NCAS Conference 3rd February 2011
Summary of Conference of National Clinical Assessment Service
Disruptive Behaviour:Tackling Concerns about Practitioner Performance.
Queen Elizabeth 2 Conference Centre, London
3rd February, 2011
After welcoming the 700 delegates, Professor Alistair Scotland, Medical Director of NCAS , opened the session on Disruptive Behaviour-Symptom, cause or both, with a presentation on ‘What you think you are looking at may not be what you are seeing-ten years experience at NCAS’
One doctor in 200, 1 dentist in 250 are referred to NCAS each year, there are about 1000 referrals a year. .The overlap with professional regulators is very small
The groups more likely to be referred are those who are older, of consultant grade, male, single handed if in GP, or if in secondary care non white and an overseas graduate.
Conduct is defined as:- a specific incident which breaches operating rules and may lead to disciplinary action-e.g he attacked him.
Behaviour is defined as :- how an individual typically acts and interacts with others at work:- eg he is bad tempered. Concerns about behaviour, conduct, health and governance issues all overlap. .Clinical knowledge and skills are closely linked to and influenced by health, work context and behaviour. .Non clinical concerns include conduct issues:- theft, breach of contract, misuse of resources, use of pornography at work, sexual misconduct, assault, bullying, harassment, or discrimination. Also behavioural issues:- communication, team working, style of leadership and workload management. Personal concerns include :- aggressive, ,erratic or withdrawn and isolated behaviour.
Health issues include:- physical and mental health issues, disability, cognitive problems, alcohol or drug misuse. .Issues in the work environment include:- team working, ,issues with support systems or other resource problems. There may also be personal issues underlying all these. .Health concerns are more prominent in white and other UK graduates, psychiatrists and pharmacists[small sample]Clinical and governance concerns are more prominent in the GP sector and in older and higher grade practitioners .Behavioural issues increase between ages 40-50 which may simply reflect the U bend of life, as self reported well being dips at that time. Behaviour and conduct do appear to be associated.
General themes from what NCAS is told:-Conduct issues more prominent in younger and training grades, behavioural issues more common in consultants, rising to middle age, then declining, women have fewer conduct but more behavioural concerns. Dentists and Pharmacists:- fewer behavioural, more conduct issues, GPs:- more clinical and governance issues, less behavioural issues, General Medicine:- less clinical and governance issues, more behavioural issues, Psychiatrists:- more communication issues, less clinical, governance, safety issues.
Dr Jenny King, Clinical Psychologist from the Edgecumbe Group Disruptive Behaviour-What Lies Beneath.
She used a definition of Disruptive Behaviour from the College of Surgeons and Physicians of Ontario, Canada..’ A physician (doctor) with disruptive behaviour is one who cannot or will not function well with others to the extent that his or her behaviour, by words or actions, interferes or has the potential to interfere with quality healthcare delivery’. She described how underlying factors such as psychological factors, training and education, work load, family pressures, sleep loss, organisational culture and health problems can set up a cycle and feed the behaviour problem.The Big 5 Features of Personality are:- emotional stability, extraversion, openness, agreeableness and conscientiousness. The doctors seen were more emotionally reactive, more introverted, less open, much more agreeable, conscientious and perfectionist and anxious to please than the general working population. Disruptive behaviour results from a strength overplayed. The plan is to retain the strength but restrain and set limits on the behaviour.If capacity is the problem this is a fundamental problem not likely to change , and a change of speciality or career is required. .If knowledge, skills or experience are lacking, then training and feedback are required. A lack of motivation should be tackled with counselling, mentoring and a new role/project. If there is distraction from elsewhere then support should be provided and reasonable adjustments made. If there is deep rooted resentment and alienation then there should be a move from that department and support given.Some problems are intractable:- a longstanding grievance/grudge, some health problems or ingrained behaviour and lack of insight . These need set limits and a behavioural contract.
The Final Paper in this Section was on:-
Clinicians behaving badly: Conduct and Behaviour. The relevance of Personality, by Dr Gwen Adshead, Forensic Psychiatrist.
Rules make social spaces work. There are formal rules-laws, policy directives, and informal rules of conduct and behaviour, which recognise the boundaries between people. Rule breakers break the boundaries and cause alarm in groups. People who break the rules get excluded from groups .People with personality problems struggle with interpersonal boundaries. The good personality traits for the medical profession include being extravert, cooperative, conscientious, agreeable, open, committed and mildly obsessional..
