|Helping healthcare professionals|
|Thursday, 01 July 2010|
Douglas Fowlie reports on the trial clinical service for 30,000 doctors and dentists living and working in the London Strategic Health Authority area
The NHS Practitioner Health Programme (PHP) is a clinical service for doctors and dentists established as a prototype by the Department of Health (DoH) in September 2008.
Data at 12 months show that 184 practitioner patients were assessed covering an age range of 24 to 65. One hundred and fourteen had mental health problems and 66 addictive disorders. Clinical conditions co-existed but also included neurological disorders. Fourteen patients required admission. Abstinence was achieved in 42 of the 51 cases where it was required.
The clinical assessment and management complements existing clinical services. The PHP has identified unrecognised, undeclared or unmet needs in these clinicians with clinical problems. The presentations are frequently characterised by altered mood, distorted perception, impaired insight or compromised cognition in addition to clear signs of stress.
"Burnout is one of the most serious outcomes of chronic stress, but the effects of stress manifest themselves in many other discrete and subtle ways, and effective management of stress can enhance safety in the operating theatre and prevent the inevitable slide to burnout."
The PHP offers a multi-professional response, case management and support to practitioners subject to regulatory and disciplinary procedures. It has immediate access to specialised mental health and addiction services.
Clinicians’ mismanagement of their own health was identified by the Merrison Report into the regulation of the medical profession in 1975. The General Medical Council (GMC) acknowledged the conjunction of mental illness with compromised fitness to practise and psychiatric examination and supervision contributed to the regulatory framework. Specialised treatment services were not developed.
The complex associations between professional practice and psychiatric disorder were dissected by the Shipman Inquiry in 2004. A subsequent regulatory review and White Paper promoted a recommendation to establish specialised clinical services in 2007. The DoH commissioned PHP as a prototype to test the concept and generate information on outcome, perhaps anticipating UK service development.
The PHP’s first-year report provides verifiable evidence for improvement in mental health and social functioning for patients, many of whom had not been clinically identified previously. Thirty-six out of the 78 patients not working at first referral returned to work. Audit and economic evaluation is ongoing. The PHP continues to deal with complex cases and has now registered more than 300 new patients.
The PHP is co-ordinated by a Medical Director who is a General Practitioner with established expertise in mental health and addiction. Her service is embedded within a normal General Practice but has administrative, medical and nursing input using designated computing and consulting areas.
PHP provides an integrated approached to care and offers appointments within two days for first contact. It is active from 0730 to 1830 hours on weekdays and 0900 to 1300 hours on Saturdays.
Confidentiality is sacrosanct unless a practitioner patient poses a significant risk. Memoranda of understanding with the GMC and General Dental Council are established.
The component making the biggest impact on unmet need is the specialised psychiatric provision. Mental illness and addictive disorder are treatable conditions and recovery is often possible.
Attitudes including denial and false expectations tend to lead clinicians to use clinical services idiosyncratically, often bypassing General Practice. The impact of these illnesses on behaviour is considerable and an assertive and enduring clinical response is needed. The core clinical skills required are most highly developed within psychiatry.
Practitioners have the means to disguise their illness from others and continue to prescribe for themselves. Even if illness is recognised by colleagues and performance is diminished, there may be reluctance to refer or report because the outcome is perceived as disciplinary and punitive. The work environment may contribute to the problem. Clinicians may be unwilling to admit to ill health, harbour concerns about confidentiality or even hope that self-treatment
Studies reveal high rates of depression, anxiety and substance misuse in healthcare professionals. The greater than expecteddeath by suicide, especially for women, remains a consistent reflection of that morbidity. The necessary clinical network surrounding PHP is extensive but the core is formed by general practice, psychiatry and occupational health.
The high standards achieved by PHP derive from the quality of the staff. Vigilance surrounding the assessment, management, treatment, support, rehabilitation, recovery, resettlement and remediation of patients is incorporated into clinical case management within which risk is quantified. Patient feedback is extremely positive. Employers, deaneries, regulators and investigators have come to endorse the service because of its rigour and effectiveness. All parties seem to acknowledge that it is worthwhile to address the hidden health needs of practitioners who, of course, discharge significant clinical responsibilities and manage expensive resources.
The vulnerability of doctors and dentists to insidious disablement arising from these core conditions points to the likely future benefit of co-ordinating a service for the UK.
The skills deployed in delivering PHP are now designated as competencies following initiatives by the Royal Colleges of General Practitioners and Psychiatrists and the association of National Health Service Occupational Physicians.
The principles underpinning the provision of specialised services can be deployed in different ways. PHP is based on an enhanced primary care model.
These concepts, if incorporated into undergraduate medical and dental students’ curricula, could increase acknowledgement, acceptance and anticipation of risk and promote prevention. Establishing a service would increase the likelihood of clinical engagement and continuity of care following graduation.
Whilst covert ill health is likely to remain an issue, PHP has demonstrated conclusively that undeclared morbidity can be identified, assessed and treated.
Licensing and revalidation are likely to add to the identification of this morbidity. Remediation may be accelerated if specialised clinical services are deployed. In any event, duty of care provides a powerful reason to promote these concepts.
It seems highly likely that if a UK service is established as a component of the NHS, the health, social and economic benefits both to clinicians and the population would be considerable.
Douglas G Fowlie, Consultant Psychiatrist and Honorary Research Fellow, University of Aberdeen, Clinical Advisor to the Practitioner Health Programme
For more information, visit: www.php.nhs.uk