Doctors: the invisible patients

Authors: Caroline White 

Publication date:  21 Apr 2010

Caroline White looks at the government’s latest venture into the health of doctors

The NHS has an impressive history of wringing its hands over the neglect of the health needs of its own staff but doing relatively little about it. Various professional bodies and government sponsored taskforces have been flagging up the cultural and professional barriers that obstruct timely recognition and treatment, and the enormous personal and national costs, for more than 20 years.

The most recent addition to the library is Invisible Patients,[1] published last month by the Department of Health and covering regulated professionals in every sector of health care.

Alastair Scotland, who chaired the reference group that produced the report, also heads up the National Clinical Assessment Service, which advises on performance concerns in doctors, dentists, and pharmacists. Health issues feature in almost a quarter of referrals to the service.

He thinks the momentum of a quick succession of “three major reports all pointing in the same direction” on workplace ill health in general and in the NHS in particular—from Carol Black (2008),[2] Steve Boorman (2009),[3] and now Invisible Patients—signals a steady shift in attitudes and a tipping point for action.

“Our most important resource is our staff, and we are at a moment in history where that is starting to become embedded in the consciousness in a way that it’s not been before,” he suggests.

As the report itself makes clear, this is underpinned by recognition of the link between a healthy workforce and improved quality of care and patient safety, and that regulatory reform needs to be balanced with better support for those with health problems. Indeed, the report’s reference group was set up on the back of the 2007 regulatory white paper Trust, Assurance and Safety.[4]

The pressing need to save money as the public sector funding squeeze tightens has also focused minds. Absenteeism alone directly costs the NHS £1.7 bn every year. And “presenteeism”—coming to work when ill and subsequently performing under par—is estimated to cost one and half times as much as absenteeism among those with mental health issues. Healthy employees are three times as productive as those in poor health, the evidence suggests.

The report includes a systematic framework for action. Based on the available evidence and good practice, it sets out the responsibilities of the individual, the clinical team, the employer, and the relevant national bodies in fostering good health and in swiftly tackling its opposite—from student education to postgraduate training and throughout career progression.

Many of its suggestions are relatively inexpensive, such as making better use of existing organisational data and equipment reviews, and providing more visible and targeted information for staff on what to do when health concerns arise. But it also calls for occupational health services to be beefed up, given a more proactive role, and made more widely available, particularly for those in primary care and the independent sector.

And it argues strongly for early intervention, with fast track access to a network of general practitioners and occupational physicians specially trained in the treatment of their professional colleagues. Furthermore, up to four confidential specialist centres should be set up around the country for the assessment and treatment of complex mental health or addiction problems that cannot be dealt with locally and that may compromise patient care.

“The most important thing we can do, to reassure the public and provide the assurances that the governance is there to provide, is to pick up any health problem quickly and get that individual the right support as soon as possible,” says Professor Scotland.

Following the chief medical officer’s report Good Doctors, Safer Patients,[5] the pilot Practitioner Health programme was set up in 2008 for doctors and dentists living or working within the M25. It is suggested as a suitable template because rates of recovery and return to work during its first year of implementation, mostly in doctors, are high.

The Department of Health currently foots the £1m annual bill for the programme. If this sum was divided up among the capital’s NHS trusts, each would have to stump up £29 000 a year—roughly equivalent to the exclusion of one doctor from work for seven weeks.

“This is about investing to save,” states Professor Scotland simply. “This is a high stakes, high stress environment, so it’s really important to look after the health of staff.” And there is no evidence of a let-up in medical staff sick rates any time soon. If anything, it is likely to get worse.

Most of the research on health professionals has focused largely on doctors, the balance of which needs to be redressed, says the report. But what research repeatedly shows is that doctors are particularly reluctant to admit to health problems; unable or unwilling to seek help; and frequently not treated appropriately when they do access services, by which time they are often very sick.

Suicide rates are higher among doctors than in other groups of health professionals, and the evidence indicates higher rates of depression, anxiety, and substance misuse among health professionals than among other groups of workers.

