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A C I L A L L E N C O N S U L T I N G REPORT TO THE NURSING AND MIDWIFERY BOARD OF AUSTRALIA MARCH 2015 ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS ACIL ALLEN CONSULTING PTY LTD ABN 68 102 652 148 LEVEL FIFTEEN 127 CREEK STREET BRISBANE QLD 4000 AUSTRALIA T+61 7 3009 8700 F+61 7 3009 8799 LEVEL TWO 33 AINSLIE PLACE CANBERRA ACT 2600 AUSTRALIA T+61 2 6103 8200 F+61 2 6103 8233 LEVEL NINE 60 COLLINS STREET MELBOURNE VIC 3000 AUSTRALIA T+61 3 8650 6000 F+61 3 9654 6363 LEVEL ONE 50 PITT STREET SYDNEY NSW 2000 AUSTRALIA T+61 2 8272 5100 F+61 2 9247 2455 SUITE C2 CENTA BUILDING 118 RAILWAY STREET WEST PERTH WA 6005 AUSTRALIA T+61 8 9449 9600 F+61 8 9322 3955 ACILALLEN.COM.AU RELIANCE AND DISCLAIMER THE PROFESSIONAL ANALYSIS AND ADVICE IN THIS REPORT HAS BEEN PREPARED BY ACIL ALLEN CONSULTING FOR THE EXCLUSIVE USE OF THE PARTY OR PARTIES TO WHOM IT IS ADDRESSED (THE ADDRESSEE) AND FOR THE PURPOSES SPECIFIED IN IT. THIS REPORT IS SUPPLIED IN GOOD FAITH AND REFLECTS THE KNOWLEDGE, EXPERTISE AND EXPERIENCE OF THE CONSULTANTS INVOLVED. THE REPORT MUST NOT BE PUBLISHED, QUOTED OR DISSEMINATED TO ANY OTHER PARTY WITHOUT ACIL ALLEN CONSULTING’S PRIOR WRITTEN CONSENT. ACIL ALLEN CONSULTING ACCEPTS NO RESPONSIBILITY WHATSOEVER FOR ANY LOSS OCCASIONED BY ANY PERSON ACTING OR REFRAINING FROM ACTION AS A RESULT OF RELIANCE ON THE REPORT, OTHER THAN THE ADDRESSEE. IN CONDUCTING THE ANALYSIS IN THIS REPORT ACIL ALLEN CONSULTING HAS ENDEAVOURED TO USE WHAT IT CONSIDERS IS THE BEST INFORMATION AVAILABLE AT THE DATE OF PUBLICATION, INCLUDING INFORMATION SUPPLIED BY THE ADDRESSEE. UNLESS STATED OTHERWISE, ACIL ALLEN CONSULTING DOES NOT WARRANT THE ACCURACY OF ANY FORECAST OR PROJECTION IN THE REPORT. ALTHOUGH ACIL ALLEN CONSULTING EXERCISES REASONABLE CARE WHEN MAKING FORECASTS OR PROJECTIONS, FACTORS IN THE PROCESS, SUCH AS FUTURE MARKET BEHAVIOUR, ARE INHERENTLY UNCERTAIN AND CANNOT BE FORECAST OR PROJECTED RELIABLY. ACIL ALLEN CONSULTING SHALL NOT BE LIABLE IN RESPECT OF ANY CLAIM ARISING OUT OF THE FAILURE OF A CLIENT INVESTMENT TO PERFORM TO THE ADVANTAGE OF THE CLIENT OR TO THE ADVANTAGE OF THE CLIENT TO THE DEGREE SUGGESTED OR ASSUMED IN ANY ADVICE OR FORECAST GIVEN BY ACIL ALLEN CONSULTING. © ACIL ALLEN CONSULTING 2014 ACIL ALLEN CONSULTING C o n t e n t s 1 2 3 4 Introduction 1 1.1 Australia’s national registration scheme 1 1.2 This literature review 1 Health practitioners 3 2.1 Physical health and disability 3 2.2 Ageing 3 2.3 Mental health 3 2.4 Substance misuse and addiction 4 2.5 Risk factors 5 Impairment 7 3.1 Definition 7 3.2 Prevalence 7 3.3 Impairment versus practicing with illness or disability 8 3.4 Risks of impairment for practitioners, patients and the profession 8 Major models of impaired practitioner support services 10 4.1 Phone support line 10 4.2 Support Service 10 4.3 Case Management 11 4.4 Regulator management 11 The role of regulators 13 5.1 Type of activity 13 5.2 Information-sharing arrangements 14 6 Principles of best practice 15 7 Alignment of program and service categories with best practice principles 18 Identification, referral and reporting of impaired practitioners 22 8.1 Identification 22 8.2 Reporting versus referral 22 8.3 Referral sources 23 8.4 Relationships between regulators and health programs/services regarding referral and reporting 24 5 8 ii ACIL ALLEN CONSULTING 9 8.5 The role of coercion 27 Assessment 29 9.1 Source of initial assessment 29 9.2 Assessment components 29 9.3 Impairment assessment 30 9.4 Role of the regulator 31 10 Treatment, rehabilitation and monitoring 33 10.1 Role of the health program 33 10.2 Program specialisation 33 10.3 Treatment types 35 10.4 Monitoring strategies 36 10.5 Work restrictions 36 10.6 Role of the regulator 37 11 Outcomes 39 11.1 Outcome types 39 11.2 Recovery from substance use disorders – rates and contributing factors 40 11.3 Recovery from non-substance use disorder impairments 41 12 Costs 43 12.1 Costs of practitioner impairment 43 12.2 Costs to the regulator 44 12.3 Costs of health programs 45 12.4 Costs for clients 46 13 Funding 47 14 Role of other stakeholders 49 14.1 Employers 49 14.2 Medical indemnity insurers 51 14.3 Professional Colleges and Associations 51 14.4 Education Providers 53 15 Conclusions Appendix 1 54 Methodology 57 iii ACIL ALLEN CONSULTING List of tables Table 1 Alignment of major categories of impaired practitioner support service with best practice principles 17 Table 2 Management programs for impaired practitioners: selected examples 20 Table 3 Management programs for impaired practitioners: key features of interest 21 Table 4 Referral 28 Table 5 Assessment 32 Table 6 Treatment and rehabilitation 38 Table 7 Outcomes 42 Table 8 Funding sources and arrangements 48 iv ACIL ALLEN CONSULTING Abbreviations AHPRA Australian Health Practitioner Regulation Agency AHPRA Australian Health Practitioner Regulation Agency CAN-EIP College of Registered Nurses of British Columbia – Early Intervention Program (Health) NHS National Health Service NMBA Nursing and Midwifery Board of Australia NMHPV Nursing and Midwifery Health Program Victoria SUD Substance use disorder UK-PHP NHS Practitioner Health Program US-HPRP Michigan Health Professional Recovery Program US-PHP US Physicians Health Program v ACIL ALLEN CONSULTING 1 Introduction 1.1 Australia’s national registration scheme In recent years, registration of health practitioners in Australia has moved from a complex localised scheme of regulatory bodies to a National Regulation and Accreditation Scheme (the National Scheme) with one national Board for each health profession regulated under the scheme (Australian Health Practitioner Regulation Agency 2011). This process involved the consolidated over 80 boards and their associated structures. The Australian Health Practitioner Regulation Agency (AHPRA) supports the work of 14 National Boards (some with state and territory Boards and committees) representing 14 health professions (Australian Health Practitioner Regulation Agency 2011). The National Scheme began on July 1 2010 (Australian Health Practitioner Regulation Agency 2011). One objective of the scheme is to increase standardisation and consistency in health practitioner regulation approaches, systems and standards across Australia, where a cacophony of local differences existed previously. Both prior to the implementation of the National Scheme and to this day, regulatory approaches to managing impaired practitioners vary substantially between states and territories (Siggins Miller 2012). The National Scheme has called into question the continued government funding of health programs for impaired practitioners in Victoria, which were previously funded by two state Boards (namely the Victorian Doctors Health Program and Nursing and Midwifery Health Program Victoria). Further impetus for considering these issues comes from ongoing debate regarding the role of mandatory reporting of impaired practitioners (Australian Health Practitioner Regulation Agency 2011) and a current formal review of the National Scheme, planned since the outset of the scheme to assess its effectiveness (Australian Health Workforce Ministerial Council 2014). Other entities – including education providers, employers, health services, professional associations and colleges, and insurers also have a role in the identification, referral, assessment, treatment and rehabilitation of impaired practitioners. This adds to both the opportunities and challenges of developing an agreed and standardised approach to the issue. In light of this context, the Nursing and Midwifery Board of Australia has commissioned this study to explore the need for, and value of, a national referral, assessment, treatment and rehabilitation service for regulated health professions and the relationship between such services and the regulator. This is an opportunity to review consistent, evidence-based models of management, referral, assessment, treatment and rehabilitation of impaired practitioners (Australian Health Practitioner Regulation Agency 2014a). 1.2 This literature review This literature review explores available academic and grey literature on practitioner impairment, and specifically, Australian and international models of referral, treatment and rehabilitation programs for practitioners with a healthATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 1 ACIL ALLEN CONSULTING related impairment. In particular, it focuses on the role of the regulator in these models, and the interactions and interfaces between regulators and the programs in their jurisdictions. Where possible, it also considers issues regarding costs and benefits, including cost effectiveness. Some discussion of the roles of other stakeholders – including education providers, professional colleges, employers and indemnity insurers – is also included. This literature review is not a comprehensive analysis of all available literature, or all health program models in place globally. Rather, it provides an overview of the types of programs and program models found in Australia and internationally, with particular reference to specific exemplars that represent this diversity. The review has prioritised literature relating to nurses and midwives. Literature relating to other health professions was used wherever nursing and midwifery-specific research was not available. This review is structured according to the key stages involved in managing practitioner impairment: identification, referral and reporting; assessment; treatment and rehabilitation; and outcomes. The literature review method is described in more detail at Appendix 1. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 2 ACIL ALLEN CONSULTING 2 Health practitioners The range of health conditions affecting the health practitioner population is the same as that affecting the general population (Clode 2004, Kay and Izenour 2008). Like many comparatively socio-economically advantaged groups, health practitioners are healthier on average according to measures of physical health (Shanafelt, Sloan et al. 2003, Clode 2004). They also tend to live longer than the general population (Frank, Biola et al. 2000). However, they are not immune to physical illnesses and disabilities that may impact on their work, including degenerative conditions (Clode 2004, Kay and Izenour 2008). Furthermore, certain characteristics of healthcare jobs, and the types of personalities they attract, put practitioners at higher than average risk of certain difficulties, especially those relating to mental health (Rucinski and Cybulska 1985, Royal Australasian College of Physicians 2013). 2.1 Physical health and disability Physical disabilities may be congenital, or acquired at any point in a practitioner’s life (Kay and Izenour 2008). Examples include cerebral palsy, spinal cord injury, epilepsy, multiple sclerosis, Parkinson’s disease, and hearing and vision loss (Kay and Izenour 2008). Literature on physical disabilities in health professionals is scarce. One study found that seven specific disabilities accounted for half of all physicians who contact the American Society of Handicapped Physicians (in decreasing order of frequency): spinal cord injury, multiple sclerosis, stroke, arthritis/connective tissue disease, post-polio weakness, lower limb amputation and diabetic retinopathy (Kay and Izenour 2008). However, given that the data were obtained from the American Society of Handicapped Physicians, they are likely skewed toward more serious and ‘visible’ physical disabilities (Kay and Izenour 2008). 2.2 Ageing While not always technically a ‘health condition’, aging can bring about changes – often slowly and at first subtly – that impact performance and can eventually amount to disability (Kay and Izenour 2008). These include hearing and vision loss, and psychomotor and cognitive slowing (Goldstein 2000). These changes may be more difficult for colleagues to detect, and affected practitioners often deny or minimise them (Kay and Izenour 2008). 2.3 Mental health Overall, research suggests that practitioners are at a higher risk of mental health issues than other professionals and the general population – although studies are mostly limited to doctors, nurses, dentists and pharmacists (and students of these professions) (Clode 2004, Oakley Browne, Wells et al. 2006, beyondblue 2013) The most common mental health concerns are the experience of stress and ‘burnout’, common to caring professions (Clode 2004). Among nurses, Australian ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 3 ACIL ALLEN CONSULTING studies have identified higher than average levels of occupational stress across several fields of nursing, including nursing management, mental health nursing and emergency nursing (Lee nd, Happell, Pinikahana et al. 2003, Safe Work Australia 2010). For example, a study of 196 psychiatric nurses in Victorian acute and forensic settings found almost 30 per cent were affected by symptoms consistent with post-traumatic stress (Lee nd). Among doctors and medical students in Australia, rates of two elements of burnout —high emotional exhaustion and cynicism—have been measured at 31.6 per cent and 34.6 per cent respectively (beyondblue 2013) Studies have found that 28 per cent and 60 per cent of doctors show symptoms for stress (Cohen and Rhydderch 2006) and burnout (Paterson and Adams 2011) respectively at any one time. Nurses and midwives also experience high levels of stress and burnout as a result of their employment. For example, Adriaenssens et al. 2012 found that nurses, and in particular emergency nurses, were confronted frequently with traumatic events (such as death or serious injury of a child/adolescent), which has meant approximately one-third of nurses met sub-clinical levels of anxiety, depression and somatic complaints and 8.5 per cent met clinical levels of post-traumatic stress disorder (PTSD). Further, British and Canadian studies have shown that the level of PTSD among emergency nurses is around 20 per cent, this figure increases to 25-33 per cent in American studies (Helps 1997, Clohessy & Ehlers 1999, Laposa et al 2003, Gates et al 2011, Dominguez-Gomez & Rutledge 2009). Health practitioners are known to have higher rates of suicidal ideation and suicide than the general population (Frank, Biola et al. 2000, Clode 2004, Hawton, Malmberg et al. 2004, Schernhammer and Colditz 2004, beyondblue 2013). Doctors in an Australian study were almost four times as likely to have experienced suicidal ideation in the past 12 months compared with the general population (10.4 per cent compared with 2.7 per cent) (beyondblue 2013). A systematic review of international studies found that the suicide risk of male doctors ranged from 1.1 to 3.4 times that in the general male population. The equivalent risk in female doctors was 2.5 to 5.7 times the general female population (Schernhammer and Colditz 2004, Kay and Izenour 2008). 2.4 Substance misuse and addiction Health practitioners display distinctive patterns in the types of substances they use compared with the general population (Berryman 2002, Kay and Izenour 2008, Elliott, Tan et al. 2010). That is, they are more likely to use prescription substances (particularly tranquilisers, sedatives and stimulants), but are less likely to use illicit substances such as cocaine, marijuana, hallucinogens and heroin (Berryman 2002, Clode 2004, Kay and Izenour 2008, Elliott, Tan et al. 2010). Similar patterns have been found in doctors, nurses, pharmacists and dentists (Berryman 2002, Brown, Trinkoff et al. 2002, Dunn 2005, Kay and Izenour 2008, Elliott, Tan et al. 2010). The most common prescription drugs misused by doctors are opiates, benzodiazepines, amphetamines, barbiturates and steroids (Clode 2004, Kay and Izenour 2008, Elliott, Tan et al. 2010). There is also some evidence that nurses use tobacco and alcohol at higher rates than the general population (Berryman 2002). Disproportionate use of prescription medications is due in large part to easier access through work environments and self-prescribing (Dunn 2005, Kay and Izenour 2008). Nurses with substance use disorders (SUDs) are more likely to be addicted to medications to which they have easiest workplace access (Trinkoff, ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 4 ACIL ALLEN CONSULTING Zhou et al. 2000). One US study found that among 381 internal medicine residents, over half of those using a prescription medicine had self-prescribed by sourcing drugs from either the sample closet, a self-written prescription or direct from pharmaceutical representatives (Kay and Izenour 2008). The problem is amplified by many health practitioners’ ’pharmacological optimism’ (confidence in the ability of medications to solve problems and relieve pain), and a sense of familiarity and mastery over medications (Buxton 1982, Dunn 2005). This can lead many to feel they can use substances without harmful consequences (Buxton 1982, Dunn 2005). The compounding combination of SUDs and mental illness are also apparent in practitioners (Trinkoff, Zhou et al. 2000, Center, Davis et al. 2003, Clode 2004). Mental illness and SUDs are common among health practitioners who die by suicide (Center, Davis et al. 2003, Clode 2004), with depressive symptoms shown to reinforce substance misuse in nurses (Trinkoff, Zhou et al. 2000). 