The less good traits are narcissism-‘I am the greatest’, perfectionism, compulsiveness, denigration of vulnerability and shame Only 4% of the population has a personality disorder of any kind, and only !% a severe disorder Severe personality disorder is selected against in doctors, but mild/moderate dysfunction may occur, also associated with depression and substance misuse
The First Workshop was Behaviour in Teams
Lynn Markiewicz started the session by asking the members of each table group to introduce each other and state something good that had happened in the previous 24 hours.
She stated that the aim of the session was to describe the characteristics and effects of productive and non productive working in teams, to identify the causes of destructive behaviour in teams, and to develop strategies to promote positive team working and manage destructive team working. Effective team working has been shown to reduce costs, increase effectiveness, increase the well being of the members, implement innovations, reduce errors and reduce turnover in the team and sickness rates. The degree of innovation increases with the professional diversity of the team. The team needs to be inter-dependent but also recognise individual needs. Both the team and individuals need to develop. . A number of teams may have to work together to achieve one goal.. A successful team allows all members to use all their knowledge, skills and experience, and produces a positive emotion which improves team performance. A rude person in the team stunts creativity and may encourage similar behaviour in others. The top 7 aspects of positive team behaviour are:- co-operation, support to others, respect of others, valuing other opinions, support learning/development of all in the team, commitment to the team, polite pleasant behaviour.
The top 7 aspects of negative team behaviour are:- ignoring views of others, being rude/angry, intimidation of juniors, blaming others for mistakes, lack of commitment, frequent absences, being self focussed.We then carried out exercises in our table groups to discuss further some of the above issues.
The next presentation was by Lord David Owen on the Hubris Syndrome. In his book ‘In Sickness and In Power: Illness in Heads of Government during the last 100 Years’ , and his co-authored paper ‘Hubris Syndrome : An acquired personality disorder? A study of US Presidents and UK Prime Ministers over the last 100 years’ Lord Owen describes what he means by Hubris Syndrome in terms of political heads of government. In the paper, he states’ Charisma, charm, the ability to inspire, persuasiveness, breadth of vision, willingness of take risks, grandiose aspirations and bold self confidence – these qualities are often associated with successful leadership. .Yet there is another side to this profile, for these very same qualities can be marked by impetuosity, a refusal to listen to or take advice and a particular form of incompetence when impulsivity, recklessness and frequent inattention to scale. The attendant loss of capacity to make rational decisions is perceived by the general public to be no more than ‘making a mistake’. While they may use discarded medical or colloquial terms such as ‘madness’ or ‘he’s lost it’ to describe such behaviour, they instinctively sense a change of behaviour although their words do not adequately capture its essence.’
A common thread tying these elements is hubris, or exaggerated pride, overwhelming self confidence and contempt for others. How may we usefully think about a leader who hubristically abuses power, damaging the lives of others? Some see it as nothing more than the extreme manifestation of normal behaviour along a spectrum of narcissism. Others simply dismiss hubris as an occupational hazard of powerful leaders,, politicians or leaders in business, the military and academia; an unattractive but understandable aspect of those who crave power. But the matter can be formulated differently so that it becomes appropriate to think of hubris in medical terms. It then becomes necessary first to rule out conditions such as bipolar ( manic depressive) disorder, in which grandiosity may become a prominent feature. .From the medical perspective, a number of questions other than the practicalities of treatment can be raised. For example can physicians and psychiatrists help in identifying features of hubris and contribute to designing legislation, codes of practice and democratic processes to constrain some of its features? Can neuroscientists go further and discover through brain imaging and other techniques more about the presentations of abnormal personality? We see the relevance of hubris by virtue of it being a trait or a propensity towards certain attitudes or behaviours. A certain level of hubris can indicate a shift in the behavioural pattern of a leader who then becomes no longer fully functional in terms of the powerful office held.
