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In the spotlight: your performance

Performance evaluation in Ireland has been taken up a notch with the introduction of on-site practice assessments; Dr Muiris Houston looks at what they mean for doctors and patients

The regulatory landscape in which doctors in Ireland practise continues its rapid pace of change. Following on from making fitness to practise hearings public events, the Medical Council has just introduced on-site practice assessments of doctors’ performance for the first time. It means a small number of doctors can expect their standard of patient care to be looked at as they actually go about their daily work; their interaction with patients and how they perform clinically will now be closely examined.

The actions of disgraced medical practitioners such as Harold Shipman and Michael Neary were rare and exceptional; nonetheless they caused the public to re-evaluate their trust in all doctors. A possible reflection of this trend is the MPS experience of the past five years, which has seen medical claims costs increase by 26% per annum in Ireland.

A small number of doctors can expect their standard of patient care to be looked at as they actually go about their daily work

In turn, politicians took steps to tighten oversight of doctors’ professional activities. In the Republic a new Medical Practitioners Act came into force: among many changes it increased lay representation on the Medical Council; fitness to practise proceedings now take place in public unless the complainant specifies otherwise; and it strengthened the oversight of doctors’ continuing medical education.

Not least, the new Act made it easier to detect and help doctors who were underperforming because of personal illness or addiction. And new performance assessments will now further strengthen the Medical Council’s regulatory role. In the run-up to the new procedures, a consultation process invited views on each of the individual draft rules governing performance assessment; the Medical Council then invited comments on the proposed performance procedures.

Approximately 25 organisations and individuals provided feedback with three main issues emerging as areas of concern:

  • The standard against which doctors will be assessed
  • The timeliness and confidentiality of the procedures
  • Processes for communication with the employer.

Some 355 doctors were surveyed last September, with the following among the opinions expressed about performance assessment: respondents would like to see the process record areas of satisfactory practice as well as those requiring improvement; and they want the process to record health and structural issues within the health service that may be preventing the doctor from engaging in good practice.

It is in everybody’s interest that the Medical Council has a robust process in place to ensure patients receive a high standard of professional care from their doctors

Anecdotally, there is concern among practitioners as to who will be responsible for the not insubstantial costs of what may be a 2/3 day on-site visit. The Medical Council reserves the position that it may levy fees and expenses for the performance procedures and activities. It is currently determining policy in relation to how it will exercise this position, which it says “includes engagement with indemnifiers and the Department of Health and Children”.

“It is in everybody’s interest that the Medical Council has a robust process in place to ensure patients receive a high standard of professional care from their doctors,” said John Delap, Chairman of the Irish College of General Practitioners.

“It will be important that the standards set are based on the highest quality for patients within the level of resources available in our health system. The College will have a role in providing opportunities and support for doctors to meet their educational needs.”

Chart 1: The introduction of performance assessment as an additional procedure for handling concerns about doctors’ performance modernises and strengthens the role of the Medical Council in protecting the public and supporting good professional practice


In the spotlight chart

Medical Council President Prof Kieran Murphy told Casebook: “New performance procedures will further enhance the Medical Council’s processes in protecting the public. This marks the culmination of a number of years of development work and is a further safeguard, which will help to both protect patients and to promote good professional practice among doctors.

While doctors endeavour to provide safe, high quality care, sometimes performance problems may arise

“While doctors endeavour to provide safe, high quality care, sometimes performance problems may arise. Performance assessment will not replace other procedures that the Medical Council already has in place, but will allow us to work in a more targeted and effective way with doctors who are experiencing problems in some aspects of their practice.”

So how many assessments does the Medical Council expect to carry out per annum? “It is difficult to predict the number of assessments that will be conducted in the first year as it will depend on the number of instances that arise where Council feels it needs assurances about the quality of a doctor’s practice,” Prof Murphy said.

Both staff and patients will be canvassed for their views on a wide range of issues concerning the doctor’s professional abilities and attributes. A sample of the practice’s patient records will be looked at to assess their quality, and the doctor may be asked to demonstrate his clinical skills to the assessors.

At the end of the process a report will be considered by the Medical Council, who will then decide what action (if any) is necessary to ensure the ongoing competence of the doctor who has been assessed. Prof Murphy sees the latest development as a key element in the overall package of protecting the public.

He said: “It’s important that the public is aware that these procedures will be used when Council feels it needs assurances about the overall quality of a doctor’s practice. While this situation may arise following a complaint about an isolated incident, in general these new procedures will be triggered by the Council in response to information about the overall pattern of a doctor’s performance rather than how the doctor performed in relation to an isolated incident.”

In other words, fitness to practise inquiries will remain the principal mechanism through which the Council investigates a doctor whose care in a specific case is alleged to have fallen below an acceptable standard. Where the Medical Council identifies resource or systems failures as part of a visit or investigation it will write formally to the Health Service Executive or the Health Information and Quality Authority to tell them about the problem.

In turn, these agencies are expected to communicate with the Council about any concerns that arise about the performance of individual doctors. It’s all part of an intricate jigsaw with patient safety at its centre.

At the end of the process a report will be considered by the Medical Council, who will then decide what action (if any) is necessary to ensure the ongoing competence of the doctor

Dr Muiris Houston is a medical journalist and part-time GP from Co Galway, Ireland

MPS has considerable expertise in assisting doctors with performance assessments in other jurisdictions and whilst the Medical Council is quite different to its UK counterpart, the experience gleaned by MPS makes us better able to support Irish doctors with this new element of accountability, which, in some circumstances, may be quite a daunting procedure.
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