Practitioner Health Matters Programme
Healthy Doctors – Safer Patients
A dedicated healthcare programme for
clinicians
Briefing Paper
November 2014
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1.
History of the Organisation
The Sick Doctor Scheme (SDS) was founded in 1985 to meet the needs of doctors with
addiction problems. It was formed by representatives from four separate organisations: the
Irish Medical Organisation (IMO), the Irish College of General Practitioners (ICGP), the
College of Psychiatry of Ireland, and the GP Wives Association (GPWA). Since its inception,
the SDS has provided support, medical advice and referral to appropriate treatment by
specialists in the field of addiction. The SDS has also assisted in the follow-up, monitoring
and rehabilitation of doctors who use the service.
The SDS is a registered charity and is administered by trustees, one from each of the four
parent bodies. The funds, which are usually channelled through the chairperson and
treasurer, have been used to provide financial help to individual doctors and/or their
families. Current funding is maintained through donations and interest on fund investment.
Since its establishment, the SDS has quietly assisted many doctors with substance misuse,
addiction and other problems. The decision to establish the Practitioner Health Matters
Programme (PHMP) is intended to build on the work of the SDS and to upgrade the
organisation in line with international best practice in this field. PHMP will also expand the
service to care and assistance to dentists and pharmacists as well as doctors.
Dr Íde Delargy who was Chairperson of the SDS is the Medical Director of the Practitioner
Health Matters Programme and will take a lead role in the development of the PHMP. The
memorandum and articles of association for the PHMP were registered with the Companies
Office in July 2013. As a company limited by guarantee, the directors are Mr Hugh Kane
(company chairman), Mr Fintan Hourihan (company secretary), Ms Frances Nangle-Connor
and Dr. Kieran Doran. It will operate on a not for profit basis and we are awaiting charitable
status from Revenue.
2.
A specialised Practitioner Health Matters Programme
2.1 Evidence base for a dedicated Practitioner Health Matters (PHM) Programme
The report of the former Chief Medical Officer in the UK, Sir Liam Donaldson which was
entitled Good doctors, safer patients (2006), acknowledged that doctors and dentists can
face a number of barriers when dealing with health difficulties, particularly mental health
and addiction problems. It recommended that a specialised treatment service be
commissioned and that methodologies for the assessment of practitioners with mental
health and addiction problems be developed. Following on from this report, a UK expert
working group developed proposals for a Practitioner Health Programme. These proposals
were presented in the 2007 White Paper, Trust, Assurance and Safety – the Regulation of
Health Professionals in the 21st Century. This paper proposed a pilot service for practitioners
with health problems and a UK national advisory group was convened. As a result, a
successful Practitioner Health Programme has been operational in London since 2009. An
ever increasing body of evidence in the medical literature suggests that specific confidential
services which provide a specialised health care service to health professionals can be highly
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successful (Brewster et al, BMJ Editorial, 2008; Marshall EJ, Journal of Occupational Health,
2008, Three Year Report, Practitioner Health Programme London 2014; BMJ Editorial,
Doctor’s health – taking the Lifecycle Approach, Dr Mike Peters, BMA).
The proposal for the Practitioner Health Matters Programme in Ireland has been modelled
on the London programme and has adapted operational protocols informed by visiting
programmes in the UK, USA and Canada. Our model conforms to international best practice
in the area of practitioner health.
2.2 Specialised nature of a practitioner health programme
The specialised nature of dedicated practitioner health programmes is that they recognise
the characteristics which distinguish how, why, and when clinicians present to clinical
services. It can deal with the idiosyncratic ways in which these clinicians take short cuts or
avoid engagement. It promotes optimal assessment, management, treatment, recovery,
rehabilitation and support in the face of the morbidity engendered especially by mental
illness and addictive disorders.
A successful service will require a core team who are:

specially trained and experienced in treating doctors, dentists and pharmacists
with complex needs and who understand the working environment of
practitioners with its unique pressures and requirements;

competent to deal with all health difficulties likely to be encountered in
practitioners;

take into account the requirement to protect the safety of patients who may be
cared for by the practitioner-patient and know how to apply this principle in
practice;

link effectively with other specialists as necessary in the wider health care
system; and,

effective at devising care plans and can demonstrate how continuity of care will
be achieved.
2.3 Skill mix of the clinical advisory team
The minimum requirements for the core clinical advisory team will include:
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
a medical director supported by a range of clinicians who have the appropriate
qualifications, skills and experience in treating health professionals. The team
will include individuals with suitable experience in managing mental health,
substance misuse and addictive disorders;

a clinical case manager, with relevant specialist skills and experience (most likely
to be a senior nurse with enhanced skills);

a senior manager/administrator - with responsibility for operational
management, finance, programme development, expansion and promotion; and,

staff with audit/research skills.
The Medical Director will have dedicated time to work on the PHMP. Experience from other
countries suggests that the programme’s success relies heavily on the vision, energy and
leadership of the medical director, and their ability to engage with a range of stakeholders.
3.
The Practitioner Health Matters Programme
3.1 General overview
The PHMP will provide a specialist health service for doctors who have health problems
mainly relating to mental health or substance misuse issues. However following a
comprehensive assessment the practitioner may be supported if they have other relevant
health conditions.
3.2 Funding
The PHMP will operate on a not-for profit basis and will be free of charge to doctors at
the point of care. Our objective is to primarily secure funding by collection of a minimal
annual payment from each registered medical doctor. We would hope to secure funding
also from other bodies involved in representing doctors (including medical defence bodies),
training bodies and insurance bodies to provide some start-up funding.
An estimate of the initial year one costs is set out in the accompanying Business Plan. It is
estimated that start -up funds of approximately €100,000 will be necessary to enable the
establishment and operation of PHMP for an initial period of twelve months.
No fees will be payable to any directors involved in overseeing the administration of
the programme. Annual reports will detail income and expenditure earned and incurred by
the PHMP.
3.3 Confidentiality
Where individual practitioners self-refer or are referred to PHMP for advice or treatment,
they will be assured that, once the safety of their patients is not compromised, their case
will be handled on a strictly confidential basis. This will be a fundamental principle of the
programme.
In the Medical Council Ethical Guidelines 2007, there is a clearly stated onus on doctors who
know that a colleague may be suffering with an alcohol or substance misuse problem to
report that colleague to the Medical Council. In such circumstances, doctors, colleagues and
the families of doctors with problems sometimes find it difficult to know how best to help.
There is recognition that obtaining appropriate and early medical help is the best way
forward for the doctor patient. However a misplaced sense of loyalty often prevents people
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from taking the appropriate course of action.
PHMP will be required to develop systems to protect the confidentiality of practitioners
engaging with the programme, while at the same time being able to identify and address
those circumstances where patient safety may be at risk. The PHM Programme will work to
the now agreed Memorandum of Understanding with the Medical Council which will set out
the requirements for passing information to the regulator.
In those rare cases where a practitioner is not willing or able to comply with advice on
managing their health problem and their condition may pose a risk to their patients, PHMP
has a responsibility to act.
3.4 Independence
The PHMP will operate entirely independently of the regulatory bodies. A Memorandum of
Understand (MoU) has been agreed with the Medical Council of Ireland. A similar MoU and
is currently under discussion with the dental and pharmacy regulators. All records of
activities of the PHMP relating to an individual medical practitioner will remain confidential
and will only be accessible to the PHMP. In the event, however, that the PHMP believes that
the practitioner represents a risk to the public interest, the matter will be referred to the
Medical Council and PHMP will provide all material and documentary evidence in its
possession to Council for consideration.
3.5 Aims and objectives of service
The primary aim of the service is to provide for a previously unmet need to intervene,
assess, treat or refer doctors, dentists or pharmacists who have mental health or substance
misuse problems. It is generally accepted that practitioners are unlikely to use existing
services due to perceptions of stigma and lack of confidentiality.

The service will also provide advice, comprehensive assessment, case
management services and, where necessary, onward referral to specialist
services.

The service will provide a comprehensive, holistic support service which will
include occupational health, psychological services, career advice/mentoring,
financial advice and peer support.

The service will provide case management for practitioners to support them
through efficient and effective treatment and/or monitoring and, where
appropriate to get them safely back to work as soon as possible.

The service will encourage effective use of local primary care, occupational
health and specialist services where these are available and appropriate.
3.6 Expected outcomes
As a result of prevention, earlier intervention, effective treatment and improved well-being,
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the expected outcomes for the programme will include:
4.

safe return to work in the majority of cases (70% to 80% practitioners);

improved abstinence rates – alcohol and drugs;

increase in practitioner wellbeing (and the quality of life of their families);

greater understanding of practitioner health; and,

improved data and analysis around practitioner ill-health.
Scope of the Practitioners Health Matters Programme
4.1 Eligibility criteria
The PHMP will provide a specialist health service for doctors, dentists and pharmacists who
have health problems relating to:

any mental health issue; and/or,

substance misuse issue (at any level of severity).
4.2 Core service provision

The PHMP will be provided by highly skilled and experienced staff, with appropriate
qualifications and registered with the relevant professional bodies.
4.3 Multi-disciplinary working relationships
Improving practitioner health and wellbeing depends on the inter-connection and
cooperation between many services. The PHMP service should not work in isolation and
should work with other disciplines as required in order to attain optimal outcomes. To
support effective multidisciplinary working, clear care pathways and formal working
agreements will be in place. Partners will include: GPs with training in providing care to
health care professionals, community mental health teams, inpatient addiction services,
inpatient mental health services, psychological services and occupational health services.
Other services and teams will need to be identified on a case-by-case basis.
4.4 Interdependencies with other services
The service will engage with other specialised services for assessment and advice on
management or treatment of health concerns other than mental health or addiction.
Through clinical case management, the PHMP can support the process of return to work by
liaising, as appropriate, with the employer. Adjustments to the workplace may be required
and often a phased plan for successful re-entry to work will be appropriate. Some
practitioners may need a period of re-training, a clinical placement, or interim restrictions
on their practice. Others may need to consider returning to work in a different field and may
need career coaching and/or mentoring.
For practitioners with addictive disorders, workplace supervision or monitoring will usually
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be needed. This may involve liaison with the treating doctor, occupational health and
workplace supervisors as appropriate. The PHMP will identify an appropriate provider of
laboratory testing to support the monitoring of practitioners with addiction problems.
The PHMP will establish links with services that are local to the practitioner while respecting
the requirement for confidentiality. These may include general practitioner and specialist
services, occupational health, peer support and self-help. It may be necessary to develop a
network of appropriate service providers around the country.
5.
Service Delivery
5.1 Service model overview

PHMP will offer a confidential telephone line and email contact point which will
provide an expert clinical advice service.

PHMP will arrange face to face consultations and a case management function.

PHMP will arrange referral to specialist secondary care providers, enabling rapid
access for further assessment and treatment where required. When access to
outpatient and inpatient treatment for addictions is necessary, this will be arranged
in a timely fashion.
5.2 Initial Contact with the services
Initial contact with PHMP can be made by telephone, email or written referral. Contact may
range from requests for advice only to complex and emergency referrals. Practitioners
themselves, or their colleagues, family or friends may contact the service. Occupational
health services, general practitioners or employers may contact the service for specialist
advice or to make a referral.
Following initial contact, the PHMP will provide telephone advice and/or make
arrangements for a face-to-face assessment of the practitioner. The telephone/email
contact service must have timely access to support by suitably qualified and registered
health professionals who are able to deal with a range of issues accurately and promptly.
5.3 Response time and prioritisation
Following the initial contact the practitioner will be offered an appointment with a suitably
qualified clinician ideally within two days or at a date and time acceptable to the
practitioner-patient. This assessment will be provided during office hours.
5.4 Initial assessments
Face-to-face full clinical assessment will be carried out by suitably qualified senior clinicians
with skills and experience to enable them to make sound judgements, particularly in
relation to the management of risk. Collateral information may be sought at this stage, with
consent from the practitioner, to ensure a comprehensive assessment.
Following initial assessment, all cases will be discussed by the multidisciplinary Clinical
Advisory Group, and a case management decision will be agreed with input from the
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practitioner patient. The practitioner’s own GP will be informed.
The initial assessment may lead to one or more of the following outcomes:

advice, with no further action required;

extended assessment in cases where it may not be possible to make a diagnosis of a
practitioner’s health problem during an initial assessment or where a small number
of therapeutic consultations is likely to address the practitioner’s problems more
effectively;

referral to specialist assessment and treatment including psychiatry, occupational
health, cognitive behavioural therapy, motivational interviewing, psychotherapy;
and/or,

liaison with the practitioner’s GP.
5.5 Case management and follow-up
Once a case management plan is agreed, a designated case manager will be assigned to
each practitioner. The case manager will have a vital role in ensuring communication
between all clinicians and organisations involved in a practitioner’s long-term care. Case
managers may also provide support to the practitioner during the time they are accessing
specialist services, and (with the practitioner’s consent) will help to coordinate care with the
practitioner’s GP and/or occupational health services to plan a back to work strategy.
5.6 Monitoring of practitioners with addictions
Monitoring is a vital and integral aspect of treatment and will need to be negotiated and
agreed with the individual practitioner-patient. It may involve one or more of the following:
random drug screening, workplace supervision, supervision by a psychiatrist, attendance at
therapy sessions, attendance at self-help or peer support groups.
Monitoring will include feedback provided from a number of sources such as their treating
doctor(s), general practitioner, supervising doctor, employer, occupational health physician,
and/or workplace supervisor. Feedback will usually include laboratory testing for biological
markers to complement clinical assessment. Useful feedback may also be obtained from
family members, friends and colleagues. The clinical case manager can help with making
arrangements for monitoring and liaising with local organisations to help practitioners get
back to safe practice.
Local treatment, supervision, monitoring and support may need to be in place for some
years, with central coordination as an essential aid.
5.7 Care plan review
Each practitioner’s care plan should be reviewed and evaluated with the practitioner at
regular intervals throughout the intervention. This review will be conducted by the
designated case manager and if any concerns are raised, these concerns will be brought to
the attention of the Clinical Advisory Group.
5.8 Discharge criteria and planning
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Discharge from the service will follow strict discharge planning protocols and will only be
agreed following discussion with the Clinical Advisory Group. The designated case manager
will inform all relevant agencies involved in the care of the practitioner including the
practitioner’s GP. Where a practitioner is returning to work, this will be a supported process
with the help of the case manager and/or an occupational health physician.
A diagram detailing the general care pathway through the PHMP can be found below.
6.
Operational Issues
6.1 Location of service
PHMP will be provided from a single location in Dublin, with convenient access for
practitioner-patients. A single location will facilitate the development of multidisciplinary
case conferences, team identity and provide for immediate and regular advice, support, and
clinical supervision for clinicians working within the service.
Suitably confidential rooms will be available for face-to-face assessments, limited
therapeutic interventions, physical examination and sample taking (for example, blood,
urine). Appropriate arrangements have been made for the confidential booking of
appointments, waiting area and storage of clinical records.
6.2 Hours of operation and contact details

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PHMP will provide a service through a dedicated telephone line during office
hours, with suitable arrangements made for out of hours cover with the
practitioner’s own GP.

A website with a dedicated confidential email contact is in development.
6.3 Protocols
Protocols for the provision of advice, assessment, treatment, referral and overall case
management will be developed in conjunction with the Clinical Advisory Group. These
protocols will support the work of the clinicians and may provide a model for possible
extension of the PHMP in due course.
7.
Staff Training and Support and Programme Evaluation
7.1 Staff Support
Supervision
Any clinician, regardless of discipline, who is seeing practitioner patients, will receive
appropriate training and supervision. The supervision will be informed by best practice and
will consider the following:

practitioner’s emotional well-being;

workload;

practice/clinical issues and standards;

reflective practice;

service standards; and,

individual training and development needs.
Training
There will be a need for ongoing training which will ensure the following:

audit of staff skills, competencies and training;

identification of staff skills/ training needs;

access to training programmes to ensure CPD of all staff; and,

roles and responsibilities of each member of the multi-disciplinary team will
need to be made explicit.
7.2 Data collection and evaluation
The PHMP will use an appropriate confidential clinical information management system to
support clinical management of cases.
Clinical records will be maintained and stored in line with normal clinical practice.
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Evaluation of the programme is a key aspect and the collection of anonymised data will
include:

evaluation of referral patterns;

assessment of the impact of the service;

external clinical evaluation; and,

user satisfaction assessments.
The evaluation of the PHMP will support the:

further understanding of the aetiology and management of ill health in doctors
and dentists; and,

training and education programmes for health professionals and managers.
7.3 Awareness raising
The service will need to be well publicised and promoted to demonstrate how it will:

provide an accessible and confidential service for practitioners who may have
difficulty in acknowledging their health problems and/or accessing services

advise on and/or assess, treat and manage practitioner health problems caringly
and appropriately
Promotional activities should be undertaken using, for example, the internet, publications,
and presentations.
The PHMP will work with the relevant professional associations and other professional
bodies and services to promote the service.
We have been heartened by the support we have received from a range of organisations
who have pledged support for the PHMP, as follows –
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
Forum of Medical Post-Graduate Training Bodies

Health Service Executive

Irish Dental Association

Irish Hospital Consultants Association

Irish Medical Organisation

Medical Council

St. Patrick’s Hospital Dublin
8.
Action Plan
Phase 1 – Planning for change

Nominees for the Clinical Advisory Group will be sought.

A Memorandum of Understanding has been agreed with the Medical Council of
Ireland.

Suitable funding sources such as the professional colleges, the Department of
Health, the HSE, the Medical Council, and the medical insurance companies will
be agreed.

A reporting mechanism between the PHMP and all other relevant agencies or
individuals will be agreed.

Identify suitable services both inpatient and outpatient, to support the PHMP.
Appropriate referral pathways and protocols will be agreed.

Agree criteria and standards for evaluation and doing clinical audit.
Phase 2 – Implementation

Develop and agree suitable assessment tools and standardise the specialist
referral and reporting templates.

A suitable premises for medical assessments has been secured.

A website has been developed.

Confidential helpline and email contact established.

Set an implementation date for the programme as outlined above.
Phase 3 – Evaluation (after one year in operation)
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
A full external evaluation of the programme will be conducted after one year.
This will include a clinical audit, and an operational and financial review.

If the evaluation is successful, consideration can be given at this to further
expansion of the service
Appendix A:
Estimated PHMP Costs: all costs are approximate
(a full Business Plan has been prepared and is available on request)
Annual Costs
all PC sums €
Medical Director
Nurse Practitioner
Clinical Advisory Group
20,000
15,000
15,000
Administrator




Training & Courses
Telephone
Internet
Website Setup
Website Service
Room Rental
Stationery
Miscellaneous
Recruitment
Promotion of Service
10,000
5,000
1,000
1,000
10,000
2,000
5,000
1,000
10,000
2,000
3,000
TOTAL
€100,000
The Medical Director role is based on rate of €250 per session and once weekly
session initially.
Nurse Practitioner: €15,000 on a half time basis approx.
Clinical Advisory Group: based on an honorarium of €100 per person for one
meeting per month.
Administrator is based on €20 per hour and six hours weekly.
All costs are estimated figures and will be finalised at the end of the pilot phase.
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