First, several characteristics of hubris are easily thought of as adaptive behaviours either in a modified context or when present with slightly less intensity. .The most illustrative such example is impulsivity, which can be adaptive in certain contexts. .More detailed study of powerful leaders is needed to see whether it is mere impulsivity that leads to haphazard decision making, or whether some become impulsive because they inhabit a more emotional grandiose and isolated culture of decision making We believe that extreme hubristic behaviour is a syndrome, constituting a cluster of features (‘symptoms’) evoked by a specific trigger (power) and usually remitting when power fades. ‘Hubris syndrome’ is seen as an acquired condition, and therefore different from most personality disorders which are traditionally seen as persistent throughout adulthood. The key concept is that hubris syndrome is a disorder of the possession of power, particularly power which has been associated with overwhelming success, held for a period of years and with minimal constraint of the leader.The ability to make swift decisions, sometimes based on little evidence, is of particular importance-albeit necessary- in a leader. Similarly a thin-skinned person will not be able to stand the process of public scrutiny, attacks by opponents and back-stabbings from within, despite some form of self-exultation and grand belief about their own mission and importance. Powerful leaders are a highly selected sample and many criteria of any syndrome based on hubris are those behaviours by which they are probably selected-they make up the pores of the filter through which such individuals must pass to achieve high office.
Hubris is associated in Greek Mythology with Nemesis. The syndrome, however, develops irrespective of whether the individual’s leadership is judged a success of failure; and it is not dependent on bad outcomes. For the purpose of clarity, given that these are retrospective judgements, we have determined that the syndrome is best confined to those who have no history of a major depressive illness that could conceivably be a manifestation of bipolar disorder. Hubris is acquired, therefore, over a period. The full blown hubris, associated with holding considerable power in high office, may or may not be transient. There is a moving scale of hubris and no absolute cut-off in definition or the distinction from fully functional leadership. .External events can influence the variation both in intensity and time of onset.
The NHS is moving away from the one to one patient /doctor relationship and also from the vocational aspects of the profession. ‘A good physician treats the disease, a great physician treats the patient’ quote from Sir William Osler. Medicine was initially an art, but the scientific aspects increased during the great advances of the 20th century. At the same time society has become less deferential. .A wise physician does not exercise too much influence over their patients. The hubris syndrome is most likely to affect doctors in powerful administrative positions. Continuity of vocational care is the corner stone of medical care but we now have discontinuity of medical care. Doctors were initially made more cost aware when working in an internal market. The introduction of the external market in England will fundamentally challenge the vocational aspect of the profession when decisions by GPs may be made on the basis of cost. There is a risk that the best of the Medical Principles of Hippocrates will die or be privatised. The Medical Profession and the Colleges must fight for the medical principles in which they profoundly believe. Hubris can happen to senior clinicians in positions of power when they get the ‘adrenaline’ rush. It is important that younger doctors are made aware of the syndrome.
The second Workshop was on Health and Behaviour. Dr Peter Dickson , Senior Policy advisor at NCAS, spoke on ‘Disentangling Health and Behaviour- an NCAS overview.
When health and behaviour overlap there are likely to be submerged problems, such as family pressures, social isolation or mental illness. A cycle of stress can develop causing illness leading to professional error. Increased worry and then more stress can develop.
The GMC is not involved if the sick doctor has insight into the extent of their condition, is seeking appropriate treatment and is following advice regarding their work pattern, including appropriate restrictions in their practice. .Health professionals can be invisible patients because of fears about stigma, risk to career, confidentially, letting down patients and colleagues, financial worries, and there may be lack of training of others as to how to do with the illnesses of colleagues. The prominent issues for invisible patients are stress, stigma, self treatment and system constraint. NCAS advises the health organisation on the handling of the problems but does not advise on the investigation or treatment of the health condition.
Dr Nick Brown, Psychiatrist then spoke on Behaviour and Health. The behavioural concerns seen at NCAS include poor communication, poor stress management, weak leadership, poor decision making, and grievance and grudge as a legacy of inter-personal conflict with colleagues. These may show as:- lateness, absences, a work backlog, over or under investigating, poor record keeping, complaints, lack of verbal fluency, memory, concentration ,decision making of learning problems, irritability, denial, forgetfulness, arrogance, isolation, withdrawal or poor personal interaction. There may be aggressive or passive behaviour or a mixture of both. A psychological assessment may identify underlying personality traits and other contributory factors and recommend a way forward. Health problems such as a serious physical or mental illness may influence behaviour. NCAS will identify and recognise the health issues, and assess their effect on the practitioner’s ability to work. Occupational Health will help to organise treatment and support the practitioner. Consideration of the health of practitioners is challenging because there are higher rates of depression, anxiety, suicidal thoughts, suicides, substance abuse in health professionals than in the general population. The health practitioners are reluctant to admit to health problems, the health problems may be masked, and treatment plans not followed.
