and support general practitioners when they are struggling in delivering safe, efficient and effective services

Every NHS region has medical directorates that have the power to investigate individual GPs and practices to the extent that they deem necessary. All GPs, whether partners, salaried or locums, are obliged to cooperate with the investigation process.

In more serious cases NHS directorates may impose restrictions on practice, refer for clinical assessment by NHS Resolution Practitioner Performance Advice Service (formally known as the National Clinical Assessment Service) or suspend doctors.

An NHS performance investigation can be triggered by an adverse incident, a safeguarding referral, reports from other health organisations or by local monitoring of performance and quality of care. An investigation may also result from a complaint made by anybody working in, attached to or associated with a practice. This would include clinical, administrative and managerial staff, pharmacists and community staff (such as health visitors, midwifes or district nurses). In addition, patients and/or their relatives can also bypass normal practice complaints procedures and complain directly to the NHS.

When a GP’s performance is questioned it is important to understand the context of the issues that are raised. Experience has shown that some of these issues are because of health issues, some are caused by employment or partnership issues and some are because of an individual’s performance falling below an acceptable standard. Inevitably, there are also some concerns raised that do not have any basis in fact.

If a GP has health issues they are required, under their registration with the GMC, to ensure this does not put patients at risk. The LMC often gets approached by GPs with health issues and can offer advice, help and support for those who need it.

If a GP has partnership issues or employment issues, again the LMC can offer help and advice.

The LMC has two roles in terms of performance, firstly, to support the individual GP and, secondly, to represent the profession in defining the standard of care that it would normally be acceptable for a GP to provide.

The LMC would always advise any GP that has been referred to the NHS Performance Team to cooperate openly and honestly.

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Local Performance Procedures

Following the Shipman Enquiry, a document was published called “Supporting Doctors, Protecting Patients”. This led the way, not only to the introduction of Revalidation, but also to the Performers List and locally based performance procedures. To work in general practice as a GP you must be registered with the GMC and be included in the Performers List. There is one single Performers List for England, managed by the Area Teams via PCSE. There are similar lists in Scotland, Wales and Northern Ireland. In order to practice within England, you will need to be included on the England Medical Performers List.

In 2013, the NHS introduced a National System of Performance Regulations that are now applied across England to provide fairness and consistency.

These procedures cover some but not all primary care performers, namely: GPs, Dentists and Optometrists. Pharmacists are not included on a performers list currently and therefore work under slightly different policies and procedures.

There are two stages to the procedures:

  1. The Performance Advisory Group (PAG).
  2. The Performers List Decision Panels (PLDP).

When a concern is raised about a GP, that concern will usually be referred to the Performance Team in the local office of NHS England. The referral may come from a variety of sources.

It can feel uncomfortable raising concerns about a colleague, but we have a professional duty to do so in order to protect patients. Serious concerns often come to light as a result of multiple, recurrent issues observed by colleagues.

The Performance Team consists of people who specialise in this area and will include GPs, other Clinicians, and Managers. The team have trained investigators, both clinical and non-clinical.

When instructed, a case investigator will visit a practice to collect evidence, possibly over the course of several visits. This may include viewing patient records, hospital letters, complaint letters, audits, witness statements, practice policies and procedures, and can include emails, social media posts and even CCTV or telecommunications data. Often the practice are asked to provide the information for review before a visit takes place.

They may undertake a random case review, with assessment of a random selection of consultations. Evidence may also be collected at interviews with clinicians, members of staff or other relevant individuals, with the provision of signed statements by those involved.

Clinicians who are interviewed as part of an investigation have the right to be accompanied, for example by a representative of their medical defence organisation. It is strongly advisable for clinicians to cooperate with the interview, as this is one opportunity in the process for them to set out their side of the case. A refusal to cooperate would invariably be a harmful strategy.

Most concerns will then have a period of fact finding and potentially an investigation and then the resulting information will be presented to the PAG. If a formal investigation becomes necessary, the GP will be informed of the criteria for investigation and a “Terms of Reference” document will be shared with them.