2.5 Risk factors Factors found to predispose healthcare practitioners, in particular to drug and alcohol misuse and mental health problems, include (Brown, Trinkoff et al. 2002, Katsavdakis, Gabbard et al. 2004, Kay and Izenour 2008): reduced use of healthcare services (Gross, Mead et al. 2000, Thompson, Cupples et al. 2001, Kay, Mitchell et al. 2004, Kay and Izenour 2008) easy access to prescription drugs (Trinkoff, Zhou et al. 2000, Brown, Trinkoff et al. 2002, Kay and Izenour 2008) narcissistic personality characteristics (Brown, Trinkoff et al. 2002, Clode 2004, Kay and Izenour 2008) abuse or mistreatment during training and work (Brown, Trinkoff et al. 2002, Clode 2004, Kay and Izenour 2008) unrealistic expectations of one’s career (Brown, Trinkoff et al. 2002) high working hours and adverse work schedules (e.g. nightshifts and weekends on) (Berryman 2002, Brown, Trinkoff et al. 2002, Clode 2004, Kay and Izenour 2008) mental health conditions, stress and burnout (Berryman 2002, Brown, Trinkoff et al. 2002, Clode 2004, Kay and Izenour 2008) perfectionism, chronic self-doubt, and marked sense of responsibility (Clode 2004, Kay and Izenour 2008) dissatisfaction with career choice and feeling ‘trapped’ by it (Clode 2004), and high pressure training and work environments (Berryman 2002, Clode 2004). Self-diagnosis and self-prescribing poses a unique risk to practitioners, who are less likely to have a regular source of healthcare compared with the general population (Gross, Mead et al. 2000, Thompson, Cupples et al. 2001, Clode 2004, Kay, Mitchell et al. 2004, Marshall 2008). Self-prescribing can cloud practitioners’ judgement about their own health condition (Kay and Izenour 2008). It can also allow them to avoid seeking professional help for longer, as they are more able to self-medicate for symptoms (Kay and Izenour 2008). Research on a mix of all health professional types in Britain found that they feared being stigmatised or labelled if their colleagues knew they were affected by addiction (73 per cent) or mental health issues (63 per cent) (Ipsos MORI 2009). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 5 ACIL ALLEN CONSULTING Among doctors, a survey of 2,500 British doctors found that only 13 per cent would seek help for mental health or addiction issues, with 87 per cent choosing alternative paths such as self-medication or informal help (Hassan, Ahmed et al. 2009). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 6 ACIL ALLEN CONSULTING 3 Impairment 3.1 Definition The Health Practitioner Regulation National Law (National Law) defines ‘impairment’ to mean ‘physical or mental impairment, disability, condition or disorder (including substance abuse or dependence), that detrimentally affects or is likely to detrimentally affect a registered health practitioner’s capacity to safely practise the profession or a student’s capacity to undertake clinical training’. The American Medical Association defines ‘impairment’ as ‘any physical, mental, or behavioural disorder that interferes with the ability to engage safely in professional activities’ (Kay and Izenour 2008). The common thread is that impaired practitioners are unable to practise their professions with reasonable skill, safety and professionalism due to mental illness, physical illness or disability, or the misuse of substances. The term ‘impairment’ is distinct from ‘incompetence’ and ‘unethical conduct’. Incompetence is lacking the requisite skills, knowledge and qualities to perform effectively within the scope of one’s professional practice (Kay and Izenour 2008). Unethical conduct is conduct that fails to conform to moral standards or policies (Kay and Izenour 2008). While the terms are distinct, impaired physicians commonly display incompetent or unethical conduct (Kay and Izenour 2008). Conditions and/or states that can lead to impairment include: (Kay and Izenour 2008) substance use disorders (SUDs) (including alcohol and other drugs) psychiatric disorders (including mood, anxiety, psychotic and personality disorders) stress and ‘burnout’ cognitive impairment (including as a result of aging), and physical illness or disability (including neurological, movement and sensory impairments). 3.2 Prevalence It is estimated that 10-15 per cent of medical practitioners will, at some time in their careers, become ill enough for their professional performance to be impaired (Clode 2004). For clients of the Nursing and Midwifery Health Program Victoria, the majority are primarily treated for mental health problems (58 per cent), with 42 per cent being treated primarily for SUDs (Hamilton and Duncan 2012). Most cases of impaired practitioners seen by Practitioner Health Programs (PHPs) in the US (between 58 per cent and 93 per cent) are due to substance abuse and/or mental illness. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 7 ACIL ALLEN CONSULTING 3.3 Impairment versus practicing with illness or disability Health conditions or disabilities do not necessarily equate, on their own, to ‘impairments’ in the context of practitioner performance (Kay and Izenour 2008). For example, approximately 10 per cent of the nursing population has a substance abuse disorder (Ponech 2000, Brown, Trinkoff et al. 2002). But of those, only 6 per cent have a condition severe enough to interfere with their immediate ability to practise – i.e. they are impaired (Ponech 2000). More importantly, many practitioners practise safely with illness and disabilities (Sanderson-Mann and McCandless 2005, Sanderson-Mann and McCandless 2006, White 2007, Altchuler 2009, Snashall 2009, DeLisa, Silverstein et al. 2011, Melnick 2011, Smith and Allen 2011). Practitioners with health conditions can prevent (or reverse) their health condition or disability from becoming an impairment through various means including: selecting a specialty and work environment that suits their circumstances (Dawkins, Golden et al. 2003) ensuring ‘reasonable adjustments’ to counter or avoid the impact of any limitations (Dawkins, Golden et al. 2003, Kay and Izenour 2008, Kane and Gooding 2009) imposing appropriate limits on their own practice (Dawkins, Golden et al. 2003), and accessing and complying with appropriate treatments (Kay and Izenour 2008). Where these measures are resisted or insufficient, or where the practitioner is attempting to hide a problem or is in denial, the health condition can cross over into an impairment of potential regulatory interest (Kay and Izenour 2008). At this point, the impairment may pose a risk to patients (Fletcher 2001, Dunn 2005, Hamilton and Duncan 2012). 3.4 Risks of impairment for practitioners, patients and the profession The consequences of practitioner impairment can be felt by the practitioner and those close to them, as well as their colleagues, patients, employers and society at large (Fletcher 2001, Dunn 2005). Risks to the practitioner: The underlying health conditions that commonly result in practitioner impairment can result in morbidity, disability and even death (Frank, Biola et al. 2000, Boisaubin and Levine 2001, Carr 2008, Kay and Izenour 2008, Selby 2008). They also place practitioners at risk of contact with the criminal justice system, strained workplace relationships and job loss, including the stress, financial and social losses associated with these (Fletcher 2001, Galletly 2004, Dunn 2005, Kay and Izenour 2008). When a health issue results in impairment, further risks to the practitioner include disciplinary action by employers or regulators, loss or restriction of practising license/registration, legal action and loss of career (Fletcher 2001, Galletly 2004, Dunn 2005, Kay and Izenour 2008, Hamilton and Taylor 2011). All of these impacts can generate knock-on problems for the practitioner in family and personal relationships, social standing, reputation, finances, and mental and physical health (Galletly 2004, Dunn 2005, Kay and Izenour 2008, Rosen, Wilson et al. 2009, Wilson, Rosen et al. 2009). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 8 ACIL ALLEN CONSULTING Risks to patients: By definition, impaired practitioners pose a potential risk to their patients due to their inability to safely, competently and professionally practise (Fletcher 2001, Hamilton and Duncan 2012). The claim is made in much of the literature that impaired practitioners can and do cause direct harm to patients (Fletcher 2001, Dunn 2005, Hamilton and Duncan 2012). There are high-profile legal and regulatory cases where impaired practitioners have harmed patients (Robinson 2014, Russell 2014). Drawing on Australian examples, the harm in such cases includes major clinical errors and ‘botched’ procedures (Robinson 2014), infection of patients with blood-borne diseases via needle re-use (Russell 2014), and patients receiving saline or tap water instead of pain relief following theft of drugs for personal use (News 2014). An Australian study also found that doctors with poor psychological support, were more likely to sexually abuse patients (Galletly 2004). Importantly, there are almost no research studies that correlate impairment with breaches in safe practice by health practitioners. An evaluation of Victoria’s Nursing and Midwifery Health Program in 2012 found no such studies regarding nurses or midwives (Hamilton and Duncan 2012). Two systematic reviews involving multiple professions, published in 2009, also found no such evidence (Crawford, Shafrir et al. 2009, Harvey, Laird et al. 2009). This presents a notable and significant gap in the literature supporting formal management of health practitioners with impairment. The one minor exception was a US study which found that paediatric residents who were depressed made six times as many medication errors as those who were not (Fahrenkopf, Sectish et al. 2008). Other research supports the view that impaired practitioners pose a danger to patients, without drawing that specific conclusion. For example, mental illness and SUDs are known to impair judgment, memory and concentration (Helfert and Mitchell 2003, Kay and Izenour 2008). Furthermore, age-related changes have been shown to contribute to miscommunication, and may impact negatively on surgical performance, hand-eye coordination, and interpretation of test results (Goldstein 2000). Evidence also suggests more subtle impacts of practitioner impairment on patients. For example, it has been shown that patients are less likely to trust the advice of doctors exhibiting signs of burnout (Royal Australasian College of Physicians 2013). There is also evidence that the health habits of practitioners are associated with the advice they give to patients (Clode 2004). This association extends to both mental health issues and substance misuse, where practitioner’s own difficulties can compromise their treatment of patients with similar concerns (Clode 2004). Risks to professions: Damage to the public’s trust in health practitioners, the healthcare system as a whole, and practitioner regulation, is a potential impact of impaired practitioners (Dunn 2005). In Australia, several high profile cases, investigations and reports regarding impaired practitioners have attracted negative public comment on complaints-handling and regulatory systems (Legal and Social Issues Legislation Committee 2014, Robinson 2014, Russell 2014). Furthermore, regardless of the gaps in academic literature and evidence, a UK study found that the public view addiction among practitioners as a significant threat to patient safety (Ipsos MORI 2009). Members of the public considered a dentist smelling of alcohol or a GP with depression to pose a medium risk, but a surgeon with an addiction problem to pose a high risk (Ipsos MORI 2009). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 9 ACIL ALLEN CONSULTING 4 Major models of impaired practitioner support services The types of health programs and services for practitioners identified in this review can be broadly categorised into four types. These are: phone support line, support service, case management and regulator management, described below. Australia has examples of all four service categories. Most programs and services examined in this review in Australia (Siggins Miller 2012) and the UK (General Medical Council 2014) fall into the support line and support service categories. In contrast, for the US (White, DuPont et al. 2007, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Pooler, Sheheen et al. 2009, Skipper and DuPont 2011) and Canada (Brewster, Kaufmann et al. 2008, College of Registered Nurses of British Columbia 2012), the vast majority of programs fell into the case management category (White, DuPont et al. 2007, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Pooler, Sheheen et al. 2009, Skipper and DuPont 2011). New Zealand had programs at both ends (Medical Council of New Zealand 2011, Doctors' Health Advisory Service 2014). 4.1 Phone support line Phone support line services offer ‘hotlines’ which affected practitioners and/or concerned others can ring for support, information, and referral. Calls are typically allowed to be anonymous. These services are typically independent of regulators – except in limited cases where mandatory reporting applies, and may necessitate reporting of impaired practitioners to regulators. Strengths of this model include its potential to encourage help-seeking and promote trust through allowing anonymity, using peer-to-peer support approaches, independence from the regulator and specialising in health practitioners. On a practical level, extended and/or all hours access, easy access for the geographically isolated, comparatively low cost to funders, and low or no cost to practitioner users, are all benefits. Weaknesses of the phone support line approach include limited continuity and follow-up, reliance only on caller-provided data for assessment, and inability to provide intensive support, treatment, rehabilitation and monitoring. Another concern is that anonymity hampers reporting of practitioners who pose a series risk to the public. Australian examples of these types of service include Doctors’ Health Advisory services (NSW, ACT, Qld, NT, WA), the AMA Peer Support Services (Vic, Tas) and CRANAplus’ Bush Support Line. International examples include the Statewide Peer Assistance Program for Nurses (US), the Doctors’ Support Line (UK) and the Royal College of Nurses Counselling Service (UK). 