Support for doctors

Support for doctors

The BMA has assembled an excellent collection of links to organisations providing support to doctors in difficulty - access this page via the link below.
BMA doctors' wellbeing

Specialist mental health services for doctors

DocHealth - new psychotherapy service for doctors

DocHealth, a new specialist psychotherapeutic service for doctors supported by the British Medical Association and the Royal Medical Benevolent Fund has recently opened in London. The service is to be run on a not-for-profit basis with fees varying depending on the grade and circumstances of the doctor. The experienced clinicians are ex MedNet (a London psychotherapy service for doctors - now closed) and include eminent names in doctors' health in the UK, Dr Tony Garelick, Dr Julia Bland and Dr Matthias von der Tann. Self-referring doctors can access up to six face to face sessions with the service and further care can be advised.  

All doctors in the UK are able to self refer to this service.

NHS GP Health

The NHS GP Health Service is a free, confidential NHS service for GPs and GP trainees in England.  It can help with issues relating to a mental health concern, including stress or depression, or an addiction problem, in particular where these might affect work.  The service is self-referral.  It is provided by health professionals specialising in mental health support to doctors and is available in various locations across England.  

Contact the service via their website , email or phone 0300 0303 300. The service is available 08.00 - 20.00 Monday – Friday and 08.00 – 14.00 Saturday.

Health for Health Professionals Wales

The Health for Health Professionals (HHP) Wales helpline is a new face to face counselling service for all doctors in Wales.  It provides doctors with access to a BABCP (British Association of Behavioural and Cognitive Psychotherapies) accredited therapist in their area. This service is confidential and is fully funded for doctors in Wales by the Welsh Government. The service is currently administered by Cardiff University. 

HHP Wales helpline (09.00 - 17.00, Monday to Friday) - telephone: 0800 058 2738  A doctor advisor will ring back within 24 hours and is able to put you in contact with a therapist if it is felt that the service is appropriate for you. Outside these hours, the service recommends that you contact the BMA counselling service on 08459 200 169 if you need to speak to someone.

Practitioner Health Programme

The largest service currently specialising in treating doctors with mental health issues is the Practitioner Health Programme in London.  The Practitioner Health Programme was established in 2008 and covers doctors and dentists living in the London region and other specific South East areas (see their website for details of eligibility). The service will support practitioners with mental or physical health problems including addiction, particularly if these affect their work. 
If you are not covered by PHP's residence or work criteria, it is possible to self refer to the service if funding can be agreed - details available on their website.

Dedicated telephone support for doctors

BMA Support The BMA runs a dedicated 24 hour support line staffed by professional counsellors as well as the Doctor Advisor service.  
BMA Counselling and Doctors Advisor service
The Psychiatrists' Support Service is a free, confidential support and advice service for members, trainee members and associates of the Royal College of Psychiatrists who find themselves in difficulty or in need of support.
Psychiatrists' Support Service

Voluntary sector support - specifically for doctors

The British Doctors and Dentist Group is a mutual support society for doctors and dentists who are recovering, or wish to recover, from addiction/dependency on alcohol or other drugs.
British Doctors and Dentists Group
The Doctors' Support Group provides support to doctors or dentists facing suspension, exclusion, investigation of complaints and / or allegations of professional misconduct. 
Doctors' Support Group
The Sick Doctors' Trust provides support and help for doctors, dentists and medical students who are concerned about their use of drugs or alcohol.
Sick Doctors' Trust
The Tea & Empathy group is an open Facebook group for health professionals to provide informal peer support to each other.
Tea & Empathy

Occupational Health : how we can help doctors 

Doctors' Support Network 2016 Dr Janet Ballard mental health
By Dr Janet Ballard

​Janet has been an occupational health physician for seventeen years working mainly within the NHS.

​Janet is clinical lead for the Health at Work team for the West London Mental Health NHS Trust. 
What Occupational Health CAN do 
As an occupational health physician (OHP) for seventeen years, working mainly within the NHS, I have seen doctors at all stages of their careers in my clinic. My role includes providing support and advice during sickness absence or periods of stress, signposting to other services (I am fortunate to work in London and have resources such as the Practitioner Health Programme and MedNet, as well as organisations such as Doctors’ Support Network), advising on return to work plans or adjustments, and advising employers about disability law. 

What Occupational Health CAN’T do 
As an OHP, I can only advise a manager regarding adjustments to work, I cannot make him or her follow my advice. Occupational health does not usually provide clinical care (you should have a GP, and possibly a specialist, for this) although departments may offer interventions such as physiotherapy or counselling. As the OHP, I cannot be your advocate as I have a responsibility to advise your employer, as well as to you; I am required to give an impartial, professional opinion.  

