The Management of Suspensions of Clinical Staff in NHS Hospital and Ambulance Trusts in England REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1143 Session 2002-2003: 6 November 2003 The National Audit Office scrutinises public spending on behalf of Parliament. The Comptroller and Auditor General, Sir John Bourn, is an Officer of the House of Commons. He is the head of the National Audit Office, which employs some 800 staff. He, and the National Audit Office, are totally independent of Government. He certifies the accounts of all Government departments and a wide range of other public sector bodies; and he has statutory authority to report to Parliament on the economy, efficiency and effectiveness with which departments and other bodies have used their resources. Our work saves the taxpayer millions of pounds every year. At least £8 for every £1 spent running the Office. The Management of Suspensions of Clinical Staff in NHS Hospital and Ambulance Trusts in England REPORT BY THE COMPTROLLER AND AUDITOR GENERAL HC 1143 Session 2002-2003: 6 November 2003 Ordered by the LONDON: The Stationery Office House of Commons £10.75 to be printed on 3 November 2003 This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act. John Bourn National Audit Office Comptroller and Auditor General 3 November 2003 The National Audit Office study team consisted of: Simon Smith, Matt Evans, Jeff Round and Alison Terry under the direction of Karen Taylor This report can be found on the National Audit Office web site at www.nao.gov.uk For further information about the National Audit Office please contact: National Audit Office Press Office 157-197 Buckingham Palace Road Victoria London SW1W 9SP Tel: 020 7798 7400 Email: [email protected] THE MANAGEMENT OF SUSPENSIONS OF CLINICAL STAFF IN NHS HOSPITAL AND AMBULANCE TRUSTS IN ENGLAND Contents Executive summary 1 Appendices 1. Methodology 40 Part 1 2. The Suspension of Dr O'Connell 42 - PAC Recommendations and NHS response The scale and costs of exclusions 11 3. The National Clinical Assessment Authority 45 4. The National Patient Safety Agency's 47 Why clinical staff may be excluded from work 11 Decision Tool Committee of Public Accounts hearing on 12 The Suspension of Dr O'Connell Bibliography 49 The Department's monitoring of the cost and 14 duration of exclusions Our survey of trusts and methodology 15 The cost of exclusions 19 Part 2 The efficiency of the exclusion process 23 The Department's guidance on the 23 suspension process Trusts' exclusion policies 24 The effectiveness of trusts’ procedures 24 Part 3 Protecting patients and other staff 35 where clinical staff are excluded Use of alert letters 35 Other employment checks undertaken by trusts 36 Protecting patients when a clinician resigns or 37 retires during investigation Supporting Doctors, Protecting Patients 37 THE MANAGEMENT OF SUSPENSIONS OF CLINICAL STAFF IN NHS HOSPITAL AND AMBULANCE TRUSTS IN ENGLAND executive Executive Summary summary 1 There are 700,000 clinical staff providing direct care to patients in NHS hospital and ambulance trusts in England, 75,000 consultants, doctors and dentists (referred to as 'doctors' in this report) and 625,000 other clinical staff, such as nurses, midwives and other health professionals. From our survey of these trusts we found over 1,000 clinical staff were excluded for more than one month between April 2001 and July 2002 and we estimated annual additional costs to the NHS of £29 million, covering the costs incurred on staff cover to replace the excluded clinician, management time related to the administration of the exclusion, and legal costs. The £11 million employment costs of the excluded clinicians are not included as these costs would be incurred in any event. NHS spending in 2002-03 was almost £55 billion and if exclusions were managed more effectively, for example if all exclusions were concluded within six months, additional resources worth some £14 million a year would be available. Figure 1 presents our key findings and Appendix 1 describes our methodology. 1 Key findings Extent of exclusions The cost of exclusion ! Between April 2001 and July 2002 ! The annual additional cost of over 1,000 clinical staff were exclusion is £29 million. excluded from NHS Hospital and ! The annual employment cost of Ambulance Trusts in England. excluded clinicians is £11 million. ! Exclusions averaged 47 weeks ! If exclusions were completed for doctors and 19 weeks for other within six months additional clinical staff. resources worth £14 million a ! Doctors made up one fifth of year would be available. all exclusions. ! The average cost of excluding a ! 