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The Performance Advisory Group (PAG)

The PAG meets regularly and consists of 4 voting members:

  • A senior NHS Manager with a performance role who will chair the PAG.
  • A discipline-specific practitioner nominated by the NHS England Area Team’s Medical Director.
  • A senior manager with experience in primary care and/or patient safety and experience.
  • A lay member.

In the Wessex LMCs area, the LMC is always invited to Medical PAG meetings, generally to represent the LMC as a non-voting member. On Occasion an LMC GP will be present as a discipline-specific practitioner. The role of the LMC representative is not to represent the individual GP but to represent the profession to provide a view as to what the normal standards expected of a GP would be.

Most cases that are presented to the PAG are dealt with at that point and outcomes may include:

  • No action is required.
  • There are some issues which are not serious, and advice is given.
  • There are issues which are deemed to be more serious and are referred to the PLDP.
  • The issues are serious and pose a potential threat to patients and these may be referred to a panel who have the power to suspend a GP.

It must be remembered the purpose of the PAG is to provide advice, support, and act where performance concerns have been raised. The PAG can choose to review cases after a period of time if advice has been given to a GP, to ensure that advised actions have been undertaken. Action or inaction by the GP on advice given may cause the PAG to change its decision.

Doctors do not attend the PAG but will be informed of the outcomes shortly after the meeting.

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The Performers List Decision Making Panel (PLDP)

The PLDP will consider fewer cases than the PAG and follows a much more formal structure.

Membership of the PLDP consists of the following individuals:

  • A lay member who will be the Chair of the PLDP.
  • A discipline-specific practitioner (i.e. GP).
  • A senior NHS England manager/director with responsibility for patient safety/experience.
  • The Medical Director for NHS England or their nominated deputy.

All members have a vote and the chair has the casting vote if necessary.

Additional non-voting members and advisors may also be invited by the Chair from time to time. The GP will be informed of the date and timing of the PLDP and would not be expected to attend in person. These meetings are held to discuss any paper evidence, and the GP is asked for their comments in advance of the meeting unless the concerns raised identify an immediate patient safety issue or an incident has been identified that would otherwise be in the public interest. If a proposal is made to take regulatory action the performer would then be invited to attend an “oral hearing”. The performer may be accompanied by a legal representative, or an advocate or an LMC member.

Note that there are two potential reasons why an LMC GP may be present. They may be there at the request of the individual GP. In this scenario they are present in a supportive and advisory capacity for the individual GP. If an LMC GP is on the Panel, however, they will be representing a view of the acceptable standards of the profession and not there making representation for the individual GP.

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What can the PLDP do?

Once a case is considered, the Panel have many options:

  • Exonerate the GP and essentially say that there is not a performance issue.
  • Detail concerns and suggest that the GP voluntarily undertakes some learning or change in practice.
  • Propose or invoke Regulatory action: e.g. decide that there are more serious concerns and place conditions on the GPs registration. So, this for example may be restricting the prescribing of controlled drugs or working under supervision etc. or it may be that there is a recommendation of training which the individual must undertake, or risk being removed from the performers list.
  • Suspend the GP. This is meant as a neutral act – (the GP would be prevented from working but may be entitled to receive 90% of their NHS income whilst under suspension). This is usually implemented where there are serious performance concerns and the facts are being investigated.
  • Referral to the Occupational Health Service and/or NHS Resolution to establish if there are any underlying health issues and if the practitioner needs support or special measures for them to continue working.
  • In the most serious circumstances, NHS England can remove a GP from the performers list and prevent them from working as a GP. It should be noted that only the GMC can prevent a doctor working as a doctor.

The important thing to remember is that this procedure is still about supporting doctors and protecting patients.

Most doctors will be unaware of the high level of collaboration and information sharing between NHS directorates and the GMC. As a regulatory body the GMC does not itself undertake detailed investigations and relies on the findings of NHS investigations. Practitioners have a right to appeal against PLDP decisions and to take these to tribunal.