“A lot of people simply don’t do anything, because they just don’t know what to do,” says Michael Wilks, of the Sick Doctors Trust, a support organisation for doctors with drug and alcohol problems and their families. That includes colleagues, who are usually only too well aware of the problem, he says.

Traditional avenues of support don’t cut the mustard. “The level of knowledge about how to deal with addiction in general practice is lamentable,” he suggests, adding: “The joke used to be that an alcoholic only drinks as much as his GP.”

“One of the issues about substance misuse is denial, so doctors are very very ill indeed before they seek help, and usually that’s only when they have reached a crisis point and been arrested for a drink or driving offence, assault, or stealing to feed their habit,” he says.

“That’s why deaths from cirrhosis are so much higher among doctors. It’s not because they drink more than anyone else; they get to the end of their illness without getting the help they need,” he contends.

Wholesale culture change is needed to enable sick health professionals to seek prompt treatment without fear of discrimination or stigmatisation, factors that often act as deterrents, says the report. It calls for an understanding of health issues to be incorporated into undergraduate and postgraduate curriculums.

Tony Weetman, who chairs the Medical Schools Council, claims that educators have already recognised this. “Obviously there is more we can do, but every medical school has made huge efforts over the past 10 years,” he says.

In collaboration with the GMC, the council has published its own fitness to practise guidance for students, which includes a section on health, and it brings together the key players every year to share experiences and good practice, he says.

It has also just set up a group, which includes representatives from the BMA and the GMC, to look at all aspects of the transition from student to practitioner, including the transfer of information on health issues. “We recognise that this is a critical period in a young doctor’s life,” says Professor Weetman.

The GMC has also just produced a leaflet (Your Health Matters) for registrants on the need to tackle health issues to safeguard patient care. Importantly, this emphasises how few sick doctors need to be referred to the regulator, providing they recognise they have a problem and are getting and complying with treatment—a fact that is often not well understood in the workplace, says the report.

The structure and organisation of work have a far greater impact on stress and mental health than dealing with sick and dying patients and their distressed relatives. Long working hours, shift work, dysfunctional teams, a punitive and opaque organisational culture, and poor supervisory and managerial support all take their toll, not only on health but also on safety, shows the report.

“We are in a much more safety focused culture, and rightly so, and I do think the report chimes with the thinking behind the European Working Time Directive, [which limits doctors’ weekly working hours to 48 to improve their welfare],” comments Professor Scotland.

But a recent study showed that the amount of sick leave taken by trainees at one hospital had more than doubled since its introduction. Their shift patterns cut the amount of support they received, putting them under more stress, which suggests that tackling one workplace stressor in isolation isn’t always the solution.

“The research shows that a supportive structure reduces patient mortality, so it doesn’t just benefit staff wellbeing,” comments Karen Charman, head of employment services at NHS Employers. The level of unreported ill health in the NHS is of concern, she added.

“Employers have to recognise that this is not a new responsibility that has turned up at a time of recession,” she emphasises. “[They] have a general duty under the Health and Safety Act and the NHS Constitution, which makes key pledges on a healthy working environment for staff.”

And prevention is cheaper than cure, she says. “Start now,” she exhorts NHS trusts. “You have the opportunity to invest to save this year to set systems up for the future, when there will be further restrictions on spending going forward. Staff are your most valuable asset. Make sure they are coming to work well and coming to work productively.”

Competing interests: CW was a member of the technical support group for the health of health professionals working group.


  1. Department of Health. Invisible patients. Report of the working group on the health of health professionals  . Crown, 2010. [Link] .
  2. Dame Carol Black. Working for a healthier tomorrow  . TSO, 2008. [Link] .
  3. Boorman S. NHS health and wellbeing  . Final report. Crown, 2009. [Link] .
  4. Department of Health. The white paper: Trust, assurance and safety: the regulation of health professionals in the 21st century  . Crown, 2007. [Link] .
  5. Chief medical officer. Good doctors, safer patients: Proposals to strengthen the system to assure and improve the performance of doctors and to protect the safety of patients  . Crown, 2006. [Link] .

Caroline White freelance journalist London

Cite this as BMJ Careers ; doi: