1. The Problem Registrar Dr Kevin Hill Deputy Postgraduate GP Dean East Midlands Healthcare Workforce Deanery

2. Potential Problems INDIVIDUALORGANISATION HEALTHCARE SYSTEM Health Personal Clinical Conduct Team skills Communication Leadership Cultural issues Changing systems

3. Individual issues HEALTH CONDUCT CLINICAL KNOWLEDGE & SKILLS Physical Mental Behaviour Substance abuse Aging Internal – fraud, prescriptions External – convictions Lack of basic knowledge Approach to CPD Consultation skills

4. Problems identified Usually multi-factorial Knowledge ‘Rusty’ clinical skills Application of knowledge in the general practice context Consultation skills –Language –Communication skills Attitudinal and behavioural problems –Professional values –Cultural issues –Team-working Health / Personal life issues Conduct problems Impact on relationship with GP Trainer

5. The Players CHRE Civil Courts Deanery PCT Practice GMC Criminal Courts NHS Ombudsman Healthcare Commission LMC Media Medical Defence Legal Advisers Patients / Relatives NCAS ARCP Panel Occupational Health GP Trainer Programme Director Police / CPS BMA

6. Complaints Procedures Patient Practice Primary Care Trust Healthcare Commission NHS Ombudsman Legal Advisers Civil litigation Medical Defence

7. Training Support GP Trainer / E.S. Programme Director ARCP Panel Deanery BMA Legal Advisers

8. Conduct General Medical Council Council for Healthcare Regulatory Excellence Employer Disciplinary Procedures Police Crown Prosecution Service Criminal Courts Deanery

9. Conduct YOU are the employer Follow the normal disciplinary procedures [BMA Framework for a written contract of employment for GP Registrars] Keep the Deanery informed

10. Reference material A guide to Specialty Training in the UK ‘The Gold Guide’ Maintaining High Professional Standards in the NHS BMA Framework for a written contract of employment for GP Registrars NHS (Performers List) Regulations 2004

11. A difficult balancing act Ensuring patient safety Supporting the doctor in difficulty Supporting the Trainer / Trust as educational supervisor Recognising that the Practice or Trust is the employer Financial implications

12. Case study – Dr P Discuss in with your neighbours Consider What factors might be contributing to this doctor’s difficulties? How would you initially manage this in your practice? What help might you call on?

13. Deanery arrangements The Deanery is not a ‘Magic Box’! We don’t have hospital posts or training practice placements that are ‘sin bins’ Operationally existing training practices or additional hospital posts have to be used for ‘targeted training’ –In hospital posts this is done by additional funding being granted for locum cover to make the SHO ‘supernumerary’ in their existing post –In practice this entails additional time in a ‘targeted training placement’ Training extensions now determined through ARCP process ‘usually a maximum of SIX months’

14. Deanery arrangements Practice Initial local action – discussion with Programme Director / ‘patch’ Associate GP Dean Informal discussion with Deputy Director responsible for performance Hospital Involve Trust Educational Supervisor / Clinical Director Involve Human Resources All Doctors in training Formal referral for Deanery review and support –Referral sheet –Background information Doctor / Trainer has discussion with Training Support Unit TSU Reference Group – advice / monitoring

15. Current options 1 Targeted training placement Focussed work on knowledge, skills, communication –Within current placement –In an alternative placement [Deanery may pay enhanced training grant during targeted training period depending on level of supervision required] Consultation & Communication skills Training Support Unit Simulated Patients Occupational psychologist Myers Briggs Multi-source feedback

16. Current options 2 Occupational Health Assessment Counselling support Time limited confidential counselling Coaching Career management advice Focussed discussion on career aspirations, development, and alternative options

17. Decision time At the end of a targeted training placement (ARCP Review) Sufficient progress has been made such that there is a substantial likelihood of successful completion of the training programme – return to formal training programme Progress made but not yet ready to return to formal training programme – agree further targeted training [GP Dean must agree but risk of deferring the inevitable!] Unlikely ever to reach required standard – exit programme and seek alternative career path [Right of appeal / risk of litigation]