Doctors as patients 
It is increasingly acknowledged that doctors don’t make good patients and may need ‘permission’ to be unwell, particularly for mental health issues. A relationship of trust between the doctor and the OHP is important in allowing the doctor to be the patient, and to accept help. 
NHS appointments for mental health problems often take too long, but dedicated services for doctors are able to respond in a timely fashion (e.g., the Practitioner Health Programme). This type of service is being replicated across the country, but slowly. 
I try to start a conversation with the doctor about return to work plans once their recovery is underway, as this supports the expectation of recovery. A plan to address work-related problems needs to be discussed. Occupational health is also best placed to flag when disability should be considered. A doctor may need to have a renegotiated job plan to return to work, such as reduced commitment, to allow for disability. 

Confidentiality - who needs to know what? 
Occupational health consultations must be confidential, unless overridden by mandatory disclosure requirements such as safeguarding of children. Information provided to others should not include confidential information. There is no need nor obligation for occupational health to disclose an employee’s diagnosis or personal circumstances to anyone – just to advise what the employee can or cannot do. 

All communication is disclosable to the individual (under Data Protection law). You should be shown the letter for your employer, for your agreement to send, and to allow correction of any factual errors. 

Key relationships for OHPs exist with Medical Directors and Human Resources Directors, as well as clinical and training programme directors. There may be tensions for the OHP as the Medical Director and Human Resources Directors are usually also the professional manager and line manager, respectively. Despite this, occupational health must keep staff medical details confidential. No-one in the employing organisation has right of access to the OH files; this is supported by statutory and case law. Disclosure of confidential information is strictly controlled, and does not allow for the Medical Director to demand to know. But, you should remember that the GMC has the same rights as a court of law, and can require disclosure of all of your medical files. 

Adjustments to support return to work 
A successful return to work may require temporary adjustments, such as reduction of workload, responsibilities and/or out of hours working, usually time limited over four to six weeks. Longer term adjustments may need to be considered for the doctor with ongoing health problems. Occupational health does not have the authority to mandate changes, but can have a key role in negotiating 'reasonable adjustments' with management (under the disability provisions of the Equality Act 2010). This is not just what works for the doctor, it has to take into account service needs and the impact on others. 

Where tensions do exist, these must be challenged because the best outcome for all – the doctor, the employer, the patients and the OHP – is for you to be well and at work. 
Meanwhile, organisations like the Doctors’ Support Network are invaluable to doctors coping with health and employment problems, by providing emotional and practical support, but also by demonstrating that the doctor is not alone. A doctor not in work is in a very isolated and lonely place.

Pull down your own oxygen mask first

Doctors' Support Network 2016 Dr Clare Gerada mental health
By Dr Clare Gerada

Dr Clare Gerada MBE, FRCP, FRCGP, MRCPsych is well known to the world of physician health as the medical director of the Practitioner Health Programme. Clare is also a General Practitioner and was until 2013, the chair of the Royal College of General Practitioners. Clare lectures and publishes widely on the themes of doctors’ health and specifically addiction. She spoke at the 2014 DSN conference. 
​This article was first presented at the Medical Women's Federation in October 2014.
Over recent months I have repeated the phrase ‘pull your own oxygen mask down first’, not I hasten to add be-cause I am now moonlighting as an airline stewardess, but because it’s a phrase I use when talking to doctors about how to stay mentally and physically healthy in these troubled times within the NHS. 
Doctors not immune to mental illness 
Doctors are not immune to mental illness; in fact, doctors have high rates of depression and anxiety, and female doctors in particular have significantly higher suicide rates than the general population. Since 2008, I have run a confidential NHS service for doctors with mental health and addiction problems. Our experience at the Practitioner Health Programme is that, by and large, most doctors have months of distress and disability until they present as unwell after a work or home crisis. Many doctors who come to our service often talk about the shame associated with not ‘coping’ or becoming unwell, and of their fear that disclosure of their mental illness would lead to ‘career suicide’. They worry about confidentiality and about being referred to the regulator if they admit to having a mental illness. 

The NHS is depressed 
There are other deep-rooted problems. I have written recently that if the NHS were a patient, it would be depressed and in need of psychological treatment. The NHS is troubled for many reasons, but predominantly due to increasing workload and decreasing support systems. Also, constant reorganisation is creating a culture of fear: fear of exposure, fear of being shamed, named and blamed. This working environment is undermining the development of resilience. In recent years, a culture of increasing blame, bullying, and retribution has developed in medicine. 
The General Medical Council estimates that one in eight doctors in training has suffered bullying. Constant reorganisations destabilise relationships, and coupled with early retirements and the moving of older and more established doctors, this removes the continuity and corporate memory that builds resilience in institutions. Paradoxically, shorter working hours may also be a contributory factor. Working time rules mean doctors work shifts, which further fractures the relationships between staff and patients that provide support and feedback to build resilience for trainees. Changes to working hours also erode continuity of care, which is valued by healthcare workers and patients alike. 

Super–human doctors 
The relationship between doctors and patients rests on the unconscious assumption that patients embody illness and, in contrast, doctors stand for health and immortality; if doctors are ill, they ‘have only themselves to blame’. When consulted in an independent survey to evaluate the need for a confidential, stand-alone mental health service for doctors, the public admitted to regarding doctors and dentists as ‘super-human’ rather than ‘normal people’. On further reflection they were aware of, and empathetic towards, the health impacts of such a stressful job. So … maybe we need to admit to our vulnerability more often … perhaps we do only have ourselves to blame …. 
Health professionals rightly have a strong sense of vocation to ‘help people’, but sometimes it is done to divert the helper from their own psychic pain and vulnerability, and leads to the denigration of their own needs. This means that when unwell, rather than seeking help or taking time out from the work space, doctors merely work harder, in the assumption that this will ‘make things better’. Not surprisingly, this approach rarely helps, and a study has shown that when doctors finally allow themselves to take time off for ill health, they tend to be off work for longer periods because they consult so late. 

Look after ourselves first 
The General Medical Council exhorts us to ‘make our patients our first concern’. So does this run counter to the advice that I gave at the start? I don’t think so. Putting patients first means recognizing where we cannot deliver care to the standard that our patients warrant – for example, when we are exhausted or suffering from physical or mental illness. This isn’t to promote taking sick leave for any minor problem – but just being mindful of our own health needs and how they might impact on the patients we treat. 

The GMC advises that doctors should be ‘alive to mental health problems, depression, and alcohol and drug dependence [in colleagues]’ and should ‘act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.’ In most circumstances, this means advising that they take time out, removing themselves from the work-place and seeking appropriate help. 

The good news is that it is still unusual for doctors to become mentally unwell, and most pass through training with few problems. Predictors of good psychological wellbeing are the same in doctors as in the rest of society: stable relationships and a high level of support from family members. Doctors tend to have many of these positive protective factors, being highly educated and having good friendship networks. However, we must not be complacent. 
Doctors are an important and expensive resource for society, and loss of this workforce due to avoidable ill health is a waste to the health service, a loss to patients, a stress on colleagues, and a disruption to individual careers. Avoidable causes of ill health in the system that doctors work must be dealt with, and doctors must have timely access to confidential help. 

Pull down your own oxygen mask first 
Perhaps it is time to be honest with our patients and accept that a good and safe doctor means replacing the exclusive and somewhat over idealised medical role that dictates we serve patients come rain or shine. Instead, we should adopt a more mature role that ex-tends to self-care and putting the needs of doctors alongside the demands of patients – indeed, pulling one’s own oxygen mask down first is better for doctors and better for the patients they serve.

The rewards of keeping doctors healthy

Doctors' Support Network 2016 Dr Richard Duggins mental health
By Dr Richard Duggins

Richard is a consultant psychotherapist and psychiatrist . He was lead clinician of House Concern, which provided dedicated psychotherapy services for career grade doctors and dentists within the Northern region. Richard is a long standing supporter of DSN and has frequently presented at our conferences.
The 'Cliff' – The Performance Curve of the Doctor-in-Difficulty 
Over 50% of the doctors presenting to House Concern show the 'cliff' pattern of ill-health. The cliff has three components: 
  1. A long tail of months to years of overwork, exhaustion and increasing burnout. As this progresses work performance tends to be protected, whilst other aspects of the doctor’s life start falling apart, including family life and other leisure activities. 
  2. The cliff represents a steep sudden decline in work performance usually resulting in needing a period away from work. 
  3. The gradual recovery stage, which may lead to a higher level of performance than has been achieved previously. 
What factors contribute to 'the cliff'? 
The teapot. Dr Claire Gallagher, GP in Practitioner Health Programme, London, likens doctors to a teapot and people they care for are the cups (patients, colleagues, family). She sees the system as becoming out of balance with a doctor pouring out care into cups, without taking the time to get care for him, or herself, to ensure the teapot is refilled. 
The milking stool. A symbol of balance - there are three legs representing work, family and self. As doctor focuses increasingly on work, due to overwork and developing burnout, he or she often begins to neglect family and self resulting in instability. 
Plate spinning on your own. Doctors are trying to cope with too many demands on their own. 
Superman/ superwoman to super-failure. Doctors’ high expectations and high levels of self-criticism lead to a dichotomous way of viewing their performance as either superman / superwoman or super-failure. 

Healthy Habits often developed by doctors seeking help 
Memento Mori. Popular belief suggests a Roman General in a victory triumph would employ a slave to whisper in his ear, “Look behind you! Remember you are a man! Remember you’ll die. “ Many doctors develop a helpful internal advisor that reminds them they are a human with limitations like everyone else.
The devil and the angel. Many doctors become much better at balancing their critical internal voice (devil) with one that is more realistic and forgiving (angel). 
Moving from independence to interdependence. There is often a move during therapy to interdependence, including sharing difficulties and issues with others, and sharing and delegating tasks. 
'The hedgehog.' Isaiah Berlin divided the world into hedgehogs and foxes, based upon an ancient Greek parable. “The fox knows many things, but the hedgehog knows one big thing.” The fox has a myriad of complex ways to attack the hedgehog. The little hedgehog rolls up into a perfect little ball and is fine. People, who are like foxes, never integrate their thinking into one overall vision. People, who are like hedgehogs, simplify the world into a single organising idea. In this way, people in therapy tend to focus on key priorities, while developing the ability to say no to other activities. 
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