4.2 Support Service The support service approach encompasses services whereby affected practitioners have voluntary, brief contact with the service, which offers referral and ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 10 ACIL ALLEN CONSULTING occasionally limited therapeutic services such as counselling. Many are funded through charitable organisations or employers, and offer limited counselling as their only or main service. These services are typically independent of regulators – except in cases where mandatory reporting applies. Strengths of this type of service include the ability to directly offer some treatment and rehabilitation, and a less formal and less ‘high stakes’ than other approaches which helps reduce the fear and resistance associated with more coercive approaches. They are also comparatively low cost to funders, and low or no cost to practitioners. Some weaknesses of this type of service include limited-hours access, difficult access for the geographically isolated, and limited monitoring and follow-up. In jurisdictions where mandatory reporting is in place and clients are not protected by special shielding arrangement, trust in the service may be hampered by fear of reporting. In the case of Employee Assistance Programs, access is restricted to those currently employed by a service that offers such programs. Examples of this model include services offered by Medical Benevolent Associations (Vic, NSW, ACT, SA), the Dr DOC Program (SA), Health for Health Professionals (Wales) and health service Employee Assistance Programs. 4.3 Case Management The case management approach involves affected practitioners engaging with specialised services which manage and coordinate the practitioner’s longer-term involvement in an intensive, formal program of assessment, treatment and rehabilitation, monitoring and often agreed (temporary) restrictions on their practice. Most do not offer much in-house treatment and rehabilitation, but instead develop, coordinate and monitor treatment plans which involve referral to external treatment services and practitioners. These services typically have formal agreements with regulators that allow the program to operate in harmony with regulator systems, and to shield clients from regulatory action as long as they comply with the program. (Gray 2006, DuPont, McLellan et al. 2009) The strengths of this approach relate to its intensity, and include extensive assessment and individualisation, high continuity of care, long-term monitoring and follow-up and intensive support, treatment and rehabilitation, including crisis and inpatient options. It also promotes public protection through putting agreed and/or voluntary work restrictions in place, enabling regulator action in cases of serious risk and having formal agreements with the regulator. There is also goodquality evidence that these programs have high success rates, and encourage alternative-to-discipline approaches to regulation of impaired practitioners. Practical weaknesses of the case management approach include high costs for practitioners and/or funders, difficult access for the geographically isolated, work stoppages or restrictions that compromise confidentiality, and (often) large periods of time out from practice. Some such programs have also attracted public criticism due to perceptions of protecting and ‘hiding’ unsafe practitioners. 4.4 Regulator management The regulator management approach encompasses cases where affected practitioners who come to regulator’s attention are directly assisted by the regulator ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 11 ACIL ALLEN CONSULTING to access assessment, treatment, rehabilitation and monitoring (often through less formally-defined processes than case management). This service is inextricably linked to the regulator that offers it, and is often offered as an alternative-todiscipline, with non-compliance potentially leading to more punitive regulator action (Medical Council of New Zealand 2011) The major strengths of this approach is that it targets those at risk of, or already affected by, regulator attention and disciplinary action, enabling regulators to take action in cases of greatest public risk. As with case management, extensive individual assessment and information-gathering is possible, allowing an individualised approach which sources services and treatment providers experienced in supporting health practitioners. Weaknesses of this approach are that is often somewhat piecemeal, and as a result often lacks both transparency and evidence of efficacy. Inextricable links to the regulator can also result in distrust, fear and dishonesty on the part of practitioners, as well as potential or actual conflicts of interest. The approach also does not promote early intervention, taking effect only when a practitioner has come to the regulator’s attention. Finally, this approach can attract public criticism due to perceptions of protecting and ‘hiding’ unsafe practitioners. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 12 ACIL ALLEN CONSULTING 5 The role of regulators Regulators face two major decision axes in determining the nature and extent of their involvement with impaired practitioners. These are (a) the type of activities they will undertake themselves; and (b) the information-sharing arrangements they will put in place. 5.1 Type of activity There are five main types of regulator activity in relation to the management of impaired practitioners. 1. Promotion and endorsement of programs and services: For example, the Department of Licensing and Regulatory Affairs of Michigan actively promotes the Michigan Health Professional Recovery Program on its website (Department of Licensing and Regulatory Affairs 2014). 2. Referral of specific practitioners to programs and services: For example, the UK’s General Medical Council (NHS Practitioner Health Programme and General Medical Council 2013) and General Dental Council (NHS Practitioner Health Programme and Council 2009) both have formal memorandums of understanding with the NHS Practitioner Health Programme, which encourages the Councils to discuss potentially impaired practitioners with program staff with a view to potential referral. 3. Funding part or all of programs and services: For example the Victorian Nursing and Midwifery Health Program was funded by the Nurses Board of Victoria prior to the National Scheme , using funds collected from registration fees (Standing Committee on Legal and Social Issues Legislation Committee 2013). The Nursing and Midwifery Board of Australia has agreed to fund this program until 30 June 2016 (http://www.nursingmidwiferyboard.gov.au/News/2013-09-04-mediarelease.aspx) The College of Registered Nurses of British Columbia entirely funds the Early Intervention Program (Health) (College of Registered Nurses of British Columbia 2012). In the United States, The Health Professionals Services Program (Minnesota) is 98 per cent funded by health –licensing boards, and lastly the Washington Physicians Health Program is 65 per cent funded by the regulator (WPHP 2015, HPSP 2015). 4. Maintaining formal agreements with programs or services: These agreements usually cover issues that include information-sharing and confidentiality (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). For example, all US PHPs have formal agreements with relevant regulators that provide a degree of ‘shielding’ from reporting to the regulator and/or disciplinary action for compliant participants (DuPont, McLellan et al. 2009). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 13 ACIL ALLEN CONSULTING 5. 5.2 Providing part or all of programs and services: For example, as part of administering the NSW Impaired Registrants Program, the Medical Council of NSW often appoints a practitioner to assess potentially impaired doctors (Medical Council of New South Wales 2010). The College of Registered Nurses of British Columbia administers its own health program (the Early Intervention Program (Health)) (College of Registered Nurses of British Columbia 2012). Information-sharing arrangements There are three main models for information-sharing between regulators and practitioner health programs: No formal arrangement: Under this model, there is no formal arrangement between the program and the regulator about the exchange of client information, though information may still be exchanged for ethical or legal reasons (e.g. mandatory reporting). This model is common with phone lines and support services, such as the Medical Benevolent Association of New South Wales (Medical Benevolent Association of New South Wales 2014). Formal arrangement – distinct entities: Under this model, health programs have a formal agreement with regulators (sometimes enshrined in law), which sets out requirements for exchanging information about clients. The health program or service is a separate legal entity operating at arms-length from the regulator. Variations on this model are common (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013), and appear to apply to all PHPs in the US (DuPont, McLellan et al. 2009). Formal arrangement – same entity: Where a regulator is inextricably intertwined with the health program or service (such as the College of Registered Nurses of British Columbia Early Intervention Program), (DuPont, McLellan et al. 2009, College of Registered Nurses of British Columbia 2012) an agreement governs how information obtained in the course of administering the program will be used (or not used) for disciplinary and regulation purposes within that same entity. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 14 ACIL ALLEN CONSULTING 6 Principles of best practice One way regulators can choose between the activity and information-sharing options described above is to consider and evaluate them against principles of best practice for managing impaired practitioners. Key principles common to many regulators working in this area, including the Australian National Boards, are (Fletcher 2001, DuPont, McLellan et al. 2009, Medical Council of New Zealand 2011, Agency 2014, College of Registered Nurses of British Columbia 2014, General Medical Council 2014): 1. Protect the public from harm 2. Maintain confidence in regulator and profession 3. Support timely access and response 4. Optimise recovery and rehabilitation 5. Manage risks in proportionate manner 6. Assist practitioners to remain in / return to the workforce 7. Promote trust, honesty, help-seeking 8. Ensure natural justice and fairness 9. Minimise regulatory costs and burden 10. Evidence-based and tailored to the needs of health practitioners. At times the above principles will be in tension or even clash directly, with each other. Some examples are set out below. Encouraging help-seeking vs public protection: Some measures intended to encourage help-seeking and program compliance can clash with the desire to protect patients and the public from impaired practitioners ( Jenkins 2013). For example, where services allow anonymity, this may encourage impaired practitioners to seek help who otherwise may not do so for fear of retribution, regulatory action, stigma etc (Bosch 2000, Gastfriend 2005, Sick Doctors Trust 2014). However, anonymity blocks the potential to report practitioners who pose a serious risk to the public. Encouraging compliance vs ethics of coercion: Some programs shield practitioners from regulator reporting or related action while they are compliant with the program, but report them as a direct consequence of non-compliance (Darbro 2009). This ‘high-stakes’ coercive arrangement is believed to be a major contributor to the high success rates of these programs, but raises ethical questions about natural justice, procedural fairness, and the role of coercion in informed consent and the treatment of clients (Darbro 2009, Boyd and Knight 2012). Public protection vs workforce retention: The tension between public protection and maintaining practitioners in the workforce is also a consideration. This is especially true given the significant cost to society of educating and training practitioners, and the costs of practitioner loss and early retirement (Boorman 2009). This has led to public criticism of health programs, in both the USA and ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 15 ACIL ALLEN CONSULTING Australia, as ‘hiding’, ‘protecting’ or ‘being soft on’ dangerous practitioners (Swan 2005, Wohlsen 2007, Skipper and DuPont 2011, Hagan 2012). Public protection vs discrimination: With respect to managing impaired practitioners, there is tension between public protection, and anti-discrimination laws and principles. There is a pocket of literature exploring these issues from the UK and USA, with a particular focus on nursing students and practitioners, and the concept of reasonable adjustments (Sanderson-Mann and McCandless 2005, Sanderson-Mann and McCandless 2006, Morris and Turnbull 2007, Morris and Turnbull 2007, Grainger 2008, Sin and Fong 2008, Schroeder, Brazeau et al. 2009, Tee, Owens et al. 2010, Storr, Wray et al. 2011). Issues to consider include the potential for legal challenges to regulator mandates or actions, claims of workplace discrimination, maintaining workforce diversity, public safety, reasonable adjustments, and employer encumbrance (Oliver, Bernstein et al. 2004, SandersonMann and McCandless 2005, Sanderson-Mann and McCandless 2006, Morris and Turnbull 2007, Morris and Turnbull 2007, Grainger 2008, Sin and Fong 2008, Schroeder, Brazeau et al. 2009, Tee, Owens et al. 2010, Storr, Wray et al. 2011). The degree to which each category of program or service type aligns with selected best practice principles is outlined in Table 1. In this report, programs have been rated based on the subjective judgement of the reviewers using a four point Likert scale (outlined in the Box below). Box 1 Likert Rating scale (1) Not applicable or limited applicability, (2) Somewhat applicable (3) Moderately applicable (4) Very applicable Source: ACIL Allen Consulting 2014 ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 16 ACIL ALLEN CONSULTING Table 1 Alignment of major categories of impaired practitioner support service with best practice principles Relative alignment rating for each category (out of 4) Phone line Support service Case management Regulator management Public protection 1 ↓ Low intensity anonymity, limited service 2 ↑ Option of reporting ↓ Limited service, no noncompliance consequences 4 ↑ Option for reporting, non-compliance consequences, strict conditions, known high efficacy 2 ↑ Direct regulatory oversight, noncompliance consequences, strict conditions ↓ Only for those known to regulator), practitioners reluctant to come forward Supports safe practice 1 ↓ Low intensity, anonymity 2 ↑ Some treatment support ↓ Low intensity 4 ↑ Re-entry & job retention oriented, voluntary work restrictions, intensive, known high efficacy 2 ↑ Re-entry & job retention oriented, intensive ↓ Discourages help-seeking (fear, non-transparency) Natural justice and fairness 4 ↑ No coercion, voluntary, anonymity 4 ↑ Low coercion, voluntary 3 ↑ Agreed treatment contracts, transparency, clear expectations ↓ Coercion 2 ↑ Clear compliance rules for participant ↓ Limited transparency / accountability, coercion Cost-effective 2 ↑ Free to practitioner ↓ Limited benefit 2 ↑ Free to practitioner ↓ Limited benefit 3 ↑ Known high efficacy ↓ High cost to practitioner 3 ↑ Minimises administrative & cost duplication ↓ High cost to practitioner, efficacy unclear Evidence-based 1 ↓ Limited to no evidence 1 ↓ Limited to no evidence 4 ↑ Much evidence, known high efficacy 2 ↑ Some well-evidenced components ↓ Limited evidence for this model Maintains public confidence 1 ↓ Rarely known to public, unknown efficacy 1 ↓ Rarely known to public, unknown efficacy 3 ↑ Transparent, public reporting, known high efficacy ↓ Perceived to ‘hide dangerous practitioners’ 2 ↑ Regulator oversight ↓ Non-transparency, rarely known to public, limited public reporting, perceived to ‘hide dangerous practitioners’ Timely 4 ↑ Out of hours available 2 ↓ Wait list, office hours 3 ↑ Most have no wait list ↓ Office hours for intake 3 ↑ No wait list ↓ Office hours for intake, slow regulator action Proportional 2 ↑ Low intensity ↓ May not report serious risks 2 ↑ Low intensity ↓ Inadequate for major problems 4 ↑ From low to very high intensity, individualised 4 ↑ Individualised Total score 16 16 28 20 Note: ↑ indicates an advantage; a↓ indicates a disadvantage ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 17 ACIL ALLEN CONSULTING 7 Alignment of program and service categories with best practice principles There is extensive research evidence regarding the high efficacy and favourable outcomes of the case management model, which has existed in the US since the 1970s (Mansky 1996, Gray 2006, Freckelton and Molloy 2007, White, DuPont et al. 