The steel-framed door tucked between a Tesco and a hardware shop on a busy South London street is neat and anonymous. And for doctors such as John who pass through it, safe in the knowledge that their confidences will be protected, it is the salvation from years, if not decades, of chaotic health battles fought in silence.
John, now in his early 40s, was an accomplished GP until a mix of stress, depression and addiction took control of his life. A decision to start self-medicating — a bit of valium “just to take the edge off work” — spiralled into a dependency almost without bounds. John became the most high-functioning of addicts; a GP who would administer powerful sedatives to cancer sufferers on house calls before heading home to finish off the vial of diamorphine. Five milligrams, as recommended, for the patients — then five times that amount for himself. He would spend the remainder of the evening slumped in the “whatever” euphoria associated with the drug’s more common name: heroin.
The doctor describes his years of alcohol and drug abuse as an exercise in personal and professional self-denial, fuelled in part by a health service that struggles to help its own practitioners when they need it most.
Speaking to The Times about how he came to confront his condition, John struggled to keep his emotions in check. “It was the gift of desperation,” he said, describing how fears of coming to the attention of medical regulators and colleagues — of being seen as “a doctor who couldn’t even look after himself” — fell away with the realisation that it was a simple choice: help or death. “The most important thing was staying alive.”
When John stepped through that unmarked door in South London he joined the Practitioner Health Programme (PHP), the first NHS clinic to offer care and counselling for doctors, and in confidence. John’s ordeal may sound extreme, but it is far from unique. A government review published last year suggested that more than a third of the health service workforce is in moderate to poor mental health. Figures from the PHP’s first year show that 184 doctors and dentists sought help from the service, with some as young as their mid-20s and the oldest a few months short of retirement. Almost half have been women.
Mental health problems were cited by 114 of them, ranging from depression and anxiety to undiagnosed psychosis, eating disorders and obsessive behaviour. A further 67 had addictions, with alcohol the main crutch but also including ketamine, cocaine and heroin. A small number attended with physical problems, such as cancer, deafness and multiple sclerosis.
All had been competent health professionals at some stage in their lives, and all had struggled to access NHS care in a form with which they could cope — be it GPs, dentists, psychiatrists, surgeons or junior doctors.
For Clare Gerada, head of the PHP and a family doctor with expertise in psychiatry and substance misuse, the work has been satisfying — the outreach is working — but a worrying insight into how entrenched the problem has become.
“[The doctors] can be catastrophically humiliated and ashamed at what has happened, but they feel an immense sense of relief to be able to tell their story. It could be for the first time in 20 years — for many of them it has been the first time they have had that conversation. And if they weren’t a doctor it would have been one that they had with their own GP many moons ago.”
The pressures that John felt before joining the PHP last year — both professionally and in his personal relationships, where his partner was expecting a child — are echoed in reports from others in similar trouble. The dentist dependent on tranquillisers who ended up in inpatient rehabilitation after his attempts at forced abstinence brought on a mental breakdown; the junior doctor with psychiatric complaints now back in training; the alcoholic GP petrified at “who will see the referral letter” now teetotal and back treating patients.
On arriving at the surgery, the doctors (known as practitioner-patients in the paperwork) are ushered through to a consulting room immediately. Some initial contact will have been made already, although as Dr Gerada observes, their wariness can make things quite cryptic.
“They can e-mail using hotmail addresses, which are often strange and created just to send [the message], and it might say ‘I am a doctor and I think I’m being chased by dogs’. You might think that’s ridiculous, but we will ring them back and say, ‘We are here’.
“No matter how strange their query is, we will chase them up, because we have learnt that what they are ringing up for is something very serious and very real.”
When doctors such as John — whose name has been changed — book into the clinic, they enter a surgery much like any other, and one that also serves the local community in southwest London. They pass the familiar posters about repeat prescriptions and swine flu reminders to consulting rooms where a two-hour assessment takes place. Problems are discussed and observed, follow-up is arranged and the beginnings of a treatment plan fall into place.
For John, as with so many, the greatest fear about being logged in the system was that he might come under the scrutiny of the General Medical Council, the professional regulator. The GP had managed to stay under the radar in part because of his work as a locum, covering out-of-hours calls over a large, dispersed community. His dependence on opiates between shifts grew rapidly, fuelled by the stress of “stupid amounts of contacts with a very demanding public”.
A patient suffering severe pain from kidney stones might receive between 50 and 100 milligrams of pethadine; John reached a stage where he was injecting 600 milligrams a night. Two years ago his prescribing habits drew the attention of the local primary care trust, which, following post-Shipman protocols, made inquiries.