In cases when immediate suspension is required under Regulation 12 (6) a decision may be taken outside of the PLDP meetings by the medical director, with one other director. This decision must be reviewed by two members of the PLDP or a complete panel, who have not been previously involved in the decision to suspend, or have any other conflict of interest, within two working days, beginning on the day the decision was made. The case must then be considered by the PLDP. Considerations will include whether further investigation is necessary, or if further regulatory action is appropriate.

The LMC have sat on many of these panels and we believe them to be fair and proportionate. We recognise that to go through this process for anyone is hugely stressful and not something that anyone would wish to have to undergo. The Panels are not “out to get you”, nor are they ‘anti’ the profession but there are some important factors you should be aware of:

  • The Panel is looking objectively at the evidence to see if the GP’s performance has fallen below an accepted standard and
  • If this is the case, the Panel asks if the inadequate performance put patients at risk
  • The Panel also looks for evidence that the practitioner shows insight – you would be amazed how many practitioners try to justify what is clearly indefensible – the Panel is looking for insight, humility and reflection.
  • If something has gone wrong, it is important to consider what you have learnt and what you will do to prevent this happening again and if changes to your current practice are appropriate.
  • Remember, this is largely about support and patient safety, not punishment!

More detailed information about the performance process is available here:

https://www.england.nhs.uk/publication/framework-for-managing-performer-concerns/.

GMC guidance on raising and acting on concerns about patient safety:

https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/raising-and-acting-on-concerns

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NHS Resolution Practitioner Performance Advice.

Practitioner Performance Advice is a service delivered by NHS Resolution under the common purpose, to provide expertise to the NHS on resolving concerns fairly, share from learning for improvement and preserve resources for patient care.

https://resolution.nhs.uk/services/practitioner-performance-advice/.

They are an operating division of NHS Resolution. (https://resolution.nhs.uk).

They provide impartial advice to healthcare organisations to effectively manage and resolve concerns raised about the practice of individual practitioners.

They are a good initial point of contact to confidentially discuss concerns one may have about a clinician’s performance or behaviour. They can offer you support in order to prevent escalation of the difficulties. Where appropriate they may feel that it is necessary to advise you to refer to the NHSE Performance Team or GMC

It would be expected that the practice manager would initiate contact with NHSR rather than the individual clinician or their colleague.

The advice they offer focuses on:

  • the fair and effective application of the healthcare organisation’s own local performance management and associated procedures
  • good practice in relation to local case management and investigation
  • helping to identify and consider options available to the healthcare organisation to address and resolve concerns raised about an individual’s practice
  • signposting available avenues of professional support and other resources

They are also able to provide advice directly to practitioners who may, for example, be concerned about some aspect of their own practice, or wish to access advice about rebuilding their skills after a career break.

Their advice is provided by an established team of Advisers, including GPs, comprising senior staff who are aligned regionally to specific healthcare organisations and NHS regions across England, Wales and Northern Ireland.

In some cases, they can offer more detailed input to support the management and resolution of the concerns raised about a practitioner, through their assessment and intervention services. These services include:

  • detailed, comprehensive and evidence-based assessments of an individual practitioner’s behaviour and/or clinical performance in the workplace. Their assessments provide findings and conclusions aimed at informing a clear way forward to bring the case to a resolution. This may involve a whole day in depth psychological interview and Hogan Development Survey. Clinical performance assessment is undertaken by 2 Peers over 2-3 days in the workplace observing consultations, reviewing records, case-based discussions and Interview. This service is free of charge.
  • professional support and remediation services to develop action plans to address concerns and help return an individual practitioner to safe and effective clinical practice. e.g. after prolonged sickness or extended maternity leave. This is free of charge.
  • assisted mediation in which Practitioner Performance Advice accredited mediators work with the parties in dispute on a confidential and impartial basis to help resolve difficulties which are impacting on professional relationships at work. There is a charge for this service.

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Financial entitlements for suspended GP Partners.

Suspension is supposed to be a neutral act, but practices need to ensure they know what to do financially should a GP be suspended from practice.

There are two processes:

The General Medical Services Statement of Financial Entitlements Directions

Under the directions, in any case where a partner (or GP employee)

  • is receiving at least 90% of normal monthly drawings
  • has done for at least six months whilst suspended
  • is still a partner or employee
  • and a locum has been engaged to cover the absence
  • and no payment has been claimed elsewhere for the locum

then NHS England must provide financial assistance for cost of said locum.

However it is for NHS England to decide whether or not it is necessary to engage the locum.

The Secretary of States Determination: Payments to Medical Practitioners Suspended from the Performers List

The Determination is more favourable for payments when a suspension occurs, allowing the practice to decide on the necessity of employing a locum.

However, in this case, payments, of at least 90% of normal monthly drawings/salary, to a partner / GP employee / locum must cease when suspension occurs. Payment of 90% of normal drawings/salary will then be made by the ICB directly to the GP performer.

This of course means that the practice can use the withdrawn drawings/salary to pay for a locum.

It is very important however that partnership agreements reflect this and give the remining partners the ability to withdraw the drawings form the suspended partner and to be able to use the amount of withdrawn drawings to pay for a locum.

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Useful Performance Team Contact Details

If you are a General Practitioner in the South West of England (BSW & Dorset), you will connect to the local office that manages the performers list for that area:

  • NHS England – South West

Email: england.southwestperformerslist@nhs.net

  • Iona Neeve, Head of Professional Standards, South West.

Email: iona.neeve@nhs.net   Tel: 07733 455609

  • Medical Director/Responsible Officer: Dr Kheelna Bavalia – bavalia@nhs.net

If you are a General Practitioner in the South East of England (HIOW), you will connect to the local office that manages the performers list for that area:

  • NHS England – South East

Email: england.htvps@nhs.net

  • Jeniene Scott, Head of Professional Standards

Email: jeniene.scott@nhs.net  Tel: 07824 461605

  • Medical Director/Responsible Officer: Dr Shahed Ahmad – ahmad1@nhs.net

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The General Medical Council (GMC)

All doctors who provide patient services in the U.K. must be registered with the GMC. All GPs should be aware of their obligations and the responsibilities that this bestows on them which are detailed in the GMC’s guidance “Good Medical Practice”. This document sets out the core professional standards expected of all doctors and covers fundamental aspects of a doctor’s role, including working in partnership with patients and treating them with respect.

GPs may be referred to the GMC by a patient, by a colleague or via the local performance procedures. This may be due to direct concerns about performance or may be related to a health issue (such as alcohol or drug addiction) that may adversely impact on the performance of a doctor.

The GMC can take action if the doctor’s fitness to practise is impaired. This may be for a number of reasons:

  • misconduct
  • poor performance
  • a criminal conviction or caution in the UK (or elsewhere for an offence which would be a criminal offence if committed in the UK)
  • physical or mental ill-health
  • a determination (decision) by a regulatory body either in the UK or overseas
  • lack of the necessary knowledge of English language to be able to practise medicine safely in the UK.
  • If they believe that a doctor’s fitness to practise may be impaired, they can:
  • agree undertakings with the doctor
  • place conditions on their registration
  • suspend their registration
  • remove them from the medical register.

If they believe their fitness to practise is not impaired but there has been a significant departure from the principles set out in our guidance, Good Medical Practice, they can issue a warning to the doctor.

Whatever the reason is, and whether there are grounds for the referral or not, this will be a hugely stressful time for any doctor, and they may well need help and support.

If you are facing a complaint that has been made to the GMC it is incredibly important that you seek specialist advice around filling out any forms that they send to you about you side of the issue. This may be from your MDO or a lawyer (if your MDO will not help).

The GMC review all complaints carefully to see if there are issues that they need to investigate. In some instances, they may decide to carry out a provisional enquiry. A provisional enquiry is a limited, initial enquiry at the outset of the process which helps them to decide whether to open an investigation.

If they decide that they are not the right organisation to investigate the complaint, they may pass it to your responsible officer to consider as part of your wider practice. They may also ask you to pass the complaint to the local complaints procedure to be dealt with locally by your NHSEI Performance team.

If they believe potentially serious concerns are being raised, they will investigate further themselves.

They do not normally investigate complaints about matters that took place more than five years ago, unless they consider that it is in the public interest to do so.

Before they begin an investigation, the GMC will tell you about the complaint that has been made about you and ask for details of your employer.

They will give you the opportunity to comment on the complaint. You don’t have to comment at this stage, but if you do, it may help them to resolve the case more quickly. There will be another chance to comment later if there is any likelihood of the case being referred to a hearing. Before commenting we would strongly recommend discussing your response with your MDO or a legal representative if this support is not available.

Good Medical Practice makes it clear that you must cooperate fully with any formal inquiry into the treatment of a patient and with any complaints procedures that apply to your work. You should always contact your defence organisation for advice.

The GMC will usually ask your employer and local Responsible Officer if they have any other concerns about your fitness to practise. This is to make sure they have a better picture of your fitness to practise and to allow them to feed into local clinical governance.

How they conduct the investigation will depend very much on the nature of the concerns. For instance, the investigation may involve getting:

  • further documentary evidence from, for example, your employer or the complainant
  • witness statements or expert reports on clinical matters
  • an assessment of your performance
  • an assessment of your health
  • an assessment of your knowledge of the English language

The GMC can pass complaints back to be handled under local performance procedures if they think that the complaint would not raise questions about your fitness to practice even if proven.

At the end of the investigation, two senior GMC staff known as case examiners, one medical and one non-medical, will review all the evidence collected and decide whether to:

  • conclude the case with no further action
  • issue a warning
  • agree undertakings to address a problem, or
  • refer the case to the Medical Practitioners Tribunal Service (MPTS) for a medical practitioners tribunal.

The medical and non-medical case examiners must agree to close a case or refer it to the MPTS for a hearing. If they fail to agree, the case is considered by the Investigation Committee, a statutory committee of the GMC.

If the case examiners or the Investigation Committee decide that your fitness to practise is not impaired, but that you were in breach of our guidance, they can issue a warning.

The Investigation Committee will also consider a case when case examiners consider that a warning is appropriate, but the doctor has disputed the facts, or requested a hearing of the Investigation Committee. The hearing will take place in public.

Unless the case is about your health, the GMC will tell you and the complainant what the case examiners’ decision is and their reasons. If the case is about your health, they will tell you and the complainant what the case examiner’s decision is, but will only give you their reasons. This is because they treat information about a doctor’s health as confidential.

At any stage in the investigation, they can refer you to the Medical Practitioners Tribunal Service (MPTS) for an interim orders tribunal hearing. This tribunal can suspend you or restrict you from practising while the investigation continues if they decide this is necessary to protect the public. For more information on MPTS interim orders tribunals, read their Representative resources – MPTS (mpts-uk.org)

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Warnings and Undertakings. . .

A warning is appropriate if concerns indicate a significant departure from the principles set out in GMC guidance or if there is a significant cause for concern but a restriction on your registration isn’t necessary.

A warning can be issued by case examiners, the Investigation Committee or by a medical practitioners tribunal at a hearing. For five years after it is issued, the GMC will disclose a warning to your employer and to anyone else who enquires.

A warning cannot be issued if the concerns relate exclusively to your physical or mental health.

Undertakings are an agreement between the GMC and a doctor about the doctor’s future practice. Undertakings may include restrictions on your practice or a commitment to practise under medical supervision or to undergo retraining. They allow the GMC to deal effectively with certain types of case without having to refer the matter to a hearing.

Undertakings can be agreed with doctors at the end of an investigation.

Undertakings might include restrictions on your practice or behaviour, or commitments to having medical supervision or retraining.

This information is largely taken from the GMC page:

https://www.gmc-uk.org/concerns/doctors_under_investigation/a_guide_for_referred_doctors.asp

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The MPTS …

The MPTS makes decisions about doctors’ fitness to practise. It is part of the GMC, but operationally separate and accountable directly to Parliament.

Medical practitioners tribunals consist of specially trained people, both lay and medical, who will hear all the evidence and decide at the end of the hearing whether the doctor’s fitness to practise is impaired. If it rules that it is, the tribunal will decide what sanctions may be needed to protect patients.

If the GMC refers your case to the MPTS for a hearing, they will write to you to set out the allegations. Again, it is important that you seek advice from your defence organisation if you have one or from a solicitor.

Hearings are held in public unless they are considering evidence about your health.

The tribunals are held at the MPTS hearing centre in Manchester

Emotional Support …

Please see the Complaints section for details of support offered to GPs going through any complaint. Please note that there is also a dedicated support service for doctors going through a GMC complaint called the Doctors Support Service (details in the Complaints section).

The BMA also have a dedicated service to help manage the stress.  Website: https://www.bma.org.uk/advice/work-life-support/your-wellbeing/doctor-support-service

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GPs with Financial Difficulties

Through no fault of their own GPs, as with any other person in life, can fall on hard times. There are a number of charities who can provide confidential financial advice and support to those in genuine financial need to get their lives and careers back on track.

If you need help with household expenditure, house repairs or adaptations, mortgage/ rent arrears, training or return to work expenses or school fees and some medical costs – these charities may be able to help.

Five of the charities in this sector have come together under a single portal to help individuals find the support they need.

These include:

  • The Cameron Fund*
  • The Society for the Assistance of Medical Families
  • The Royal Medical Benevolent Fund
  • The Royal Medical Foundation
  • BMA Charities

The single portal can be found here – Help me, I’m a doctor. A short, anonymous questionnaire helps you select the appropriate charities who might be able to help.

The Cameron Fund is the medical profession’s only charity providing help and support solely to General Practitioners and their dependent family, who find themselves living in financial hardship or distress.

* The Cameron fund have produced the following publication:

Money Management for newly qualified and working GPs – 10 Top Tips for Financial Wellbeing

 

Have you heard of the Cameron Fund?

Dr Will Howard, Medical Director at Wessex LMCS, talks with Vernon Needham, trustee of the Cameron Fund. Click on the image below to access the podcast.

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Support for the Whole Practice

It’s not just me, it’s my whole practice. . .

If you are finding that your whole practice is feeling the strain, you are not alone. General Practice is finding itself under unprecedented pressure and practices across the board are feeling this.

Whilst we can’t solve the national crisis single handily, rest assured your LMC is fighting for your corner every day to try and ensure fair and adequate resourcing for General Practice. We want GPs to be able to continue offering the same high-quality service that we have always strived to offer.

We believe that nationally it is recognised that General Practice is a vital part of the NHS and that has been chronically underfunded for the past decade. The GP Forward View has promised more funding and offers some solutions. The multifactorial nature of the GP crisis means a multifactorial solution. These are hard to organise when it involves so many government departments that are not necessarily cognisant of the far-reaching effect of the ripples of their individual actions.

If you feel your practice is in a place where it can’t wait for the wheels to turn again then please contact the LMC. We can offer a confidential meeting with a Medical Director or Director of Primary Care to discuss the issues that your particular practice is facing and help you to identify sources of support and potential avenues to explore.

Practice Manager Supporters

Wessex LMCs is delighted to offer support to Practice Managers through our Practice Manager Supporters who are based throughout Wessex.

Practice Manager Supporters provide ad hoc advice and support to their practice manager colleagues and offer learning opportunities to support Continuous Professional Development for PMs. The PM Supporters offer coaching and mentoring to new and experienced practice managers and have specific training to enable them to appraise fellow practice managers. They offer support in person, via email or on the telephone.

The Practice Manager Supporters will work in a completely confidential way, but are duty bound to take forward any issues that are brought to their attention that may be unsafe in any way. They are not able to offer any legal advice but will assist in signposting their colleagues towards useful resources and assistance. They will contact new Practice Managers to introduce themselves and offer any support that they might need.

The PM Supporters are financed for two sessions per month by the LMC, to support the practices. Further details here:  Wessex LMCs: Practice Manager Supporters.

See also Health and Wellbeing for the practice team (non-GP)

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Other Potential Avenues of support include. . .

NHSE General Practice Improvement Programme (GPIP)

The programme will provide support for practices and PCNs over two years (2023 – 2025) to make changes and improvements to how they work.

The programme is offering Universal, Intermediate and Intensive support along with supporting transformation in general practice. See the web page for full details.

NHS England » National General Practice Improvement Programme

RCGP consultancy and support programme

Offers tailored advice and support to GP practices seeking to improve and develop their services and workforce. PCD: GPs and practice team members

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Mediation Services

The pressures and demands of working as a GP are often intense and conflicts between work colleagues can arise.

Experiencing these difficulties can be enormously stressful and can affect the smooth running of your practice.

Early intervention can be key to avoid strain on working relationships, and to give each party the best chance to resolve issues positively.

The LMC are often approached for support in finding a solution to these difficulties.

Mediation is a specialist area and as an organisation we recognise that it lies beyond the scope of our office team. We can offer informal facilitated conversations to try to allow parties to diffuse situations and come to an agreed way forward but if this is not possible or the issue is already beyond this, we would generally signpost towards formal mediation services.

The BMA offer Interpersonal Mediation Service for GP Partners in dispute. This is free as part of BMA membership and not all Partners need to be members. Interpersonal mediation service for GP partners in dispute

The RCGP also offer mediation.

You do not need to be an RCGP member to access this but there is a fee.

NHS Resolution offer Assisted Mediation. There is a fee for this service.

Assisted mediation – NHS Resolution

There are of course other private companies also offering professional mediation services.

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Support for Locums / Sessional GPs

Being a locum gives huge flexibility but can lead to feeling isolated. It is vital both for you professionally and personally to make sure you look after yourself and keep linked in with others. Each person is different and there are multiple ways of finding that support.

Here we suggest some different organisations or groups that you might wish to consider, although most of the advice above is also relevant. You can also contact our office and we may be able to give you other local contacts and can make sure that you receive our emails which are full of information to keep you in touch with what is happening locally and in the wider NHS.

NHS GP Health Service

NHS Practitioner Health is a free, confidential NHS primary care mental health and addiction service with expertise in treating health and care professionals, open to GPs and GP trainees in England.

To access the service, complete the online form or call 0300 0303 300, 8am – 8pm Monday – Friday and 8am – 2pm Saturday. 

Small Groups

Voices in support of general practice – GP Survival

https://www.facebook.com/GPstateofemergency/

https://www.facebook.com/groups/GPSurvival/

Resilient GP – https://www.facebook.com/groups/ResilientGP/ – discussions of issues with primary/secondary care interface

First 5 & Sessional GPs (Dorset) –  https://www.facebook.com/groups/490993870926817/

Tiko’s GP Group on Facebook – https://www.facebook.com/groups/tikosgpgroup/ – Appropriately anonymised clinical issues

Your lifeline: Why you should join your local Sessional GP group: https://www.bma.org.uk/connecting-doctors/the_practice/b/weblog/posts/your-lifeline-why-you-should-join-your-local-sessional-gp-group

Practice Based Small Group Learning – https://www.pbsgl.co.uk/

Peer Support Groups – Hampshire – contact rose.debell@uhs.nhs.uk

BMA Sessional GPs Subcommittee

https://www.bma.org.uk/collective-voice/committees/general-practitioners-committee/gpc-subcommittees/sessional-gps-subcommittee

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Last Reviewed Date
08/12/2023