2007, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Boyd and Knight 2012, Brooks, Early et al. 2012, Dupont and Skipper 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013). However, this review found little evidence on the efficacy of phone support lines, support services (with one exception (Cunningham and Cookson 2009)) and regulator management models, especially in terms of client outcomes As outlined in Table 1, the balance of available evidence from this review suggests that the case management option is most closely aligned with the principles of best practice for treating and rehabilitating impaired practitioners. As a result, the remainder of this review focuses on this model, with reference to selected exemplar programs outlined in Table 2, and detailed in subsequent tables. As the regulator management model is the second most aligned with the principles of best practice from this analysis, one example of this model has been included for completeness of comparison (College of Registered Nurses of British Columbia Early Intervention Program (Health)). The exemplars were chosen for a variety of reasons relating to: availability of quality information, reflecting aspects of the Australian healthcare and regulatory environment, high documented success rates, key contrasts with current approaches in Australia and/or professions covered. The major reasons for inclusion of each model are as follows: Nursing and Midwifery Health Program Victoria nursing and midwifery specific one of only two case management programs of this type in Australia (the other is the Victorian Doctors Health Program) Michigan Health Professional Recovery Program operates in a mandatory reporting environment covers a wide variety of professions (25 at present) formal shielding agreement College of Registered Nurses of British Columbia - Early Intervention Program (Health) nursing and midwifery specific regulator management model operates in universal healthcare environment NHS Practitioner Health Programme (London) operates in universal healthcare environment no formal shielding agreement ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 18 ACIL ALLEN CONSULTING offers some therapeutic and rehabilitation services internally Hypothetical ‘archetypal’ US Physicians Health Program (PHP) (based on the average or most common response from a national survey of 42 state programs) captures data from a large number of services in one data set programs have long histories and much accumulate evidence model has high demonstrated efficacy formal shielding agreement participants. These exemplars form the focus for the remainder of the review, but other models are also mentioned. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 19 ACIL ALLEN CONSULTING Table 2 Management programs for impaired practitioners: selected examples Country Australia US Canada UK US (Archetypal) Nursing and Midwifery Health Program Victoria (Hamilton and Duncan 2012, Siggins Miller 2012) Michigan Health Professional Recovery Program (Fletcher and Ronis 2005, Bissonnette and Doerr 2010, Michigan Health Professional Recovery Program 2013) College of Registered Nurses of British Columbia - Early Intervention Program (Health) (College of Registered Nurses of British Columbia 2012) NHS Practitioner Health Programme (London) (National Health Service Practitioner Health Programme 2012) Hypothetical “archetypal” US Health Program, based on a national survey of 42 state programs (DuPont, McLellan et al. 2009) Code used in this review AUS-NMHP US-HPRP CAN-EIP UK-PHP US-PHP Established 2006 1994 2012 2009 circa 1980 Private sector contractor College of Registered Nurses of British Columbia (regulator) Self-administering NHS program Administering organisation Self-administering not-for-profit service (company limited by guarantee) Self-administering independent non-profit organisation (54% of PHPs) Program Name [state medical association – 35% licensing board – 13%t] Nurses Midwives Profession(s) 25 professions (e.g. medical practitioners, nurses, dentists, psychologists, social workers) Nurses Medical Practitioners Dentists Medical Practitioners (100% of PHPs) Dentists (51%) [veterinarians – 33% pharmacists – 21% Substance misuse ✓ (42%) ✓ (50% of cases, 38% with comorbid SUD & mental illness) ✓ ✓ (85% of cases) ✓ (100%of PHPs) Alcohol (50% of cases) Opioids (35% of cases) Impairments covered Mental health ✓ (58%) ✓ (10 % of cases, 38% with comorbid SUD& mental illness) ✓ ✓ (28% of cases) ✓ (85% of PHPs) Physical - - ✓ ✓ (17% of cases) ✓ (62% of PHPs) Aging/ cognitive - - ✓ - ✓ Note: US (Archetypal) PHP data is based on most common response and/or average from national survey of PHP programs in 42 US states.[68] Key for exemplar tables: [✓= this feature is present/applicable] [ - = this feature is not present/applicable] ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 20 ACIL ALLEN CONSULTING Table 3 Management programs for impaired practitioners: key features of interest Program Eligibility AUS-NMHP - Available to students, practitioners and non-practising practitioners - Only program of its kind in Australia - Facilitates provision of financial and legal advice - Offers treatment and rehabilitation services internally Services - General running costs are regulatorfunded US-HPRP - Very wide variety of professions covered (25) - CAN-EIP - Explicitly covers mental health, substance misuses, physical health and cognitive/aging issues - - General running costs are government-funded - General running costs are regulatorfunded - - Referral to service meets legal mandatory reporting obligations - Board-ordered participation order is publicly discoverable - Program administered by regulator - Referral not noted on nurses’ registration record if ‘all goes to plan’ - - Abstinence-based Formal treatment contracts with reporting consequences for noncompliance - Nurse must stop work, even before assessment. Can’t return without medical approval (registration changed to ‘not practicing’) Costs Regulation/ Legal Approach/ Philosophy UK-PHP US-PHP (For 100% of PHPs unless stated) - Can only self-refer if from London area - - Offers some treatment and rehabilitation services internally - - Free for London, others access on ‘cost-per-case’ Funded by NHS - - - Physically embedded within standard general practice clinic - Written operating agreement with state licensing board to act on their behalf in managing impaired practitioners - Independent legal authority based on state laws (59% of PHPs) - Long-term monitoring (5 years) with reporting to regulator - Treatment contracts with reporting for non-compliance - Total abstinence required Note: - indicates this feature is not applicable ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 21 ACIL ALLEN CONSULTING 8 Identification, referral and reporting of impaired practitioners The first stage in the treatment and rehabilitation of impaired health practitioners is the identification of those who may be at risk, followed by referral and/or reporting to services or regulators. The features of the exemplar programs relating to referral and reporting are outlined in Table 4. 8.1 Identification Identification of impaired practitioners can be difficult. Compared with the general population, health concerns in practitioners are often picked up relatively late (Ponech 2000, Clode 2004, Dunn 2005) when the problem is already severe and entrenched (Clode 2004, Dunn 2005). This has been attributed to denial and minimisation of the problem (both by the practitioner and his or her peers), stigma and shame, (Ponech, 2000, (Thompson, Cupples et al. 2001, Lillibridge, Cox et al. 2002, Marshall 2008, Ipsos MORI 2009, Breen 2011) fear of consequences leading to concealment,(Dunn 2005, Kay and Izenour 2008, Marshall 2008) and doubts about the quality of care that will be provided (Thompson, Cupples et al. 2001, Kay, Mitchell et al. 2004). 8.2 Reporting versus referral In this context, there is a difference between ‘reporting’ (‘notification’ in the Australian context) and referral. Reporting means raising a concern about a potentially impaired practitioner with a regulator, on the understanding that investigation and potential regulatory action may follow. Referral means suggesting or directing that a practitioner engage with a program or service for impaired practitioners. All North American programs examined by this review allow regulators to refer a reported practitioner to the practitioner health program, as an alternative to disciplinary action (Mehendale and Goldman , Mansky 1996, Gray 2006, Freckelton and Molloy 2007, White, DuPont et al. 2007, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Boyd and Knight 2012, Brooks, Early et al. 2012, Dupont and Skipper 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013). In some cases, legal provisions blur the line between reporting and referral. For example, in some states and provinces, such as Michigan, practitioners are considered to have met the legal obligation to ‘report’ impaired colleagues if they refer them to the recognised practitioner health program (Schouten 2000, Bissonnette and Doerr 2010). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 22 ACIL ALLEN CONSULTING 8.3 Referral sources Numerous sources of referral to practitioner health programs are identified in the literature (Fletcher 2001, DuPont, McLellan et al. 2009, College of Registered Nurses of British Columbia 2012, Braquehais, Valero et al. 2014). They include: self treatment centres employers personal lawyer colleagues treating practitioners universities regulators (professional boards, licensing bodies) indemnity insurers employee assistance programs family and friends law enforcement officials health care organisations professional organisations patients and carers health complaints entities other government authorities judiciary (standard courts, drug courts), and anonymous. Self-referral: Self-referral is widely touted as the ideal method of referral to practitioner health programs (Kay and Izenour 2008, College of Registered Nurses of British Columbia 2012, Hamilton and Duncan 2012). It is considered to demonstrate reduced stigma, practitioner acceptance that they have a problem and need help, motivation to change and faith in the quality and suitability of the program (College of Registered Nurses of British Columbia 2012, Hamilton and Duncan 2012). Self-referral may also pick up problems earlier, better protecting patients and the practitioner (Dunn 2005, College of Registered Nurses of British Columbia 2012). It is also a lower-cost option, as it bypasses the costs associated with, for example, regulator investigation leading to referral (Hamilton and Duncan 2012). The extent of self-referral varied widely in the exemplar programs from 26 per cent for US programs to 90 per cent for NMHPV. There are examples demonstrating that self-referral is higher for more established programs. For example, in its first year (2012) 73 per cent of CAN-EIP cases were self-reported. This grew to 84 per cent in 2013 (College of Registered Nurses of British Columbia 2012). Reporting by other practitioners: It is widely agreed that health practitioners have an ethical obligation to report impaired colleagues who are placing patients at risk (Dunn 2005, Farber, Gilibert et al. 2005, Raniga, Hider et al. 2005, Kay and ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 23 ACIL ALLEN CONSULTING Izenour 2008, DesRoches, Rao et al. 2010). This ethical obligation is sometimes, but not always, extended to a legal obligation (mandatory reporting) (Laliotis and Grayson 1985, Breen 2009, Jackson and Parker 2009, Breen 2011). In many jurisdictions, including all Australian states and territories, registered practitioners are required to report colleagues who they reasonably believe are impaired in a way which poses a significant risk to patients (with the exception in some jurisdictions – such as Western Australia - for treating practitioners) (Breen 2009, Jackson and Parker 2009, Bissonnette and Doerr 2010, Breen 2011, Saunders 2012). In part, mandatory reporting provisions were put in place to overcome some of the many obstacles to practitioners reporting each other, including a fear of workplace and personal retribution (Rennie and Crosby 2002, Dunn 2005) and uncertainty about the threshold where reporting is necessary (Dunn 2005, Jackson and Parker 2009). However, there are concerns that mandatory reporting may dissuade impaired practitioners from seeking help and support, especially where treating practitioners are bound by reporting (Breen 2009, Whelan 2009, Breen 2011, Saunders 2012, Siggins Miller 2012). Research is currently underway to better understand the impact of mandatory reporting on practitioners in Australia. Relative success by referral source: Data on rates of successful recovery and retention/return to work, sorted by referral source, was limited. However, such data are available for the Michigan program for the year 2000 (1090 individuals) (Fletcher 2001). Program completions deemed ‘successful’ were highest in for those who self-referred (39.2 per cent), followed by those referred by an employer (33.8 per cent), regulator (27.7 per cent), colleague (26.9 per cent) and treating practitioner (5 per cent). Overall, those who self-referred had higher rates of program-defined success (39.2 per cent) than those from all other referral sources (23.5 per cent) 8.4 Relationships between regulators and health programs/services regarding referral and reporting The review identified four existing broad models of referral and reporting between health programs/services and regulators, taking into account the presence or absence of (a) a formal public agreement, (b) mandatory reporting and (c) ‘shielding’ of clients. No formal agreement without mandatory reporting: This model is seen most commonly with phone support lines and support services in jurisdictions without mandatory reporting, such as the Doctors’ Support Line (Miller 2002) and Sick Doctors Trust Helpline (UK) (Sick Doctors Trust 2014). In this model, health services are not required to refer or report practitioners, even if they pose a risk to patient safety. However, referral or reporting can still occur (a) with the permission of the practitioner, or (b) without permission, at the discretion of service staff or volunteers (where the law and service policy allows it). No formal agreement with mandatory reporting: This model was common in Australia, for example, it is seen in the operation of the various Doctors Health Advisory phone support lines (except WA) (Whelan 2009), and services offered by ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 24 ACIL ALLEN CONSULTING Medical Benevolent Associations (Medical Benevolent Association of New South Wales 2014) and Employee Assistance programs (ACT Health 2013). Under this model, clinicians working within the program or service are bound by mandatory reporting requirements with respect to service/program clients, without a formal agreement with the regulator to guide them. This leaves service operators, staff, clients, potential clients, external treating practitioners, reporters and potential reporters confused and uncertain about the role reporting to the regulator plays (Whelan 2009). Inconsistent application and interpretation of reporting requirements have been reported, with some practitioners considering program compliance to negate the need to report, while others do not (Whelan 2009). Formal agreement with shielding: Under this model, formal operating agreements exist between health programs and regulators, which endow programs with a legal mandate to manage impaired practitioners on behalf of the regulator (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, DuPont, McLellan et al. 2009, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). Among other things, these agreements cover how and when practitioners are referred to the health program by the regulator, and impaired practitioners are reported to the regulator by the health program (Cohen and Rhydderch, 2006, Sanderson-Mann and McCandless, 2006, Department of Licensing and regulatory Affairs, 2014, NHS Practitioner Health Programme and General Medical Council, 