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There is a pressing need for the Department of Health, Strategic Health Authorities and NHS trusts to improve their management of suspensions of clinical staff, according to the head of the National Audit Office, Sir John Bourn. Today’s report to Parliament, while acknowledging the paramount importance of protecting patient safety, highlights concerns about the length of time clinical staff are being formally suspended or sent on ‘gardening leave’, and the fairness, openness and transparency of the whole process.

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Trusts may exclude clinical staff (including consultants, doctors, dentists and nurses) from work or restrict their activities where there are concerns about patient safety or where there are allegations of gross misconduct, to enable trusts to undertake investigations. Between April 2001 and July 2002, over 1,000 clinical staff were excluded on full pay from the NHS at an estimated annual additional cost of some £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. The length of exclusions averaged 47 weeks for doctors, who accounted for three quarters of all costs, and 19 weeks for other clinical staff. Fifty five per cent of the doctors were excluded for more than six months and a handful of clinical staff have been excluded for as long as four years. Forty per cent of excluded doctors and 44 per cent of other clinical staff returned to work in the NHS.

According to the National Audit Office, while most NHS trusts recognise the need for good practice in the form of timely investigations, reviews of the need to continue exclusions and identify alternatives, and the need for effective management plans, the numbers of exclusions and their length suggest that basic management principles are not being followed. Cases can continue for months and years with delays occurring at each of the principal stages: informing clinicians of the allegations, providing documentation, undertaking clinical investigations and assessments, and implementing recommendations. For the clinician, exclusion can result in reduced self-esteem and depression; and a number never work again, even if exonerated.

Clinicians and other experts have expressed concern that trusts can rush to exclude staff without considering alternatives: such as restricting the clinician from certain clinical activities or types of patient. Exclusions can occur as a result of a breakdown in team working or personality clashes where there appears to be little risk to patients. And, where there have been patient safety incidents, trusts have sometimes excluded clinicians despite evidence of systemic failures rather than individual shortcomings.

The National Clinical Assessment Authority, established in April 2001 by the Department of Health, has identified alternatives to suspension (in 30 out of a sample of 36 cases it examined); but its focus, like that of the Chief Medical Officer’s human resources adviser who was appointed to review suspension cases lasting more than six months, has been on doctors and dentists. There are no similar arrangements for other clinical staff. Some doctors have been critical of their experiences of the Authority’s assessment process.

The NAO report also points to concerns that ethnicity and gender are factors in doctor exclusion cases. A survey of all such cases lasting longer than six months showed that, while a slightly higher of proportion of ethnic minority doctors were excluded, the difference was not statistically significant. When looking at consultants, however, a significantly higher proportion of those from an ethnic minority were excluded. Regarding gender, significantly more men are excluded than women.

Where staff have been excluded and there are patient safety concerns, it is important for trusts to inform other trusts and potential employers, the regulatory bodies and the Department. When staff resign during an investigation, however, one fifth of trusts do not conclude the investigation which may not make it possible to alert prospective employers. Only a third of trusts advise the regulatory body of problems regarding clinical staff who are not doctors. As part of their pre-employment checks most trusts review alert letters but trusts are concerned whether they hold complete sets of alert letters and whether letters have been rescinded. There are also weaknesses in other pre-employment checks, in particular obtaining declarations from clinical staff of their fitness to practice, and in obtaining assurance for overseas qualifications, locum and agency staff.

The NAO recommends a number of steps to be taken by the Department to improve the whole system for managing the exclusion of clinical staff. These include developing better guidance on the suspension process to take account of NAO findings as well as work by the National Clinical Assessment Authority and the National Patient Safety Agency; extending the monitoring of long-term exclusions to include all excluded clinical staff, not just doctors under formal suspension; and encouraging the promotion of an open and fair culture.

Trusts should also limit the length of the initial investigation to a maximum of two weeks, after which the member of staff would either be formally suspended or return to work; use suspension only where there is a risk to safety or to ensure an investigation is unhindered; and consider alternatives to suspension. They should seek and act upon advice from the National Clinical Assessment Authority for all doctor cases.

There are also recommendations for the improvement of case management including the provision for excluded staff of a mentor to ensure that their psychological well-being is being monitored and that they have the opportunity to maintain their clinical skills. Patients would be better protected by improved communications with other potential employers and agencies where there are concerns about patient safety; and by ensuring there are effective systems in place for identifying patient safety incidents.

Better management of exclusions would result in additional resources being available for health services. For example, if exclusions were limited to six months, there would be additional resources worth some £14 million a year.

"Where patient safety is considered to be at risk or there are allegations of misconduct, it is vitally important for NHS trusts to be able to exclude clinical staff from work or restrict their activities so that the situation can be thoroughly and promptly investigated. At present, however, there is evidence of many cases of exclusion being allowed to drift on without resolution or proper management. This represents a serious waste of resources for the NHS and can harm the career and even personal well-being of the accused clinicians themselves.

"The Department of Health should now take further steps to achieve a system for managing the exclusion of clinical staff in which both staff and patients can have confidence."

Sir John Bourn

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