A national support service

The Royal College of Physicians’ (RCP's) publication Work and wellbeing in the NHS: why staff health matters to patient care ¹ summarises the current poor performance of the service in these matters. Sickness absence rates, a key metric reflecting morale, are 27% higher than the average for UK public services, and a shocking 46% above the UK average overall. Poor mental health underlies more than a quarter of the absences, and self-reported stress affects nearly one in four NHS employees in England. The morale of staff appears to correlate with job satisfaction and perceptions of whether individuals are valued by their employers, and there appears to be a huge variation between different NHS organisations. These issues are important, as staff health is reflected in the quality of patient care that can be provided, from reasons as varied as a lower MRSA transmission rate when staff morale is higher, to greater locum costs when staff are on sick leave. Staff in all grades – doctors, nurses, paramedics and support staff – are all prone to work-related illness, reflecting in large part their working conditions.

The RCP's publication outlines areas for action, of which the first is that trusts and commissioners should prioritise staff engagement and wellbeing. Other recent publications have emphasised another of the action points – support for clinicians to help manage psychological stress following adverse clinical incidents and during fitness-to-practice investigations. Harrison et al ² emphasised in this journal the professional and personal impact of adverse events on doctors, with the majority suffering stress, anxiety, sleep disturbance and a loss of professional self-confidence; probably a quarter of the doctors surveyed showed manifestations of post-traumatic stress disorder. However, nearly half the doctors surveyed (well over 1,000) rated the results of reporting the incident as inadequate, and indeed many incidents went unreported.

More headlines resulted from an independent review commissioned by the General Medical Council (GMC) on doctors who committed suicide while under GMC fitness-to-practice investigation – 28 in all over eight years. ³ During this period, 114 doctors had died with an open and disclosed GMC case at the time of death, and thus the 28/114 proportion is truly shocking – although it must be clear that this is very far from being a cause-and-effect relationship. The issues that underlie many fitness-to-practice investigations, such as mental health, alcoholism and drug addiction, carry with them a suicide risk, and in many surveys, doctors as a whole carry a greater suicide risk than the general population, with depression and work-related stress a common background. ⁴ Nonetheless, the review highlighted the vulnerability of doctors under investigation. Most of the recommendations of the report (produced by Sarndrah Horsfall, previously chief executive of the National Patient Safety Agency) concern current GMC practice, for example the first recommendation is that doctors under investigation should feel they are treated as ‘innocent until proven guilty’. More far reaching is the recommendation for the establishment of a National Support Service (NSS) for doctors.

The NSS would be a national body to assume responsibility for day-to-day management of doctors with health concerns, incorporating assessment, management, treatment, education and prevention. ³ The range of reasons for referral would be wide, ranging from mental health problems to addiction and drug abuse. Doctors, and indeed medical students, could self-refer in confidence, but colleagues, employers and the GMC could also refer. (The latter could provide a means to attempt to safeguard and support doctors undergoing disciplinary procedures.) The NSS would provide a medical supervisor for the doctor, coordinate and monitor an agreed treatment plan, and also assess whether the doctor's condition is putting patients at risk. The NSS is envisaged as operating independently from the GMC, but remaining under the GMC's authority. There would be an agreed process for referral to the GMC if issues of probity, illegal or very serious behaviours were involved, and for discussing with the regulator whether patient safety concerns merit short-term conditions being placed on registration.

A model for this has existed in London for some years – the Practitioner Health Programme (PHP). ⁵ Set up in 2008, PHP is a confidential, NHS treatment service for doctors and dentists who are unable to access confidential care through mainstream NHS routes due to the nature of their role and/or health condition. To date, the service has been accessed by approximately 250 doctors and dentists yearly. Its results for maintaining in/return to work are impressive. Disappointingly, the top line of its website (accessed March 2015) states ‘PLEASE NOTE: We are sorry that we are unable to accept new referrals for London residents at this time due to unprecedented demand for services’ ⁵ – ie lack of resources.

Which brings in the issue of finance. The London PHP is financed by approximately £1.2 million yearly from the London Specialised Commissioning Group. The GMC's review suggests a nationwide annual price tag of approximately £6 million for the service and speculates on where that might be raised, recommending national support (Department of Health, NHS England and the devolved administrations) for two years to set up the scheme, and subsequent funding from the GMC by a potential 5% increase in the annual retention fee or possibly from existing GMC income. ³ Strong reactions may be anticipated to some of these suggestions, but should not prevent the development of a service which will not only help doctors but, judging from the success of the London project, help protect the quality of care they provide.

• © Royal College of Physicians 2015. All rights reserved.