Practitioner Health Programme THE WOUNDED HEALER: Report on the First 10 Years of Practitioner Health Service If you build it they will come www.php.nhs.uk www.gphealth.nhs.uk Written by: Dr Clare Gerada, Medical Director, Practitioner Health Service MBE FRCGP FRCPsych Contributors: Ms Lucy Warner, Chief Executive Officer, Practitioner Health Service Mr Richard Jones, Clinical Director, Practitioner Health Service Dr Zaid Al-Najjar, Deputy Medical Director, Practitioner Health Service Acknowledgements The authors would like to thank all of those who were involved in the production of this report, and our wonderful patients who have given us the honour of caring for them. October 2018 Practitioner Health Programme 1 WELCOME Welcome to this 10-year report on the work the Practitioner Health Service has done over the years caring for mentally unwell doctors and dentists. PHS is a confidential, free, self-referral NHS service for doctors and dentists with mental illness and addiction problems. We see doctors and dentists nation-wide with all kinds of mental illness and are able to offer a wide range of pharmacological treatments and talking therapies. This report will describe these in detail. Practitioner Health Service was launched in 2008, initially only for a two-year London pilot. The intention was to expand the service beyond London, if successful, to the rest of England. Funding and other issues prevented this expansion at the time. Over the years, however, we have won new contracts for different cohorts of patients. For example, in 2015, we added the Trainee Doctors and Dentists Support Service (TDDSS) to our core offering, meaning that all doctor and dental medical trainees in London and the South East could receive a wellbeing support service. In 2017, given the particular pressures faced by general practitioners, a new service was commissioned to provide care to all GPs and GP trainees in England (GP Health Service [GPH]); we successfully won the contract to deliver this service. As of November 2017, more than 85,000 doctors can now access a confidential mental health and addiction service specifically designed to meet their needs and around 1,500 now do so every year. Sadly, 110,000 doctors across England still cannot access us directly. Clinicians and managers from across the world have come to London to learn from what PHS provides and as a service, we have led the way in a host of clinical, operational and governance areas. It is the only NHS-funded service of its kind and is probably the largest practitioner health treatment service in the world. We have influenced bodies such as the General Medical Council, many Royal Colleges, NHS England and other important organisations as to how mentally ill doctors should be treated. The old saying that doctors make bad patients is true to a degree. Doctors are reluctant to come for help. They think that they are alone, the only ones ever to become unwell or need help. They describe being ashamed at having to admit to vulnerabilities and believe that in one way or another they are letting people down by being ill. Over the years we have found that sick doctors, as with all patients, yearn to be treated compassionately – with sensitivity, sympathy, empathy and in a non-judgmental manner. All too often, however, mentally ill doctors are treated by trainers, employers and regulators as naughty schoolchildren or wrongdoers at having crossed the boundary from practitioner to patient. Unfortunately, the needs of the doctor as a patient – a troubled, desperate and unwell patient – are ignored by most treatment agencies. PHS is different. 2 GP Health Service We see the vulnerable patient behind the doctor. We understand their specific needs. However, even in the safety of a consulting room, doctors often start the consultation with a variation on ‘I am so sorry to trouble you, sorry to be wasting your time’. Each doctor has their own story of pain and distress, and all have good reasons to seek help. Many have reached the end of their ability to self-sacrifice and to care, and their professional, personal and social lives are often in tatters. They have waited too long to seek help and when adversity strikes, they work harder in the belief that their problems will magically disappear. Some begin to self-prescribe, crossing a professional boundary which invites a host of other problems; others begin to use alcohol to address anxiety; some doctors present with disruptive behaviour which masks their mental illness. We know that with the right support doctors not only make good patients, but excellent ones. They follow advice and respond to treatment. They are invested in their recovery and many thousands of the doctors attending PHS get better. Patients tell us how positive