2013, NHS Practitioner Health Programme and General Dental Council, 2013, Smith 2013, Bohegian et al., 2013, Bohegian et al., 2002, Platman et al., 2013, Krall et al., 2012). This model was the most common identified in the literature - being common in Canada, and universally applied to US PHPs (Mehendale and Goldman , Mansky 1996, Gray 2006, Freckelton and Molloy 2007, White, DuPont et al. 2007, Brewster, Kaufmann et al. 2008, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Boyd and Knight 2012, Brooks, Early et al. 2012, College of Registered Nurses of British Columbia 2012, Dupont and Skipper 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013). ‘Shielding’ gives the health program the legal right (and indeed obligation) not to report, identify, or share information about any client as long as the client is complying with program requirements (as set out in a personalised contract) (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). However, should the client break the contract, they can, and often must, be reported to the regulator (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). Referrals to the program by the regulator are usually presented as a directive ultimatum (DuPont, McLellan et al. 2009, Boyd and Knight 2012). That is, the practitioner is given the opportunity to take part in the program as an alternative to discipline (during which time the first element of shielding will apply) (Darbro 2009, Hamilton and Taylor 2011). However, they face potential disciplinary or licensure actions if they choose not to participate or comply (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 25 ACIL ALLEN CONSULTING Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). Under this model, a practitioner who complies with the program can seek help, receive it, recover, and return to the workforce if appropriate, without any regulator knowledge or intervention. This is alleged to encourage self-referral and early intervention (Taylor & Heinjus 2013). In the USA, the long-standing nature of these agreements (sometimes 40 years or more), and the associated high rates of success, promote strong referral flows into the signatory health programs (Brown and Schneidman 2004, Monroe, Pearson et al. 2008, Hamilton and Taylor 2011). For example, 21 per cent of all referrals to US PHPs come from a regulator (DuPont, McLellan et al. 2009). This is a notable contrast with models where no formal shielding provisions are in place, where referrals from regulators are either low (4 per cent for NMHPV)(Hamilton and Duncan 2012) or not recorded at all (UK-PHP) (NHS Practitioner Health Programme 2014). The contract between the Nursing and Midwifery Health Program Victoria (NMHPV) and the Nursing and Midwifery Board of Australia contains some references to operational issues, including referral and reporting (Taylor July 22 2014). However - unlike equivalent arrangements in North American programs this is not publically known, and details of the arrangement are not publically available. Furthermore, the website for NMHPV and the associated publications makes no mention of mandatory reporting, or how it interacts with the program (Nursing and Midwifery Health Program Victoria 2014). As such, a lack of transparency and clarity may contribute to similar uncertainty about the program. This may in turn prevent nurses and midwives from seeking help. Formal agreement without shielding: This model is seen in the UK, where it applies to the NHS Practitioner Health Program (NHS Practitioner Health Programme and NHS London Special Commissioning Group 2010, National Health Service Practitioner Health Programme 2012, NHS Practitioner Health Programme 2014). The program has a formal MOU with each of the two relevant regulators (General Medical Council and General Dental Council) (NHS Practitioner Health Programme and Council 2009, NHS Practitioner Health Programme and General Medical Council 2013). The MOUs cover issues such as referral, reporting, confidentiality and information sharing. However, neither these agreements, nor the law, contain any provisions to shield practitioners who are referred to, approach, or are engaged with the health program. Indeed, the MOUs specifically provide that the regulator and health program may exchange information about clients, and their involvement with the program, via detailed reports (but typically not complete medical records) (NHS Practitioner Health Programme and Council 2009, NHS Practitioner Health Programme and General Medical Council 2013). They also allow the health program to report a client to the regulator if they pose a risk to the public. This is usually done only where the practitioner poses a serious risk to the public, and is not complying with the program, treatment and/or recommendations to remain on leave from work. As a result of the absence of shielding, many practitioners engaged with the program are subject to parallel regulatory processes (NHS Practitioner Health Programme 2014). However, over the first five years of the program to 2013, the ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 26 ACIL ALLEN CONSULTING proportion of program clients also involved in regulator processes dropped from 33 per cent to 7 per cent (NHS Practitioner Health Programme 2014). This is attributed to the success of the program, and increasing acceptance and awareness which encourages practitioners to seek help before regulator involvement occurs or is necessary (NHS Practitioner Health Programme 2014). 8.5 The role of coercion In all but the ‘no shielding’ model described above, there is an element of ultimatum or coercion applied to impaired practitioners. That is, disciplinary action is held up as potential consequence of not complying with rehabilitation programs and other recommendations. This may contribute to the high recovery rates of practitioners in these programs, as compared with the general population (White, DuPont et al. 2007, Dupont and Skipper 2012) but does raise ethical concerns regarding the voluntariness of consent. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 27 ACIL ALLEN CONSULTING Table 4 Referral Program Regulator Self Clinical colleagues Referral sources ✓ (4%) ✓ (90%) ✓ (6%) Employers Treating professionals Other Legally-imposed mandatory reporting in jurisdiction Terms of formal agreement with regulator AUS-NMHP × × ✓ Where required by Health Practitioner Regulation National Law (Victoria) Act 2009 US-HPRP CAN-EIP UK-PHP US-PHP ✓ × ✓ (21% of cases) ✓ (26%) ✓ (84%) ✓ (not for out-of-area practitioners) ✓ (26% of cases) ✓ ✓ × ✓ (20% of cases) ✓ ✓ × ✓ (14% of cases) ✓ ✓ ✓ ✓ × ✓ (17% of cases) e.g. medical schools, law enforcement, family and attorneys) ✓ ✓ Patients, the State ✓ (Exemption for treating practitioners) ✓ Program must report if impaired professional chooses not to participate and poses risk to patients .× ✓ All reports are received by regulator who administers this program Where impaired professional chooses not to participate × ✓ (100% of PHPs) Formal agreement/MOU with program ✓ (only partial – limited operational elements in contract) ✓ ✓ ✓ Shielding and confidentiality for compliant practitioners . (not detailed in formal agreement, but can occur) ✓ (Except board orders for participation are publically discoverable) ✓ × Practitioners reported if they don’t participate or comply . (not detailed in formal agreement, but can occur) ✓ ✓ × (31% of participants enter through mandate from regulatory authority) ✓ (100% of PHPs) ✓ (100% of PHPs) ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 28 ACIL ALLEN CONSULTING 9 Assessment After referral, the next stage is an assessment to determine the nature of the practitioner’s illness and/or impairment (if any), and possible options for treatment, rehabilitation and other actions (Boyd and Knight 2012). The features of assessment processes for the exemplar programs are outlined in Table 5. 9.1 Source of initial assessment Programs reported a variety of sources of initial assessment. Some programs employed clinical staff such as mental health and/or addiction nurses, general practitioners or psychologists (Boyd and Knight 2012, National Health Service Practitioner Health Programme 2012). Others referred potential clients to external practitioners for assessments (Boyd and Knight 2012, National Health Service Practitioner Health Programme 2012). Assessors were usually chosen from a list of those approved by the service, to ensure quality, understanding of the assessment requirements and cooperation (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). Some programs (such as US-HPRP) allow client practitioners to select from a list of acceptable options (Fletcher 2001). Ideally, the specialty of the assessor should align with the nature of the practitioner’s impairment (e.g. psychiatrist for suspected mental illness) (Fletcher 2001, Department of Licensing and Regulatory Affairs 2014). In practice, practitioners who present with one concern, are often found to have other issues, which are often less obvious (Korinek, Thompson et al. 2009). 9.2 Assessment components Two broad types of assessment are relevant to evaluating impaired practitioners. These reflect the two elements of ‘impairment’ in this context – (a) that the practitioner must have a health issue, and (b) that the health issue must impair their performance in a way that poses a risk to patients. Health Assessments: Methods of assessing a health issue depend on the suspected nature of the matter. Assessment may include cognitive testing, psychiatric evaluation, psychological profiling, and physical examination and/or medical tests (Harrison 2008, Miller 2009, Humphrey 2010, Pham, Pronovost et al. 2013). Such assessment can establish the existence of a health issue, but cannot necessarily establish the existence of an impairment of professional performance (Harrison 2008, Humphrey 2010). For example, many practitioners with disabilities or health issues can practise safely, with or without adjustments to their work practice (Sanderson-Mann and McCandless 2005, Sanderson-Mann and McCandless 2006, Morris and Turnbull 2007, Morris and Turnbull 2007, Grainger 2008, Sin and Fong 2008, Schroeder, Brazeau et al. 2009, Tee, Owens et al. 2010, Storr, Wray et al. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 29 ACIL ALLEN CONSULTING 2011). Therefore, in order to establish the existence of a health impairment, confirming the presence of a health condition is necessary, but not sufficient. Performance Assessments: In order to establish the existence of a health-related impairment, it must also be demonstrated that a confirmed health issue impacts, or has a significant pressing potential to impact, on professional practice. Methods for assessing performance are less standardised than those for detecting the presence of health issues (Anfang, Faulkner et al. 2005, Harrison 2008, Harrison 2008, Norcross, Henzel et al. 2009, Dyer 2012), and tend to focus on competence or communication concerns rather than the impact of an impairment on clinical performance per se (Humphrey 2010). All countries from which the exemplar programs are drawn have programs (usually run by universities or regulators) for assessing practitioners with suspected performance problems (Humphrey 2010). Examples include the NCAS Assessment (National Clinical Assessment Service - UK) and the Performance Assessment Program (Medical Council of New Zealand) (Humphrey 2010). Methods commonly used in these programs include (Humphrey 2010): site visits to assess work environment interviews or questionnaires simulations practice-based observation chart review written knowledge test, and feedback from patients and peers. It is worth noting that some assessment and remediation programs for physicians have been criticised for failing to give due attention to broader systems and contextual factors that impact on performance (with the exception of NCAS in the UK) (Humphrey 2010). They were seen to focus on ‘diagnosing’ and ‘treating’ individuals, with little attention to such factors as teamwork in the workplace, working conditions etc (Humphrey 2010). 9.3 Impairment assessment To determine the presence (or absence) and nature of impairment, an illness must be identified (health assessment) and shown to impact on performance in a manner serious enough to endanger patients (performance assessment) (Pham, Pronovost et al. 2013). Only when both of these determinations are made can a valid conclusion be reached about whether an impairment is present. However, as outlined above, methods for assessing these two questions, and drawing valid causal connections between the two, are often disjointed (Humphrey 2010). In some cases, the type of assessment used to evaluate a practitioner can skew the interpretation of their performance issues (Korinek, Thompson et al. 2009). For example, a performance review that does not include a cognitive-testing component may miss the underlying cause of impairment (Korinek, Thompson et al. 2009). Efforts are being made to produce standard models, tools and guidelines for assessing and reporting on ‘fitness-to-practice’, as well as competence ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 30 ACIL ALLEN CONSULTING (Reynolds 2001, Anfang, Faulkner et al. 2005, Wall 2005, Wettstein 2005, Sin and Fong 2007, Harrison 2008, Harrison 2008, Miller 2009, Norcross, Henzel et al. 2009, Dyer 2012, Meyer and Price 2012, Price and Meyer 2013). However, there is yet to be wide acceptance of particular methods (Reynolds 2001, Wall 2005, Wettstein 2005, Sin and Fong 2007, Harrison 2008, Dyer 2012, Meyer and Price 2012, Price and Meyer 2013). Finally, it is worth noting that there a relationship between history of disciplinary action and contact with regulators, and the presence of impairment (Holtman 2007). So there is a potential role for disciplinary and/or regulator contact history to be considered in assessing potentially impaired practitioners. 