These issues were then discussed further in group work using case history examples.
The Final presentationon The Challenge of Leadership: Beware the Dark Side was givenby Psychology Professor Adrian Furnham.
The path to leadership starts with someone with technical skills, recruited for ability, knowledge and skills, who is then prompted to a managerial position as a result of their effort, progress (and politics), and who then gets a strategic position on the basis of reputation, ambition and history .The self-confident, bold, strategic, ambitious, astute, persistent, vigilant and articulate get chosen to lead. Good leaders are team builders, strategists and entrepreneurs. Many leaders who fail have had successful careers and with hindsight clues to their failure can be seen. There is a lot to be learnt about success by studying failure, but there are very few books of leadership failure, but many about successful leaders. Bad leadership in business can be very expensive. There can be a toxic mix of a destructive narcissistic leader, who operates in a conducive environment with susceptible followers.
High flyers are noticed, and fast tracked to jobs which are beyond them. Their faults and limitations are forgiven. Every competency has a potential dark side that must be considered.
A good team player will not take risks, an analytical thinker may be afraid to act, excessive integrity leads to imposition of rigid standards on others, and being too good with people means an inability to make tough decisions .A good leader can do wonders for any organisation, a bad one can lead to doom and destruction. Understanding and developing great leaders is one of the most important things we can do in any organisation.
Analysis of NCAS casework: the first eight years – Press Release
22 September 2009
The largest study of medical and dental performance concerns ever carried out in the UK has today been released by the National Clinical Assessment Service (NCAS).
NCAS casework – The first eight years report analyses cases referred to NCAS since 2001 (a total of almost 5,000). It identifies which groups of practitioners are more likely to be referred to NCAS and what can be learnt from these referral patterns. It also examines episodes of suspension and exclusion of individual practitioners. And, for more than 1,400 cases dealt with by NCAS since the end of 2007, the report analyses in depth the nature of concerns which led to referral.
Professor Alastair Scotland, Medical Director of NCAS, said: “The first eight years is a central part of our work in supporting the highest standards of patient care. The great majority of practitioners work hard to provide excellent care, but in those uncommon situations where concerns do arise about individual practice, we work closely with health services and with practitioners to ensure not only that those concerns are understood and resolved as quickly and as fairly as they can be, but also that this meets our paramount duty of protecting patients and the public.
“The heart of NCAS’ service is its case work with health services, the insights this gives us to the reasons that we are contacted for help and what lies behind those concerns. We use these insights to share what we learn with healthcare professions and with health services, so concerns can be identified much earlier and more accurately, and can be resolved more quickly and more fairly, enabling us to meet our first priority of protecting patients and the public.”
Dr Peter Old and Ms Diana Scarrott, who led the work of producing this report said “The first eight years report shows some striking findings and some consistent differences between groups.
- NCAS referrals come from all parts of the UK and across all sectors, whether in hospital or in general practice;
- Two referrals in three are about clinical skills but behavioural concerns are also common, seen in more than half the cases analysed;
- The average duration of exclusions of doctors in the hospital and community sector has fallen by over a third since 2003, which directly addresses concerns raised over the past two decades about prolonged exclusion from work;
- Amongst 144 of our cases where the most serious concerns have been raised, two thirds were back in work after remediation – rather than being lost to the service;
- Certain groups of practitioners are more likely than others to be referred to NCAS, for example men and older practitioners. The same groups are also more likely to experience exclusion or suspension from work;
- The report also examines the part played by ethnicity and place of qualification in the likelihood of referral of practitioners in hospital and community services. It shows that non-white practitioners qualifying outside the UK are more likely to be referred to NCAS, but that neither referral nor suspension or exclusion from practice is any higher among non-white practitioners qualifying within the UK.”
Dr Old and Ms Scarrott added: “We want this report to be used by health services and the professions that look to NCAS for a service to think about the arrangements they have in place to predict, to prevent, to identify and to manage performance concerns. And we want to work with them to understand more about the patterns of referral and what lies behind them. Our latest analyses of some of our most difficult cases show that most of the practitioners whose performance caused concern were able to resume safe and valued practice. That has to be the best outcome we can aim for.”
The full report (60 pages) and a 12 page summary can be viewed at: www.ncas.npsa.nhs.uk/resources/publications/caseworkanalyses/