40% of doctors and 44% of other doctor is £188,000. clinical staff returned to work. ! The average cost of excluding other clinical staff is £21,400. ! Doctor exclusions account for three quarters of all costs. Types of exclusions Reasons for exclusion ! Formal suspensions - 88% of ! Professional competence, where exclusions in our survey. there are concerns about clinical performance - 44% of doctor cases ! Other exclusions, sometimes and 19% of other clinical staff in referred to as 'gardening leave', our survey. y cover special leave, and extended ar sick leave. ! Professional conduct, where there m m are concerns about the clinician's u ! Ra ecsltirnicictiioann sm oany pbrea cptirceev ewnhteedre professional relations with patients. ve s from undertaking certain types of ! Personal conduct, where there are uti clinical work. concerns which are not related to ec x undertaking clinical duties. e ! For all exclusions, the clinician receives full pay. 1 THE MANAGEMENT OF SUSPENSIONS OF CLINICAL STAFF IN NHS HOSPITAL AND AMBULANCE TRUSTS IN ENGLAND 2 While the cost of excluding clinicians is significant, there is also a loss of clinical skills as a result of the enforced absence, with staff being paid to stay at home and not normally allowed to treat patients. For the clinician, exclusion can result in reduced self-esteem and depression, and in some cases, the clinician may feel suicidal. The clinician's family can also be adversely affected. A number of clinicians never work again, even if they are exonerated by enquiries. Clinical staff may well have undertaken expensive training and, with shortages of many staff across the NHS, unnecessary exclusions or cases where clinicians consider they have been driven out of the health service are of concern, both in terms of personal fairness and equity, and waste of scarce resources. Professor Wendy Savage "The loss of my job was like a bereavement. Powerful, confusing and shifting emotions swept over me - disbelief (can this really be happening?), sadness, guilt, self-doubt and anger." Source:Wendy Savage 'A Savage Enquiry' Virago Press Ltd 1986 3 Trusts may exclude clinical staff from work where there are concerns about patient safety or where there are allegations of gross misconduct to enable them to undertake investigations. Exclusions may be done to protect the interests of patients, other staff, or the clinician concerned until the outcome of an investigation is known. Formal suspension is deemed in law a 'neutral act' but in practice it is rarely perceived as neutral by NHS staff, patients or the wider public. 4 On the other hand patient safety is paramount and highly publicised incidents such as those which occurred over children's heart surgery in Bristol1, where poorly performing doctors continued to practice, highlight the importance of effective arrangements for investigating allegations. Where patient safety is at risk, the opportunity to exclude staff from work or restrict their activities so that the situation can be defused and investigated at the earliest opportunity is vitally important. But all parties need to be confident that the process is fair, open and transparent, and the Department of Health (the Department) has a key role to play in encouraging local trust management to establish an open culture for reporting and examining clinical incidents and promoting organisational learning. 5 Cases are often high profile and the Committee of Public Accounts examined the case of Dr O'Connell, who was suspended for more than 11 years, in its 1995 report.2 Since then there have been a number of cases of doctors being excluded for many months and sometimes years. This report examines the extent and costs of exclusions, the management of the process by trusts and the effectiveness of arrangements to protect patients where staff are excluded. Whilst it tends to focus on doctors because of the costs and high profile of such cases, it includes data on the exclusion of all clinical staff and draws on recent research on nurse suspensions. We have also published a complementary report 'Achieving Improvements through Clinical Governance' (HC 1055, Session 2002-03) which examines the wider aspects of improving clinical y ar quality and safeguarding high standards of care.3 m m u s e v uti c e x e 2 THE MANAGEMENT OF SUSPENSIONS OF CLINICAL STAFF IN NHS HOSPITAL AND AMBULANCE TRUSTS IN ENGLAND 6 A number of organisations are involved in managing the exclusion of clinical staff and supporting poorly performing clinicians: ! The Department provides central guidance and monitors suspensions of doctors lasting more than six months. In April 2001 it established the National Clinical Assessment Authority to provide an expert advice and assessment service where there are concerns about a doctor's performance. ! Trusts as employers are responsible for instigating all exclusions and their management, with chief executives ultimately accountable for decisions. Some consultants who were in post before 1990 retain national contracts and have a right of appeal to the Secretary of State if dismissed on grounds of professional competence or conduct. Under the Department's proposals for new contracts, those consultants would no longer have such a right of appeal to the Secretary of State. ! Professional regulatory bodies such as the General Medical Council and the Nursing and Midwifery Council are responsible for maintaining professional registers and conducting disciplinary investigations which can result in clinicians being struck off the professional register. They also encourage staff to undertake appropriate continuing professional development. ! The professional Royal Colleges provide external expertise. Trusts may invite rapid response teams from the Royal Colleges to carry out an independent assessment of a clinician and make recommendations for future training and employment. ! Professional associations and trades unions provide support to excluded clinical staff. Also the medical defence organisations and their lawyers represent many doctors in investigations. 