“I bluffed it,” John said of his success at persuading them that nothing was amiss. When off duty — his locum shifts involved two weeks work, then ten days off — he reverted to alcohol, “maybe two or three bottles of wine a night”.
At one point his mental health deteriorated to the point that he stopped work, telling colleagues that he was suffering from exhaustion. A return to medicine brought the demons back, and two suicide attempts followed.
“It was only at the very end that I really was aware. Doctors are well-educated, you can make up all the excuses you need. I thought, ‘I cannot be in this position. I’m still seeing lots of patients, I’m still getting lots of thank you letters.’ That was the big blindfold. I was still performing and doing a good job, but inside I was really struggling.”
Determined not to risk a six-figure salary and his medical future with a GMC inquiry, John sought help in confidential circles outside the NHS system. Until recently the British Doctors and Dentists Group and the Sick Doctors’ Trust — commendable self-help organisations involving sufferers, survivors and their families — were a desperate doctor’s only route to rescue. Then came the PHP, and a formal programme back to good health.
Dr Gerada is quick to point out that this involves the regulator where necessary — if there is any risk to the practitioner-patient or their patients. A third of doctors arrived as subjects of GMC or General Dental Council inquiries. The PHP team identified 24 “high-risk” doctors; six were advised to contact the regulator and five removed themselves from work. Three quarters of cases remained in, or returned to, their medical careers after contact with the service.
No such help was on hand for Daksha Emson, a woman cited by Dr Gerada as the genesis of her programme. Dr Emson, a psychiatric specialist registrar, suffered from bipolar affective disorder. In October 2000 she stabbed her three-month-old daughter Freya, then herself, doused them both in an inflammable liquid and set it alight. Freya died of smoke inhalation. Dr Emson, then 34, died in a burns unit three weeks later.
An inquiry found that the trainee psychiatrist had not only been failed by the NHS, but also that she had received “a significantly poorer standard of care than that which her own patients might have expected”. She had gone to considerable lengths to conceal her illness because of fears of how the subsequent stigma would have “haunted her work, life and treatment”.
Such stigma is identified by Professor Alastair Scotland, director of the National Clinical Assessment Service, as one of the four “S”s that leave doctors invisible to an NHS that should be caring for them as much as any other citizen. He believes that the PHP has finally provided a means of addressing stress, self-treatment, stigma and system constraints (the problems of accessing the right specialist treatment).
“It is introducing a culture change,” he said. “One of the most important things we want to get across to staff is it’s OK to be human. This lowers the stigma, reduces the stress, makes inappropriate self-treatment less likely and will ensure you get the most suitable care.”
At the PHP this includes all conventional mental health and addiction therapies, such as courses in cognitive behavioural therapy and substitute opiate medication. It can involve regular blood, hair and urine tests to monitor abstinence, and access to a financial adviser to help to rebuild doctors’ chaotic accounts.
Dr Gerada, who was elected last month to be the next president of the Royal College of GPs after pushing doctors’ wellbeing, said that the financial plight of some had been particularly striking. “I have been very surprised at the number of doctors who are effectively homeless. About ten were staying on friends’ floors, and others living in B&Bs or sheltered accommodation.”
So far, Dr Gerada’s clinic has mainly served doctors within the M25, but there are plans for programmes in Newcastle and Wiltshire. As Professor Scotland observes, it has proved to be invaluable service which, after 18 months and appointments for 300-plus doctors, is now developing into a key intervention.
At an average cost of £5,000 per patient — compared with the £200,000-plus spent on training and disciplining every doctor — it is money well spent. “We felt initially it was just tip of the iceberg stuff,” Dr Gerada said. “But now it feels like we are starting to reach doctors earlier in their conditions, which is real progress.”
Progress for John has seen his PHP contacts cut to the occassional meeting, a hair test every three months, and a chance to rebuild his medical career. GMC conditions placed on his doctor’s licence have been lifted, and he now follows a set of voluntary undertakings. Eleven months after going “cold turkey” on opiates, benzodiazepine, alcohol and cigarettes, he has yet to return to general practice, but is working instead on qualifications in counselling and drug misuse “to give something back”.
“The PHP has been just brilliant. They helped me tell the GMC, and they too were very supportive,” he said. “I am happier now than I have ever been. Maybe I should have been able to do it myself, but I needed to hand over the care. I needed that help. If it wasn’t for the PHP I would probably be dead. The PHP and chocolate.”
The Times, April 10 2010
Sam Lister, Health Editor