Regulating doctors, ensuring good medical practice

Barriers to and enablers of good practice

We commissioned a rapid review of evidence about barriers to and enablers of good practice.

This built on the findings in our report The state of medical education and practice in the UK: 2012. We want to understand more about these issues so that we can support doctors to deliver better care for their patients in an increasingly challenging environment.

The review was limited in scope and considered published evidence and a small number of interviews with experts in the field. It identified a number of potential barriers and enablers at three ‘levels’ of the healthcare system – the individual, the local or organisational and the wider policy framework.

Many of the themes resonate with those that doctors fed back in their comments on the rise in complaints in the October issue of GMC News. 

What were the most significant barriers?

  • Habit and self-belief can be a barrier to changing behaviour and practice.
  • Information overload with limited reading time can prevent awareness and assimilation of published guidelines.
  • Workload pressures can create an acceptance of ‘short cuts’ in the delivery of care that may lower standards.
  • Unrecognised differences between the care goals of doctors and patients can hamper effective communication and shared decision making.
  • Organisational culture can discourage individuals from raising concerns about standards of patient care.

What were the most significant enablers?

  • Various interventions that link audit and feedback, reminders, visits to other units and translation of good practice from opinion leaders have demonstrated improvements in doctors’ performance.
  • Doctors are more likely to adopt new guidelines/practices if they see them as ‘authoritative’ and relevant – ie the potential benefit to their patients is clear.
  • Doctors are motivated to implement new guidelines/practices where it is ‘easy’ to do so, for example where they have access to implementation tools, clinical network or peer support, education/training and funding.
  • Good role models – behaviours and attitudes of colleagues influence uptake of good practice.
  • Education and training can help challenge personal assumptions, beliefs and values, and encourage reflective practice and team working.
  • Commitment to improving practice tends to flourish where reflective practice and quality improvement is actively supported.
  • Organisational incentives that focus more on patient experience and patient outcomes as opposed to financial issues and throughput.

What do you think?

We would be interested to know your views on this – are these the issues that affect the quality of your practice and are there other issues we have not considered?

Comments

17 comments

Bonifacio Ricardo Jose (5 days ago)

The habits, the culture and the self belief of some patients and doctors can be a barrier to medical care. It is a question of education that sometimes can change the behaviour. The workload pressure and the bad distribution of medical personnel and patients can become the care more difficult and embarassing.

Bonifacio Ricardo Jose (5 days ago)

The habits, the culture and the self belief of some patients and doctors can be a barrier to medical care. It is a question of education that sometimes can change the behaviour. The workload pressure and the bad distribution of medical personnel and patients can become the care more difficult and embarassing.

Paul van den Bosch (2 months ago)

While not wanting to go all the way back to 1 in 2 rotas, over my career there has been a series of reductions in the time doctors are available along with an inexorable increase in the complexity of the medical problems. All the stuff about barriers and enablers written above is relevant but does not address this central issue. Clinical time is pressurised and so we prioritise what must be done which are the things we will get criticised for not doing. For all the lip service we pay to it, communicating with patients and our colleagues and giving them time to express their fears and concerns comes a long way down the list.

Omar Mohamed (2 months ago)

I agree wholeheartedly and completely with Dr. Mark Reed's comments below. Time Time Time......is of the essence.

dr tanya black (2 months ago)

To Tim Jordan sorry to hear about your trouble.It is sad to suffer like you did only because you were putting your patients first.I come from Eastern Europe and am seriously thinking about going back as I am too disillusioned with the system.I have had horrific experience with judiciary in U.K. and as for NHS things are gone downhill enormously fast in the last few years.All that people are concerned about in U.K.hospitals is how to fill their competencies folders during their training.they have lost sight of caring,compassion and common sense in dealing with their patients.It beggars belief as to how and why everything is so wrong.When people are faced with impossible tasks then I am afraid nobody can get on top of it.

Tim Jordan (2 months ago)

This is a joke right? No mention of the erosion of Professional Standards and distortion of clinical priorities by management directives driven by government interference coupled with a lack of resources. When I took a stand on the rescheduling of out-patient appointments that was and still is leading to patient neglect despite being backed by a supporting report prepared by representatives of my Royal College, I was targeted for bullying and when my health suffered I was conveniently pushed out of my job. The GMC were completely uninterested. I suffered because I was complying with the Good Medical Practice Guidelines and putting my patients interests first. I think I can say without fear of contradiction that every glaucoma clinic in Britain is neglecting its patients by failing to meet Nice guidelines for care standards, and worse. And we are supposed to take guidance from our employers! Revalidation is a waste of time. Its like press self regulation not even cosmetic.

GERARD LAITUNG (2 months ago)

Changes imposed on our practice whether on a clinical, educational or management level without evidence-base have a soul-destroying effect on senior doctors, who 'have seen it all before'.
Many decisions to change appear to be made by consensus taken by groups of interested parties.
It would be too cynical to suggest that many consultation exercises are of a cosmetic nature.

Dr Mark G Reed (2 months ago)

This summarises clearly and succinctly the "barriers" and "enablers" but I feel it underestimates the time problem. No other country in the world has such rushed, overworked doctors and nurses. There is hardly ever any time to sit and reflect on one's work. This should be a daily occurrence, not just in special PDP time, or even in proscribed breaks. We need time to consider our work every day and this can only be achieved by longer appointment times and shorter clinics. There is a misconception that doctors hate it when patients fail to turn up, but I LOVE it. It allows me to check guidelines, review GPNotebook or patient.co.uk and feel much more confident about my interactions with any prior patients from the morning I was unsure about. Regular reviewing like this is far better than noting PUNs and DENs and checking them weeks later when you have forgotten the patient. So, to summarise the above: biggest barrier is lack of time; greatest enabler is allowing time.

Avril Danczak (2 months ago)

What a great start and an interesting piece of work. It was good acknowledgement of the huge impact workload has on quality, especially as doctors face continual increases in the complexity of their task. We need to have robust approaches to workload that involve patients and regulators having realistic understanding of what can realistically be done. Also we need to develop better training tools for dealing with complexity, uncertainty and the practical application of attitudes and values in daily practice

Nancy Redfern (2 months ago)

I agree with the enablers and barriers described. I think there are more in a big secondary care environment. These can be managed, but more attention needs to be paid in complex multidisciplinary working.
Other significant barriers are a culture in which teams are not encouraged to take time away from direct clinical care to review and develop their practice.
A bullying (and sometimes also a pace-setting) management style means clinicans to adopt a 'head down, get on with the job' approach. Innovation is not respected, so practice isn't improved over the years. Doctors are just like patients - we will say something twice - if not heard we often just give up and shut up!

Dr Maria Elliott (2 months ago)

You fail to mention the most obvious barrier to "Good practice", which is time pressure.
Each consultation has limited or sometimes severe time pressure, few docotrs are able to consult to the standars they would like to.
Each workday is full of time pressure, too much is squeezed into a normal working day. Therefore most GPs have to stay long after their surgeries have closed to do their admin tasks.
CME takes low priority in a stressful work life and by the time a GPs get home they are too tired to get involved in postgraduate education.
Reflection and learning needs to be built into every GPs normal working day for it to be effective and sadly, there is no time for that. Unless this changes, I can't see real improvement in CME and revalidation will be a mear window dressing!

Dr David Jamieson (2 months ago)

Very pleased to read this new of attempts to influence training and learning for the better.
In undergraduate teaching I had concerns for many years that the PBL approach in isolation did not produce graduates with adequate basic science. This now appears to have been addressed, but it took too long.
In Postgraduate GP training I am concerned at the amount of focus on academic assessment scores and recording of performance related to them and how unprepared for the reality of the full workload of partnership, maximising income ie Points yet remaining healthy. Maintaining standards and keeping up to date after a long day suddenly becomes less feasible so influencing the abouve in a positive way seems of great value.

Dr Maria Paul (2 months ago)

I found the Consultant appraisal toolkit and yearly appraisals to be a useful exercise whilst in the UK.Having emigrated to Australia this year I find developing 'professionalism ' is a hot topic here and deatils can be found on www.racp.edu.au/page/sppp
However the tools for measuring professionalism haven't been developed yet

Nasir Hussain (2 months ago)

I think that one of the major barriers to positive reflective practice is the advent of appraisal and revalidation. I do not think there has ever been a single doctor that has not reflected on their practice whether good or bad. However, when someone is forced to demonstrate that they have undertaken positive reflection they, ironically, spend less time reflecting and more time trying to gather 'evidence' that they have reflected. The hours that I used to spend pondering cases and looking up the literature on a new clinical problem, I now spend updating folders of evidence proving that I have met targets in various domains. Increasing pressure to justify your practice is going to blunt progressive thinking and make us aspire to mediocrity.

carole luck (2 months ago)

in my opinion the insistence of some trusts that a significant part of postgraduate training be in house can be a barrier ,particularly for consultants who have been in post for over 5 years and for registrars in their final year. they need to go out and seek new ideas and experiences.
also i well remember one registrar who was in his final year and suffered from exogenous depression because he as a trainee neonatologist felt he had not seen enough really small babies to be confident as a consultant. he felt this was due to the europen hours directive

Frances Lefford (3 months ago)

Important barrier to good practice in secondary care is the poor infrastructure, by which I mean inadequate nursing care due to work overload and ? lack of support for inadequately trained nursing staff. This applies particularly to elderly patients with chronic conditions when the situation is either end-of-life or temporary hospitalisation preliminary to this. Clinical staff may be aware of what needs to be done, but there is insufficient checking of whether is it being done.

Dr David Nicholl (3 months ago)

I am somewhat limited in response as I have a paper in press on this topic which will be appearing in the Journal of Royal College of Physicians of Edinburgh next month (ie December 2012) on this topic http://www.rcpe.ac.uk/journal/index.php which will be of direct relevance to the GMC given the issues that it raises in terms of medical education (undergraduate and postgraduate), patient safety and clinical examination skills. The JRCPE will have an editorial on this topic and we have set up a Twitter feed as I suspect this paper will generate significant debate @TOSStudyGroup Kind Regards Dr David Nicholl