they are about their experiences and most report that their lives have improved after starting to attend PHS. They tell us they are happier, more relaxed, more self-confident or emotionally stronger; they talk about being able to rebuild their self- respect and improve their relationships with family members and colleagues. An unexpectedly large number of patients have credited PHS with not only changing their lives but with saving them. Several believe they would not be alive had they not found the service. One said that the service was ‘the best thing that ever happened’ to them; another that finding PHS had led them ‘to [discard] the idea of suicide’. PHS is also often credited for saving careers, with practitioner-patients telling us that they believe they would no longer be working in medicine had they not accessed the service. One doctor said, ‘[without PHS] I think I would have either hung up my stethoscope or would not be in this world’. Over the ten years we have won prizes (including The BMJ Mental Health Team of the Year in 2018); received accolades; been the focus of television and radio programmes and press reports. We have been the subject of a PhD, a MSC study and student dissertations, as well as TV, radio and print articles. This report will describe how we operate and hopefully will help doctors in need to take the brave step of referring themselves to us or to a similar service. We hope it will provide the reader with an understanding of PHS, our statistics and evidence base and will encourage others to ensure that this important population group gets the healthcare support they need. Finally, it has been an honour treating my colleagues over the past decade. The years have gone very fast and I am so proud that our service has gone from strength to strength in helping doctors in mental distress. Thank you to all who have come to our service and to the staff who have cared for them. Dr Clare Gerada 4th October 2018 Practitioner Health Programme 3 PHS is the largest physician health service in Europe and one which provides the widest range of treatments. 4 GP Health Service WELCOME 2 PART ONE: EXECUTIVE SUMMARY 8 SERVICE HIGHLIGHTS BETWEEN NOVEMBER 2008 - MARCH 2018 8 Headlines 8 • Outcomes 9 • Feedback 9 PART TWO: DOCTORS, MENTAL ILLNESS AND HEALTH SERVICES 10 Background to PHS 10 Why do doctors need a specialist mental health service? 11 Risk factors linked to doctors and mental illness 12 Stigma and shame 13 Complaints 13 Barriers to doctors seeking help for mental health problems 15 Summary of mental illness and doctors 15 PART THREE: THE NUTS AND BOLTS OF PRACTITIONER HEALTH SERVICE 16 PHS: designed for doctors by doctors 16 What PHS does not provide 17 How PHS is different from other practitioner health services 18 Comparison of of PHS to US physician health programmes 19 European provider network 20 Our team 20 Service issues 21 Ensuring sufficient capacity 22 Education and training 22 Clinical 23 Education and liaison 23 Return to work 23 Other 23 Providing shared care 23 Summary of what PHS provides 24 How PHS works for the practitioner-patient 25 Booking app 25 The patient pathway 26 Medical record 28 Multidisciplinary team meeting (MDT) 28 Risk assessment 29 Ensuring coordinated care 30 Ongoing treatment 31 Talking therapies 32 Behavioural therapy 32 Supported, computerised CBT 33 Telephone-based CBT 33 Face-to-face CBT 33 Practitioner Health Programme 5 Group therapy 33 Slow-open or closed groups 34 Drop-in groups 34 Time-limited groups 34 Monthly support groups 34 Support group for addiction 35 Residential rehabilitation 35 Managing exam stress workshop 36 Confidentiality 37 Consulting with a patient’s own GP 39 Continuing care and discharge 40 Patient organisations and networks 41 PART FOUR: HEADLINES OF OUR ACTIVITIES AT PHS 44 Decoding our data 45 Summary of care from November 2008 – March 2018 46 Numbers seen 46 Basic demographic data 47 Age 47 Gender 48 Doctors in training vs consultant-grade 50 Additional equality monitoring – protected characteristics 50 Presenting problems 51 Mental illness 53 Common mental health problems 53 Complex mental health problems 54 Addiction and doctors 57 Treatment for doctors with addiction 60 Treatment outcomes for doctors with addiction 60 Residential rehabilitation 61 Work, regulation and addiction 61 ‘Other’ mental health categories 62 Regulator/disciplinary involvement 62 How PHS helps doctors involved with the regulators 65 Work and training 66 Research and development 69 PART FIVE: HIGHLIGHTS FROM DIFFERENT SPECIALTY GROUPS 70 All doctors 70 General practitioners 70 Causes of GP distress 71 Practice meltdown 72 Too much too soon 73 The straw which breaks the camel’s back 74 From sad to bad 74 6 GP Health Service Psychiatrists 75 Surgical