On 3 December 2012 the General Medical Council (GMC), with the introduction of revalidation, was the first medical regulatory body in the world to implement large-scale changes to the regulation of doctors. Since the start of the millennium significant changes have been made to how both the regulator and organisations now manage the performance of doctors in the UK. In this chapter I will outline the processes for managing doctors’ performance through the use of appraisal and revalidation, job planning and finally, if all else fails, via the more formal processes of investigation and case management. (Further details of revalidation are presented in Chapter 17.)

Most doctors work hard to improve the quality of their work year on year, and provide excellent care to their patients. However, given the numbers of doctors working in the UK it is inevitable that some fail either to maintain standards high enough to keep patients safe or to maintain the quality of their own work. If we fail to address the poor performance of doctors then we place patients at risk of harm or even death, undermine the morale of the teams and erode public confidence in the profession.

In 1994 Professor Liam Donaldson wrote about doctors’ performance problems in hospitals (Donaldson, 1994). These included disruptive and irresponsible behaviour, lack of commitment to duties, badly exercised clinical skills, inadequate medical knowledge, dishonesty, sexual overtones in dealings with patients or staff, disorganised practice and poor communication with colleagues. He found that 6% of doctors could be of serious enough concern to warrant the consideration of disciplinary action. Donaldson commented that the management of poorly performing doctors was ‘difficult, distasteful, time consuming and acrimonious work’. He recommended that managers should: always adhere to policies and procedures for handling disciplinary problems; avoid precipitate action; remain non-judgemental; beware of manipulation by those who have axes to grind; and never avoid dealing with problems, as this may harm patients.

In the time since Donaldson was writing, the procedures have changed significantly, with a new framework for dealing with doctors’ performance and a statutory obligation for employing organisations to provide a system for the revalidation of their doctors.