7 In July 2001 the Department established the National Patient Safety Agency to encourage the reporting of patient safety incidents and to learn from analyses of such incidents. Its work promotes an open culture where trusts look to identify systemic weaknesses rather than focus on shortcomings of individuals. In the past such patient safety incidents have tended to result in clinicians being excluded from work and the Agency expects that its work might help reduce such exclusions. 8 Before the establishment of trusts in the early 1990s, Regional Directors of Public Health were called upon to advise hospital and health authority managers about exclusions and subsequently developed a degree of expertise. But trusts are likely to see only a handful of possible exclusion cases and they therefore need a clear framework of guidance from the Department and access to expertise. The Department's main guidance on managing the exclusion process was issued in 1994 and it has been working on revising it since the y Committee of Public Accounts ar m hearing in 1995. m u s e v uti c e x e 3 THE MANAGEMENT OF SUSPENSIONS OF CLINICAL STAFF IN NHS HOSPITAL AND AMBULANCE TRUSTS IN ENGLAND 9 More progress has been made in providing access to expertise. Since his appointment in 1999, the Chief Medical Officer, Sir Liam Donaldson, has taken a close interest in long term cases of doctor suspensions. Following consultation on 'Supporting Doctors, Protecting Patients',4 in April 2001 the Department established the National Clinical Assessment Authority to provide expert advice to trusts and doctors (Appendix 3). In its first two years of prototype operations it received 500 requests from trusts and dealt with most of these through advice and support, and in 10 per cent of cases it has needed to carry out a full clinical performance assessment of the doctor. The Authority has helped prevent a number of suspensions. For example it analysed a sample of 36 referrals and in 30 cases identified alternatives to suspension. The Authority has developed targets for dealing with enquiries, ranging from a 24 hour emergency service to completing detailed assessments in three months. It has not proved possible to achieve all turnaround targets as in part the Authority is dependent on cooperation with a number of organisations and people - trusts and other organisations referring doctors to it, Royal Colleges, the General Medical Council and doctors. In December 2001 the Chief Medical Officer wrote to all trusts, emphasising the need for them to consult the Authority prior to suspending a doctor but our survey found that a number of trusts had not contacted the Authority. 10 Some doctors who have gone through the assessment process told us of their concerns, pointing to an overall lack of transparency. There was uncertainty about timetables and who was to be interviewed, and it was not clear how doctors' comments on draft reports were to be incorporated. 11 In addition to the National Clinical Assessment Authority, in 2002 the Chief Medical Officer appointed a former human resources director, as a special adviser, to review suspension cases lasting more than six months and advise trusts. By April 2003 he had reviewed over 50 cases and helped resolve two thirds of them. The Chief Medical Officer has also undertaken a special exercise to identify the extent of informal suspensions, sometimes referred to as 'gardening leave', amongst doctors. Since June 2003 the Chief Medical Officer’s adviser transferred to the National Clinical Assessment Authority to take forward the review of long term exclusions whilst continuing to provide direct advice to the Chief Medical Officer. 12 As demonstrated by the establishment of the National Clinical Assessment Authority and the appointment of the Chief Medical Officer's special adviser, the Department's focus has been on doctors and there are no similar arrangements for other clinical staff. The Department's Clinical Governance Support Team, part of the Modernisation Agency, has a role to play in promoting effective team working. As part of Shifting the Balance of Power,5the Strategic Health Authorities' performance management role should include effective scrutiny of trusts' management of exclusions and they may be able to provide external advice. y ar m m u s e v uti c e x e 4