Dr Gerard Panting outlines the difficulties facing clinicians when they are unwell: the Practitioner Health Programme offers advice and access to specialist assessment services
Doctors and other healthcare professionals are not immune to illness. In fact they are more prone to some health problems than the rest of the population and are two to three times more likely to commit suicide than patients who are not doctors. The annual incidence of addiction among doctors is 0.25–0.50%, equating to a career incidence of 1 in 15. Approximately 25% of all referrals to the National Clinical Assessment Service have a health component, and of the health cases dealt with by the General Medical Council (GMC) and the General Dental Council, more than 90% are predominantly mental health or substance misuse cases.1
Not only do doctors get mental health problems more often, but a variety of factors mean they receive poorer overall care than other patients. The stigma associated with mental health problems is a powerful deterrent to seeking help from suitably qualified colleagues, as too must be fears for employment prospects—ill health might seem a very good reason for disenchanted colleagues to suggest that early retirement might be appropriate or that a less strenuous post might be more suitable, particularly if they are unfamiliar with employers’ responsibilities under the Disability Discrimination Act 1995.2
Where do doctors go for treatment?
To make matters worse, current NHS funding arrangements make it difficult for doctors to seek help discreetly. If a doctor works for the PCT that has to decide if it is appropriate for him or her to see a specialist further away from their own practice, he or she might think twice about what else the PCT might want to do to assess fitness to practise before concerning themselves about medical care. If a doctor makes use of local medical services, he or she might find themselves sitting beside one of their own patients in the outpatient department, or they might be concerned that members of staff who know them will flick through their records out of idle curiosity, if nothing else.
In practice, the net result of these concerns is that problems are left untreated and become long standing. This delay brings inevitable adverse effects on personal and family life, while the doctor attempts above all else not to allow his illness to affect his professional practice and patients.
With these concerns in mind, perhaps it is not surprising that many doctors attempt to treat themselves or consult a colleague informally. However, without specialist knowledge, skill, and the necessary professional objectivity, they tend not to make a very good job of it. Nowhere in medicine is the maxim primum non nocere (‘first do no harm’) more apt.
Who is most affected?
According to GMC figures, some specialities fare worse than others.1 Psychiatrists and GPs tend to develop more problems than ophthalmologists, gastroenterologists, and cardiologists. Although the prevalence of physical illness in doctors mirrors that of the general population, mental health problems are significantly greater, with a vastly disproportionate number of alcohol and other substance abuse problems in cases seen by the GMC.1
Almost all the cases the GMC sees that question the doctor’s fitness to practise are a result of either mental health or substance abuse problems, while the National Clinical Assessment Service (NCAS) sees a different profile of cases. Roughly 15–20% of NCAS health referrals are predominantly problems of physical illness, with the remainder resulting from depression, anxiety, alcohol and other addictions, or obsessive compulsive disorders.1
Presentation of these problems is often gradual and subtle:
- someone with obsessive compulsive disorder may be late coming to work because they have been unable to leave the house until certain that various tasks have been completed
- depression may reveal itself as dithering, poor leadership or lack of concentration, uncharacteristic failure to finish work or check results, or leaving administrative tasks to accumulate
- those misusing alcohol are unlikely to turn up to work frankly inebriated, but present as being less reliable in a variety of ways.
A change in behaviour can be the giveaway that there is something wrong, but discovering exactly what that is usually requires expert assistance.
The problems associated with managing practitioners with health problems were highlighted in the report Good doctors safer patients from the Chief Medical Officer (CMO). It said:3
‘Sick doctors (including those with substance addiction) can pose a real threat to patient safety and also pose a difficult problem for medical regulation:
- The insight of sick doctors into their condition and the impact that it has upon their performance may be severely compromised
- Illness in doctors may be poorly managed and appropriate assistance may not be sought for a variety of reasons (including low rates of registration with a general practitioner)
- Doctors may be able to disguise their illness from others, perhaps through self-prescription
- Where illness is recognised to adversely affect performance, there may be a reluctance to refer a practitioner into a system that is perceived as ‘disciplinary’ and a lack of knowledge as to alternatives
- An excessively stressful work environment may have a significant and negative impact on a doctor’s health and wellbeing.’
London Practitioner Health Programme
In response to the CMO’s report, the Government White Paper, Trust, assurance and safety—the regulation of health professionals in the twenty-first century proposed a pilot service for practitioners with health problems.4 The pilot programme, London Practitioner Health Programme (PHP), will be established for medical and dental practitioners living or working within the London Strategic Health Authority, where there are concerns about mental health, addiction problems, or physical health problems impacting on the practitioner’s performance.
The service is in addition to the help available from a practitioner’s own GP and existing support services such as the Sick Doctors Trust5 and the MedNet service.6 It will provide expert advice and case management with rapid access to specialists for further assessment and treatment where required, and will have the essential ingredients of the services doctors need. The ideal is a service which is known to provide help, is free at the point of delivery, can be accessed quickly, and provides expert assistance discreetly. Confidentiality is key, but cannot be absolute—just like any other area of medical practice, professional confidence has its boundaries. Any behaviour or underperformance that jeopardises patient care requires immediate action.
There is considerable experience with similar programmes in North America and Canada. The scheme operating in Ontario has enjoyed particular success since it was instigated in 1995 and has been a success because it is well supported by all the interested parties, including the regulatory authorities.7,8 The scheme is clear about its mandate, provides a service that is accepted as appropriate and useful by potential users, is well resourced and, above all, provides a confidential and discreet service, thereby facilitating access into the programme.
However, all is not doom and gloom, doctors with mental health problems who seek help have a good prognosis. The results from Ontario reveal that 70% of doctors with addictions recover without relapse and a further 15% experience a minor relapse but go on to recover.7 Approximately 15% quit the programme.
There are two parts to the pilot PHP, which will offer advice to both practitioners and employing/contracting authorities. It will provide:9
- a central point for expert advice, consultation, and case management
- access to preferred provider specialist services for further assessment and treatment, especially for mental health issues and addictions.
The best results from treatment are obtained through early intervention. Doctors who are ill may not have the insight to realise that something is wrong but his or her colleagues will probably be acutely aware that there is a problem and they have a responsibility to act. The temptation is to temporise in the hope that things will improve, to make the excuse that it is a bad time to raise concerns. However, delay brings no favours, just added stress, probable deterioration, and, worst of all, the potential of harm occurring to patients.
- Scotland A. The UK’s challenges and emerging responses. Presentation at the National Clinical Assessment Service. Annual conference: Overdue business—supporting the health of health practitioners, 21 January 2008. www.ncas.npsa.nhs.uk/trainingandevents/reports
- Department of Health. Good doctors, safer patients: proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients. A report by the Chief Medical Officer. London: DH, 2006. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4137232
- Department of Health. Trust, assurance and safety: the regulation of health professionals in the 21st Century. London: DH, 2007. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_065946
- MedNet. www.londondeanery.ac.uk/var/MedNet
- Kaufmann H. Experience of dealing with health concern in North America. Presentation at the National Clinical Assessment Service. Annual conference: Overdue business—supporting the health of health practitioners, 21 January 2008. www.ncas.npsa.nhs.uk/trainingandevents/reports
- Field R. Prototype for a Practitioners’ Health Programme. Presentation at the National Clinical Assessment Service. Annual conference: Overdue business—supporting the health of health practitioners, 21 January 2008. www.ncas.npsa.nhs.uk/trainingandevents/reportsG