9.4 Role of the regulator In all exemplar models, regulators can potentially receive some information about the findings of an assessment. However, the frequency and depth of such information-sharing, and the circumstances under which it occurred, vary substantially. The programs examined in this review fell into four main categories with respect to the sharing of assessment findings: Universal initial access: This model is seen where the regulator administers case management programs, or uses a regulator management approach. In these cases, full information on the outcome of the assessment is available to the regulator and is used to determine next steps in the process (e.g. whether a practitioner ought to be offered a health program option or not) (Medical Council of New South Wales 2010, College of Registered Nurses of British Columbia 2014). Whether or not the regulator has access to subsequent updates on client progress and participation varies (Medical Council of New South Wales 2010, College of Registered Nurses of British Columbia 2014). An example of this model is CAN-EIP, which follows a regulator management model (College of Registered Nurses of British Columbia 2014). In this case, the regulator orders and/or contracts assessments of potentially impaired practitioners and determines eligibility for the program based on these assessments (College of Registered Nurses of British Columbia 2014). However, details of the assessment outcome are not recorded on the practitioners’ records if they are fully compliant and successful with their rehabilitation. Access upon infringement: This model is most common among case management programs in North America which utilise treatment and/or management contracts to formalise their expectations of clients (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Boyd and Knight 2012, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). In these cases there is provision within the formal agreement with the regulator that certain information about the client, including certain assessment findings, may be shared with the regulator if the client breaks the terms of their contract (i.e. is ‘non-compliant’) (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Boyd and Knight 2012, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013). Access where mandated: This model is seen in some case management programs (e.g. US-HPRP) where rules regarding – information-sharing vary based on the ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 31 ACIL ALLEN CONSULTING entry path of the client into the program (Fletcher 2001, Michigan Health Professional Recovery Program 2013). In these circumstances, access about the assessment outcomes of clients is automatically accessible to the regulator in cases where a clients’ participation was mandated by an order of that regulator (Fletcher 2001, Michigan Health Professional Recovery Program 2013). Access in case of public risk: This model is seen in jurisdictions where mandatory reporting operates, but shielding of health program clients does not (such as UKPHP) (NHS Practitioner Health Programme and Council 2009, NHS Practitioner Health Programme and General Medical Council 2013). Under this model, the program reserves the right (of which clients are clearly informed) to report clients who are believed to pose a serious risk to public and/or patient safety – typically following non-compliance (NHS Practitioner Health Programme and Council 2009, NHS Practitioner Health Programme and General Medical Council 2013). In such cases, certain aspects of assessment findings may be shared with the regulator. Table 5 Assessment Program AUS-NMHP US-HPRP CAN-EIP UK-PHP US-PHP Internal staff External (participant given choices) External Internal staff Internal staff Physical examination × ✓ (where indicated) ✓ (where indicated) ✓ (where indicated) ✓ (where indicated) Psychological ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ ✓ Participant interview and/or questionnaires ✓ ✓ ✓ ✓ ✓ Non-referring colleagues ✓ (with permission) × ✓ × ✓ ✓ Where required by law ✓ If participation is regulatormandated, or if contract broken or relapse occurs ✓ Always – regulator decides whether nurse eligible for program ✓ Program reserves the right to report high-risk practitioners ✓ Only if contract broken or relapse occurs Initial assessment source Initial assessment types Referrer (if not the participant) Sources of information Regulator’s role Can be given information about assessment outcome ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 32 ACIL ALLEN CONSULTING 10 Treatment, rehabilitation and monitoring The features of treatment and rehabilitation in each of the exemplar programs is outlined in Table 6. 10.1 Role of the health program It is rare for health programs to directly provide clinical treatment for impairmentrelated health conditions, with the exception of some limited in-house counselling (usually just a few sessions). Instead they serve as coordinating, referral, administrative and monitoring bodies. While details vary between programs, typical treatment-related roles for case management programs include: using assessment findings to develop a management and treatment plan creating an agreement or contract with the client based on the treatment plan, which may include agreed temporary restrictions on work assisting the client to arrange and coordinate the treatment plan including referrals to appropriate treatment services (inpatient and outpatient), practitioners, support services, peer support or mutual aid groups and advocacy services monitoring compliance with treatment and management programs (for example through receipt of reports, logs and drug test results, and worksite visits) developing and implement response plans when relapse or other significant negative event occur negotiating alterations to treatment and management plans as appropriate arranging re-assessment of clients reaching the end of program participation, and facilitating return-to-work efforts (Brown and Schneidman 2004, Warhaft 2004, Hall 2007, DuPont, McLellan et al. 2009, Hambleton 2011, Skipper and DuPont 2011, Boyd and Knight 2012, Dupont and Skipper 2012). Thus, most programs are based on a distinct separation between co-ordination and provision of treatment. This allows for more individualisation and flexibility in programs (Brown and Schneidman 2004, Skipper and DuPont 2011), and helps to protect client confidentiality (National Health Service Practitioner Health Programme 2012). 10.2 Program specialisation Major lines of program specialisation occurs along three axes – geographic area, impairment type and profession ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 33 ACIL ALLEN CONSULTING Geographic area: There is little comment in the literature on the relative merits of a state-based or national approach. In the US, Canada and Australia, state or province-based programs are the norm (where they exist at all) (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Warhaft 2004, Bohigian, Bondurant et al. 2005, Brewster, Kaufmann et al. 2008, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013, College of Registered Nurses of British Columbia 2014, Nursing and Midwifery Health Program Victoria 2014). In the UK, services such as hotlines and charitable support organisations are national (Miller 2002, Sick Doctors Trust 2014), but the only case management program (UK-PHP) is fully and freely available to London-area practitioners (NHS Practitioner Health Programme 2014). Out-of-area practitioners can pay a fee to access an assessment by the program (NHS Practitioner Health Programme 2014). Impairment type: With respect to impairment types, many programs limit the scope of impairments that they cover. Substance misuse (where mental health concerns are often also present) was specifically covered by all programs identified (Bosch 2000, Fletcher 2001, Bohigian, Croughan et al. 2002, Miller 2002, Brown and Schneidman 2004, Warhaft 2004, Bohigian, Bondurant et al. 2005, Brewster, Kaufmann et al. 2008, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013, College of Registered Nurses of British Columbia 2014, NHS Practitioner Health Programme 2014, Nursing and Midwifery Health Program Victoria 2014, Sick Doctors Trust 2014). Mental health and psychiatric concerns were frequently covered, with all exemplar programs and 85 per cent of US PHPs covering these concerns (Fletcher 2001, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Skipper and DuPont 2011, Michigan Health Professional Recovery Program 2013, College of Registered Nurses of British Columbia 2014, NHS Practitioner Health Programme 2014, Nursing and Midwifery Health Program Victoria 2014). US programs have been traditionally skewed towards SUDs (DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Dupont and Skipper 2012). Fewer programs explicitly cover physical health and disability or age-related cognitive issues (DuPont, McLellan et al. 2009, College of Registered Nurses of British Columbia 2014, NHS Practitioner Health Programme 2014). For those that do, the proportion of total clients with these concerns is relatively small. For example, UKPHP reports physical illness or disability as a major concern in only 17 per cent of cases (National Health Service Practitioner Health Programme 2012). We did not identify any programs that focused solely on physical health, cognitive concerns (distinct from mental illness) or other disabilities. Profession: All of the health programs examined by this review were, to some degree, specific to health practitioners. Some were specific to only one or two professions (such as doctors, or doctors and dentists) (NHS Practitioner Health Programme 2014), while others were open to those working in a range of healthrelated occupations (25 occupations in the case of US-HPRP) (Michigan Health Professional Recovery Program 2013). Services that referred clients to external treatment or rehabilitation providers reported that they preferred services or practitioners that they deemed ‘practitioner-patient friendly’, with whom the program often had an established relationship (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, Fletcher and Ronis 2005, Brooks, Early et al. 2012, Krall, Niazi et al. 2012, ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 34 ACIL ALLEN CONSULTING Platman, Allen et al. 2013, Smith 2013). While these practitioners often had particular skills and experience in treating health practitioners, they generally provided services to non-practitioner members of the public as well (Skipper and DuPont 2011). Research in the UK found that both healthcare practitioners and the public could see the merit in tailored or specialised services for practitioners (Ipsos MORI 2009). However, the public strongly believed that while the service should be tailored to the needs of practitioners, it should not be ‘better’ than mainstream services (Ipsos MORI 2009). 10.3 Treatment types Types of treatment to which health programs in this review refer include (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009, Skipper and DuPont 2011, Dupont and Skipper 2012, Krall, Niazi et al. 2012, Platman, Allen et al. 2013, Smith 2013, NHS Practitioner Health Programme 2014, Victorian Doctors Health Program 2014): counselling – group, individual, family and marital/relationship psychology and psychotherapy psychiatry (inpatient and outpatient) addiction specialists occupational medicine specialists occupational therapists addiction recovery programs (inpatient and outpatient) general practitioners physical rehabilitation services, and peer and/or mutual aid support groups (e.g. Alcoholics Anonymous, Narcanon, Caduceus). The range of treatment options available, and the individualisation of treatment plans, was largely consistent across the programs examined. A detailed analysis of the effectiveness of these various treatments is outside the scope of this review. However, the evidence does support a multi-disciplinary, individualised and integrated approach (Mehendale and Goldman , White, DuPont et al. 2007, Skipper and DuPont 2011, Dupont and Skipper 2012). Notable features of the US PHP model include high utilisation of lengthy inpatient treatment and mutual aid groups (Brown and Schneidman 2004). Sixty-nine percent of US PHP patients are placed in inpatient care (usually for 90 days), and 95 per cent of US programs mandated mutual aid group attendance (DuPont, McLellan et al. 2009). These fit with the overall focus on abstinence-based approaches in US PHPs, which prohibit all non-medical use of drugs and alcohol for those presenting with SUDs (DuPont, McLellan et al. 2009). However, it has been suggested that the total abstinence approach may not be suitable to the Australian context (Brown and Schneidman 2004). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 35 ACIL ALLEN CONSULTING 10.4 Monitoring strategies Monitoring strategies used by health programs identified in this review include (Knight, Sanchez et al. 2002, Warhaft 2004, Ganley, Pendergast et al. 2005, Long, Cassidy et al. 2006, Brewster, Kaufmann et al. 2008, Carinci and Christo 2009, Darbro 2009, Skipper and DuPont 2011, Brooks, Gendel et al. 2013, Michigan Health Professional Recovery Program 2013): regular drug testing, including urine, blood, breath and hair (for up to five years for most US PHPs) treating practitioner feedback workplace feedback (most often by an appointed workplace monitor) unannounced worksite visits (during transition back to work or if remaining in work) documentation of mutual aid or support group attendance medical monitoring, and personal progress reports by clients. Methods, regimes and durations of monitoring varied more widely across the programs than did treatment options. A detailed analysis of the effectiveness of these various treatments is outside the scope of this review. However, research has shown that program clients believe that monitoring is cumbersome, but vital to their recovery (Knight, Sanchez et al. 2002, Fogger and McGuinness 2009). 10.5 Work restrictions All programs identified in this review included a role for agreed work restrictions or stoppages as part of treatment plans, agreements and/or contracts (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Warhaft 2004, Bohigian, Bondurant et al. 2005, NHS Practitioner Health Programme and Council 2009, Krall, Niazi et al. 2012, NHS Practitioner Health Programme and General Medical Council 2013, Platman, Allen et al. 2013, Smith 2013, College of Registered Nurses of British Columbia 2014, Nursing and Midwifery Health Program Victoria 2014, Victorian Doctors Health Program 2014). These restrictions are intended to protect patient from harm, protect the practitioner from the consequences of causing harm, allow the practitioner to focus on recovery, and maintain regulator confidence that health programs do not place patients at undue risk (Hughes, Smith et al. 1998, Haack and Yocom 2002, Dunn 2005). While most are technically voluntary (in that they are not regulator-ordered), failure to abide by such restrictions is typically considered a breach of the treatment agreement, and can trigger a report to the regulator (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, NHS Practitioner Health Programme and Council 2009, College of Registered Nurses of British Columbia 2012, Krall, Niazi et al. 2012, NHS Practitioner Health Programme and General Medical Council 2013, Platman, Allen et al. 2013, Smith 2013). In the case of CAN-EIP, all clients must initially agree to withdraw from practice and change their practising certificate status to ‘not practising’ until cleared for work by a medical doctor (College of Registered Nurses of British Columbia ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 36 ACIL ALLEN CONSULTING 2014). In all other programs where such provisions were identified, work restrictions were not so universally applied, but were determined on an individual basis. Some restrictions involve total withdrawal from work for a time, while others involve specific provisions such as not handling certain medications or working restricted hours (Hughes, Smith et al. 1998, Haack and Yocom 2002, Dunn 2005). As part of the transition back to work, these restrictions are gradually eased (Hughes, Smith et al. 1998, Haack and Yocom 2002, Wilson and Compton 2009, Angres, Bettinardi-Angres et al. 2010). One difficulty of work restrictions is that they have the potential to compromise client confidentiality. Long absences from work, the need to inform worksite monitors, managers and other staff, and changes in work permissions and tasks, can all bring about awareness of the practitioner’s health issues (Smith and Hughes 1996, Couser 2013). 10.6 Role of the regulator The most common role for the regulator during the treatment and rehabilitation stage is as the repository for reports when practitioners are non-compliant, uncooperative or choose not to engage with the health program (Fletcher 2001, Bohigian, Croughan et al. 2002, Brown and Schneidman 2004, Bohigian, Bondurant et al. 2005, NHS Practitioner Health Programme and Council 2009, College of Registered Nurses of British Columbia 2012, Krall, Niazi et al. 2012, NHS Practitioner Health Programme and General Medical Council 2013, Platman, Allen et al. 2013, Smith 2013). The general lack of ‘matter of course’ reporting to the regulator is seen as an important aspect of developing and maintaining trust between the client, their treating practitioners and the health program (Jenkins 2013). We found only one explicit reference to the progress of compliant clients being regularly reported to the regulator as a matter of course during the treatment, rehabilitation and monitoring stages (Health Professional Recovery Program 2011, Michigan Health Professional Recovery Program 2013). This occurred in USHPRP, but only for those practitioners whose participation was mandated by the regulator (33 per cent) (Health Professional Recovery Program 2011, Michigan Health Professional Recovery Program 2013). However, as this was not a systematic review, other examples may exist. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 37 ACIL ALLEN CONSULTING Table 6 Treatment and rehabilitation Program Rehab offered internally Rehab referred to AUS-NMHP US-HPRP CAN-EIP UK-PHP US-PHP Medical treatment × × × × × Psychological/ counselling ✓ Counselling × × ✓ Counselling and psychology × Peer support ✓ × × × × Medical treatment ✓ ✓ ✓ ✓ ✓ Psychological/ counselling ✓ ✓ ✓ ✓ ✓ Peer support ✓ ✓ ✓ ✓ ✓ ✓ ✓ × ✓ ✓ ✓ Stop work until return medically approved × ✓ ✓ ✓ ✓ ✓ ✓ (100 per cent of PHPs) ✓ ✓ ✓ ✓ ✓ (100 per cent of PHPs) ✓ Worksite monitor reports ✓ × ✓ (70 per cent of PHPs) Formal, binding treatment contracts Formally contracted work limitations Treating practitioner feedback Drug testing Elements of monitoring (where relevant) Workplace feedback ✓ Peer support attendance Other Regulator’s role Regulator informed of progress as a matter of course × ✓ (95 per cent of PHPs) ✓ Personal progress reports ✓ Medical monitoring × ✓ Unannounced worksite visits ✓ Only if participation is regulatormandated × × × ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 38 ACIL ALLEN CONSULTING 11 Outcomes Information on outcomes for clients of health programs is patchy, and does not report against consistent measures. As such, meaningful comparisons are difficult. However, a summary of available outcomes data is presented in Table 7. 11.1 Outcome types Health program outcomes mentioned in the literature are listed below (McLellan, Skipper et al. 2008, Skipper, Campbell et al. 2009, Health Professional Recovery Program 2011, Skipper and DuPont 2011, Hamilton and Duncan 2012, National Health Service Practitioner Health Programme 2012, Siggins Miller 2012, Rose, Campbell et al. 2014). Individual clients may experience different combinations of these outcomes. Recovery: total, without relapse or major problematic event total, with intervening relapse or major problematic event no longer a risk to patients abstinence from substance use (DuPont, McLellan et al. 2009, DuPont, McLellan et al. 2009) non-recovery, and death Licence/registration: kept, without restrictions kept, with restrictions revoked or suspended surrendered, and converted to ‘non-practising’ (e.g. retirement) Program completion: program completed failure to complete – voluntary exit failure to complete – involuntary discharge (non-compliance), and failure to engage at beginning Work status (in health profession): remained at work returned to work able to return to work, planning to return able to return to work, not planning to return, and ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 39 ACIL ALLEN CONSULTING unable to return to work. 11.2 Recovery from substance use disorders – rates and contributing factors The most commonly reported outcomes are for recovery from SUDs. This may be because abstinence from the substance of concern (or from all non-medically required drugs and alcohol) is a relative clear and measureable definition (McLellan, Skipper et al. 2008, Skipper, Campbell et al. 2009, Health Professional Recovery Program 2011, Skipper and DuPont 2011, Hamilton and Duncan 2012, NHS Practitioner Health Programme 2014, Rose, Campbell et al. 2014). Clients with substance use disorders in practitioner health programs recover at much higher rates than members of the general population undergoing substance use disorder treatment (as defined by abstinence at five years) (Domino, Hornbein et al. 2005, DuPont, McLellan et al. 2009). Optimistic estimates of recovery rate in the general population undergoing treatment generally range from 40 per cent to 60 per cent (McLellan, Lewis et al. 2000, Institute of Medicine 2006). Yet, for example, the average recovery rate for US PHP’s is 88 per cent at five years. A study of abstinence rates from the Washington Physicians Health Program showed rates of 78 per cent after 11 years (Domino, Hornbein et al. 2005). The three-year recovery rate for UK-PHP is 79 per cent. The risk of relapse is also lower in practitioners (Domino, Hornbein et al. 2005). The reasons for such high recovery rates are not entirely clear (Boyd and Knight 2012). However, several factors have been suggested in the literature. First, the quality and intensity of health programs offered to physicians outstrips those available to most members of the general population (Domino, Hornbein et al. 2005, White, DuPont et al. 2007, Skipper and DuPont 2011, Boyd and Knight 2012). Health programs for practitioners tend to be intensive, coordinated, lengthy, inter-disciplinary and individualised, which has been linked with improved outcomes (Mehendale and Goldman , White, DuPont et al. 2007, Skipper and DuPont 2011, Boyd and Knight 2012, Dupont and Skipper 2012). Second, practitioners tend to have the financial and social capital resources to engage with more intensive treatment for longer (DuPont, McLellan et al. 2009, Boyd and Knight 2012). It is known that the risk of relapse decreases the longer a practitioner stays in a treatment program (Domino, Hornbein et al. 2005). Third, practitioners in health programs face a uniquely formal, structured and ‘high-stakes’ set of consequences for non-compliance, relapse, or non-engagement with treatment (Mehendale and Goldman , White, DuPont et al. 2007, Boyd and Knight 2012, Dupont and Skipper 2012). That is, they typically face job loss, disciplinary action, public attention/exposure, and permanent career loss through registration or licensure actions. Writing these potential consequences into the treatment contract creates a clear and concrete connection between noncompliance/relapse and serious negative repercussions (Mehendale and Goldman , White, DuPont et al. 2007, Boyd and Knight 2012, Dupont and Skipper 2012). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 40 ACIL ALLEN CONSULTING Fourth, practitioners in health programs are accessing a service specific to their profession. That is, it is tailored to their unique needs and life circumstances in a way that is not mirrored for the general population (Brand, Rojas et al. 2013). It is important to note that practitioners enrolled in practitioner-specific health programs shower higher rates of recovery than those treated through mainstream means (DuPont, McLellan et al. 2009). This suggests that differences in recovery rates between practitioners and the general public are at least partially explained by the features of practitioner health programs, rather the features of practitioners as a population group (DuPont, McLellan et al. 2009). 11.3 Recovery from non-substance use disorder impairments ‘Recovery’ from mental health issues, physical illness, cognitive impairment, ageing and disability are sometimes either difficult to define or not medically possible. Therefore, data on such outcomes were sparse and vaguely described. Data on clients with mental health issues, such as those provided by the Massachusetts Medical Society’s Physician Health Service, tended to define ‘success’ as complete adherence to treatment contracts (Knight, Sanchez et al. 2007). While this is a positive measure, it is not the same as ‘recovery’. For these clients, being able to remain at or return to work could perhaps be another proxy measure of wellness considered as ‘success’. However, data on work status outcomes for clients, broken down by presenting health issue/impairment, were not found. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 41 ACIL ALLEN CONSULTING Table 7 Outcomes Program AUS-NMHP Remained at work our returned to work 58 per cent (note: status of 22 per cent recorded as unknown or N/A) Recovery rate CAN-EIP UK-PHP US-PHP [Established in 2012, too early for data] 77 per cent (after 3 years) 71 per cent (after 5 years) 79 per cent 88 per cent (monitored over 5 years) 52 per cent Deemed recovered or abstinent 48 per cent Non-recovery Practitioner satisfaction US-HPRP Very positive qualitative feedback at focus group review 98.9 per cent ‘very’ or ‘moderately’ satisfied. Of these 81.8 per cent ‘very satisfied. Average rating 3.6 out of 5 4.5 per cent (29 per cent involved with regulator processes at some stage during program contact) License status revoked, suspended or surrendered at end of program contact Informed of relapse, noncompliance or broken contract ✓ Where required by law ✓ Almost always ✓ Almost always ✓ Must report if practitioner under regulator supervision or investigation ✓ Almost always (100 per cent of PHPs) ✓ Can report highrisk practitioners Role of regulator Informed if practitioner won’t engage with program 18 per cent ✓ ✓ ✓ Reserves the right to report high-risk practitioners ✓ ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 42 ACIL ALLEN CONSULTING 12 Costs From a regulatory point of view, the cost effectiveness of practitioner health programs can be understood as a balance between three major factors—the cost of poorly treated or untreated impairment to the practitioner and the wider health system, the cost of health programs, and the costs to the regulator (e.g. if a health program is unsuccessful and disciplinary measures are required to protect the public.) Public reporting of program budgets and some publically available evaluations provide information on the overall budgets of health programs. However, information on costs to the health system and wider society that are prevented or recouped—and thus the benefit received from expenditure—is very limited. This literature review, and systematic literature reviews by others, found little or no data on, for example: the cost of losing practitioners from the health workforce due to impairment (through early retirement, removal from practice) the cost of clinical errors by impaired practitioners to the healthcare system, and the relative cost-effectiveness of different programs (due, in part, to difficulties and tensions in defining program success). 12.1 Costs of practitioner impairment Direct costs of practitioner impairment to healthcare systems include the costs of sick leave, personnel cover for everyday duties and legal and managerial costs associated with discipline, suspension, investigations, regulatory action etc. Absenteeism: Cost estimates and other publically available data about the costs of practitioner sick leave and absence typically do not differentiate between nonimpairment-related absence (e.g. for flu, cancer or accident recovery), from those directly associated with impairment (e.g. for addiction or psychiatric treatment). This renders it difficult to estimate the costs of impairment. One analysis, sponsored by the Nursing and Midwifery Health Program Victoria (NMHPV) and the Australian Nursing Federation (ANF), calculated the cost of lost productivity for an impaired nurse with time off work to be between $52,000 and $70,000 (Lorgelly 2011). This was part of a wider analysis which estimated that NMHPV saved the health sector $7.23 million in lost productivity and other costs (Lorgelly 2011). However, these figures have been questioned by departmental respondents from two other states (Siggins Miller 2012). In the UK, staff sickness absences are estimated to cost the National Health Service the equivalent of AUD$3.1 billion annually (Department of Health 2010). Mental illness-related absence of NHS staff is estimated to cost the equivalent of AUD $2.3 billion (Department of Health 2010). Stress-related disorders alone account for almost a third of National Health Service staff sick leave per year. However, the ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 43 ACIL ALLEN CONSULTING proportion of these costs which relate to conditions that meet the threshold for impairment-related is unknown. Presenteeism: ‘Presenteeism’ of impaired practitioners – coming to work and performing at less than full capacity because of ill health or impairment – is also costly. A Swedish survey found that people in the caring professions – including healthcare workers – were among those most likely to go to work while unwell (Aronsson, Gustafsson et al. 2000). Doctors were more than twice as likely to do so than other workers, while nurses and midwives were three to four times more likely (Aronsson, Gustafsson et al. 2000). Suspensions: The UK Department of Health review estimated that suspensions due to ill health (a somewhat better proxy for impairment than sick leave) cost Londonbased NHS institutions the equivalent of nearly AUD$10 million annually, above and beyond normal salary paid to replacement practitioners (NHS Practitioner Health Programme and NHS London Special Commissioning Group 2010). This was based on an estimate of 38 doctors out of 27,640 registrants, with estimated costs of AUD$262,000 each (composed of locum costs, management and legal costs, but not standard salary) (National Health Service Practitioner Health Programme 2012). Wider costs: At the societal level, the loss of practitioners to death, disability, loss of licence or the decision to leave the profession is a negative workforce impact (Department of Health 2010). This is especially true given the extensive resources invested into practitioner training (Department of Health 2010). Practitioners leaving their profession because of impairment comprise an unknown portion of early-retiring practitioners, who are estimated to cost UK society AUD$272 million annually in lost work potential and other costs (Boorman 2009). While Australian data is scarce, the NMHPV-sponsored analysis, which calculated that for the 60 per cent of impaired nurses who did not take time off, but worked under conditions, the cost to the healthcare system was estimated at $38,000 to $40,000 (Lorgelly 2011). However, these figures have been disputed (Siggins Miller 2012). Impaired practitioners also present costs to employers, including the costs of additional training or supervision, locum services during periods of sick leave, and recruitment and replacement costs if a practitioner is removed from practice. Where practitioners are unable to work at all as a result of their impairment, this can be costly to social welfare systems (NHS Practitioner Health Programme and NHS London Special Commissioning Group 2010). 12.2 Costs to the regulator At the regulator level, the introduction of health programs is associated with shifts in the role and workload of the regulator, and the balance of practitioners in disciplinary versus alternative-to-discipline pathways. For UK-PHP, the proportion of clients involved in parallel regulator processes during their engagement with the program dropped from 33 per cent to 7 per cent over the first five years of the program (NHS Practitioner Health Programme 2014). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 44 ACIL ALLEN CONSULTING Detailed breakdowns of the costs of disciplinary approaches were scarce. However, general outlines of the types of costs incurred under a disciplinary approach are listed below (Monroe, Pearson et al. 2008, Siggins Miller 2012): assessment of practitioner investigation Board sitting fees and meeting costs legal advice, legal representation, and court/tribunal costs, and salaries of staff overseeing monitoring, assessments, compliance etc. 12.3 Costs of health programs The national survey of US PHPs found an averaging operating budget for PHPs of AUD$572,000 (DuPont, McLellan et al. 2009). However, this varied substantially from AUD$522,600 to AUD$1.6 million, with a median of AUD$287,500 (DuPont, McLellan et al. 2009). These budgets include program running costs, but not treatment, rehabilitation or testing for monitoring purposes (DuPont, McLellan et al. 2009). A breakdown of contributors to these costs is available in Table 8. For example, the Australian Nursing and Midwifery Federation (ANMF) calculates that funding the Nursing and Midwifery Health Program Victoria (NMHPV) equates to a cost of $5.69 per Victorian registrant annually, all of whom can access the program at no cost if required (Siggins Miller 2012). However, it is important to note that this only covers the cost of case management and other assistance from the health program, and not clinical treatment or rehabilitation to which the program refers (Nursing and Midwifery Health Program Victoria 2014). These costs are the responsibility of the nurse or midwife. Medical Directors of both Hospital Trusts and Primary Care Trusts in the UK report that before the first pilot health program in the UK (UK-PHP), employers often met the costs for private, out-of-area treatment for practitioners with impairment-related health issues (National Health Service Practitioner Health Programme 2012). One Medical Director estimated that the redirection of this money towards the PHP had saved his Primary Care Trust over AUD$911,000 in costs from hiring locums to cover suspended clinicians, legal costs, hearings, appeals and suspensions (National Health Service Practitioner Health Programme 2012). Concerns about the relatively small number of practitioners benefiting from programs aimed at impaired practitioners is raised as a potential barrier to costeffectiveness (as well as research efficacy) (Humphrey 2010). However, figures suggest that treating even a small number of clients effectively is cost-effective. For example, in its pilot phase, UK-PHP was funded through a block contract worth $AUD1.82 million equivalent, to cover all doctors and dentists living in London (National Health Service Practitioner Health Programme 2012). When divided among all London-based Primary Care Trusts, this amounted to the equivalent of $AUD58,320 per Trust - similar to the cost of excluding just one doctor from work for seven weeks (AUD$52,860) (National Health Service Practitioner Health Programme 2012). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 45 ACIL ALLEN CONSULTING 12.4 Costs for clients In all programs examined in this review, a proportion of treatment, rehabilitation and monitoring costs were covered by the client themselves. A survey of clients of US-HPRP found that for the majority of participants, the costs of treatment, rehabilitation, aftercare and monitoring were high, with many health insurers offering little or no coverage. As a result, clients reported average out-of-pocket expenses of AUD$10,650 to AUD$32,000 for a three-year program for SUD (Michigan Health Professional Recovery Program 2013). However, these figures should be considered with caution in the Australian context, where universal healthcare and other differences in healthcare funding apply. Costs to clients can include the following: assessments and reports compliance with treatment conditions on license/registration (e.g. counselling) compliance with monitoring conditions on license/registration (e.g. urine testing) travel costs to comply with conditions income loss, and legal advice, representation and court/tribunal costs. Costs to clients varied based on factors including the type and duration of treatment and monitoring, the nature of the healthcare system, and the practitioner’s level of health insurance coverage (Michigan Health Professional Recovery Program 2013). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 46 ACIL ALLEN CONSULTING 13 Funding Both in Australia and internationally, programs and services are funded by a range of sources, including regulators, impaired practitioners themselves, insurers, employers, unions, and professional bodies. A summary of funding sources for the exemplar programs is outlined in Table 8. Most programs charge little or nothing to practitioners for the general running costs of the health program. However, in the majority of programs, the practitioner (or his or her health insurer) is responsible for the costs of treatment, rehabilitation and monitoring aspects. The one exception of the exemplar programs is the UK-PHP, where limited internal treatment services are funded by the NHS (but external services are the responsibility of the client). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 47 ACIL ALLEN CONSULTING Table 8 Funding sources and arrangements AUS-NMHP Program US-HPRP CAN-EIP UK-PHP × × × × ✓ (50% of PHPs) ✓ (via professional registration fees) × ✓ × ✓ (50% of total contributions) × × × × ✓ Hospitals (9% of total contributions) × ✓ Government – Michigan Department of Licensing and Regulatory Affairs × ✓ London Clinical Commissioning Groups (National Health Service bodies) ✓ Participant fees (16%) State medical association (10%) Malpractice companies (6%) Other (9%) ✓ (for assessment by external providers) ✓ ✓ ✓ (for out-of-area practitioners only) ✓ Practitioner ✓ (for initial internal assessment) × × × × Regulator Employer × × × × × ✓ Health insurer (79% not insured for assessments) ✓ British Columbia Nursing Union ✓ London Clinical Commissioning Groups (NHS statutory body) . ✓ ✓ ✓ ✓ Practitioner Regulator Employers General program operating costs Other Individual assessment Individual treatment, rehabilitation, monitoring US-PHP Other × Practitioner ✓ Regulator × × × × × Employer × × × × × × ✓ Health insurer (95% not insured for drug screens, 71% not insured for any treatment) ✓ British Columbia Nursing Union (travel expenses and year 1 monitoring) ✓ London Clinical Commissioning Groups (treatment internal services only) × Other ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 48 ACIL ALLEN CONSULTING 14 Role of other stakeholders 14.1 Employers The literature identified a variety of roles for employers in the management of impaired practitioners. Safe work conditions: Employers can help prevent and mitigate impairment in practitioners by providing safe working conditions, thus reducing work-related risk factors for substance misuse and mental health issues (Medew 2008, Dwyer, Morley et al. 2011). Examples include maintaining safe working hours, effective supervision, and bullying prevention (Dwyer, Morley et al. 2011). For example, these measures (among others) were adopted as part of wider context for the Royal Melbourne Hospital support program for ‘at-risk’ junior doctors, following the death of a surgical registrar by suicide (Dwyer, Morley et al. 2011). One report suggested that the UK NHS could save AUD$1.83 billion per year if it followed good practice and provided workplace health and wellbeing initiatives for staff (Department of Health 2010). However, there is little evidence on the impact of such initiatives on sickness absence or productivity (Department of Health 2010). Clear policies and protocols: Clear systems and protocols for dealing with suspected or actual physician impairment, known and applied consistently by all staff, are vital to ensuring patient safety (Leape and Fromson 2006). Such protocols can help address some of the barriers to help-seeking, referral and reporting identified in this review by removing uncertainty, creating clear expectations, and promoting a culture of patient safety (Dwyer, Morley et al. 2011). Leape and Fromson (2006) suggest that an effective system involves four key elements – adopting standards, requiring compliance, monitoring performance and responding to deficiencies. An exemplar for clear policies and protocols is the Auckland Hospital Substance Abuse Protocol (Auckland Hospital 2014). This protocol details the formation and operation of a substance use committee, mentoring, preventative education, self-care policies, investigation procedures, intervention guidelines and follow-up (Auckland Hospital 2014). Employee assistance programs: Employee Assistance Programs (EAPs) offer another support and treatment option for impaired nurses and midwives. EAPs are available to practitioners working in the public health system in all states and territories in Australia (Nursing and Midwifery Board of Australia 2012, ACT Health 2013), and to employees of certain health services in the USA and UK (Royal United Hospital Bath 2012, UC San Diego Health System 2014). However, coverage by EAPs is not universal for all nurses and midwives (including those in small-scale and/or private practices), additionally data on the use of EAPS by nurses and midwives in Australia was not available (Siggins Miller 2012). Some nurses and midwives are concerned about confidentiality because of the EAP links to their employer, as well as being treated by EAP counsellors who don’t share their profession and thus do not understand their needs and situation (Siggins ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 49 ACIL ALLEN CONSULTING Miller 2012). There are also concerns that mandatory reporting provisions apply to registered health practitioners (for example psychologists) working for the EAP (Siggins Miller 2012). Internal support and referral systems: Several educational guides for practitioners advise that referral or reporting to in-house support is the ideal first step in managing colleague impairment (Dunn 2005, Kay and Izenour 2008). Several major hospitals have internal systems for managing potentially impaired practitioners, which ideally mirror the best-practice principles of the health programs identified in this review (Dunn 2005, Kay and Izenour 2008, Dwyer, Morley et al. 2011). That is, they focus on encouraging early identification and help-seeking, referral to appropriate services, and a controlled, appropriate approach to returning to work (where appropriate). For example, the Royal Melbourne Hospital support program for ‘at-risk’ junior doctors has systems for identification, assessment, mentoring, referral, reporting, education and workplace management of distressed junior doctors (Dwyer, Morley et al. 2011). Referral and reporting to external health programs: In Australia, employers are subject to mandatory reporting laws, including cases of practitioner impairment (Australian Health Practitioner Regulation Agency 2014b). Employers were responsible for a substantial portion of referrals to the health programs identified in this review. Employer willingness to engage with health programs, and clear understandings about when and how to do so, may be key to early intervention and good outcomes. Re-entry of recovering or previously impaired practitioners: Employers play a central role in the return of recovering and previously impaired practitioners to work (Roy I and Kenison 1994, Hughes, Smith et al. 1998, Wilson and Compton 2009, Angres, Bettinardi-Angres et al. 2010). The return to work of impaired practitioners remains contentious, especially in the field of anaesthetics, which has a high rate of relapse and recidivism around substance misuse (Tetzlaff and Collins 2008, Earley and Berry 2009, Wilson and Compton 2009, Hamza and Monroe 2011). Returning or retaining recovering or impaired staff requires extra resources and careful management in the form of extra supervision, observing work restrictions, managing confidentiality and interpersonal relationships, monitoring and reporting on progress, and facilitating education and training (Roy I and Kenison 1994, Hughes, Smith et al. 1998, Wilson and Compton 2009, Angres, Bettinardi-Angres et al. 2010). An early example of work in this area in Australia was a program at Box Hill Hospital in Victoria, which returned five anaesthetists to work following drug addiction between 1993 and 2001. The outcome was mixed (Hagan 2012). Known as ‘the Box Hill anaesthetists re-entry group’, four were known to be sober and practising in 2008 (Hagan 2012). However, one had relapsed and his whereabouts was unknown to the hospital (Hagan 2012). In 2012 this relapsed anaesthetist, Dr James Peters, was convicted of infecting 55 women with hepatitis C at a Melbourne abortion clinic, after injecting himself with fentanyl from syringes he then used on patients (Petrie 2012). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 50 ACIL ALLEN CONSULTING 14.2 Medical indemnity insurers The literature identified some roles for medical indemnity insurers in the management of impaired practitioners. However, public information about this was limited. Some examples are included below. Education: Insurers have a potential role to play in educating members about the risks associated with practitioner impairment, and best practice methods of dealing with it. However, extensive searches of three major medical indemnity insurer websites from Australia – Medical Indemnity Protection Society (MIPS), Medical Defence Australia (MDA) and Avant - found no specific mention of these issues. Identification and referral: Medical indemnity insurers were listed as a referral source for health programs identified in this review (Fletcher 2001, DuPont, McLellan et al. 2009, College of Registered Nurses of British Columbia 2012, Braquehais, Valero et al. 2014). Positive relationships between insurers and health programs could foster referral and early intervention before patients are harmed. In the US, medical indemnity insurers have the ability to mandate participation in health programs (McLellan, Skipper et al. 2008). Importantly, in Australia practitioners working for an indemnity insurer are exempt from mandatory reporting of an impaired practitioner, if they form a belief that the practitioner is impaired in the course of that work (Australian Health Practitioner Regulation Agency 2014c). Service provision: In New Zealand, a free, confidential counselling service for health professionals is co-funded by the Medical Protection Society and the Medical Assurance Society. Limited to members of these insurance groups, the service is aimed at reducing stress- and mental illness-related impairment in practitioners, with the aim of preventing resulting patient harm. The service includes referral to face-to-face treatment by other practitioners. Participants reported that the service was valuable overall. 14.3 Professional Colleges and Associations The literature identified some roles for professional colleges and associations in the management of impaired practitioners. Some examples are included below. Education: Professional Colleges have a role to play in educating practitioners about impairment and the management of impairment in self and others. This can include activities from college publications such as newsletters (Royal Australian College of General Practitioners 2013), to core curriculum,(Australian and New Zealand College of Anaesthetists 2006) continuing professional development programs (Australian and New Zealand College of Anaesthetists 2014), published resources for practitioners (Australian and New Zealand College of Anaesthetists 2014), and presentations at conferences, forums etc (Australian and New Zealand College of Anaesthetists 2014). For example, the Australian and New Zealand College of Anaesthetists has a Special Interest Group for the Welfare of Anaesthetists (Australian and New Zealand College of Anaesthetists 2014). The group partakes in all of the activities mentioned above, as well as advocacy (Australian and New Zealand College of Anaesthetists 2014). They have produced a large number of publically available resource documents on issues impacting the ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 51 ACIL ALLEN CONSULTING welfare of anaesthetists including impairment-related issues (Australian and New Zealand College of Anaesthetists 2014). Help-seeking portals: The ‘Health for Health Professionals’ website (Health for Health Professionals 2010) is a web-based portal which links UK practitioners to information and services to assist them with health issues including mental health and substance misuse concerns. It is a joint project of Cardiff University, the Royal College of Psychiatrists, the Royal College of General Practitioners and the Faculty of Occupational Medicine (Health for Health Professionals 2010). The website makes several references to various colleges having ’well developed support services’ (Health for Health Professionals 2010). However, no further information could be found in the literature about these services. Advocacy: Colleges and professional associations (such as the Australian Nursing and Midwifery Federation) also play a role in advocating for improved management of impaired practitioners, so that it is effective and ethical, and protects the welfare of members of their profession. For example, the Royal Australian College of General Practitioners provided a submission to the Medical Board of Australia regarding the funding of external doctors’ health programs (Royal Australian College of General Practitioners 2012). The work of the Victorian Doctors Health Program was also mentioned by the Royal Australian and New Zealand College of Psychiatrists in their submission to a Victorian parliamentary inquiry into AHPRA (Royal Australian and New Zealand College of Psychiatrists 2013). Assessments: An international survey found that some Canadian professional colleges administer assessment programs for practitioners with suspected performance problems (Humphrey 2010). Examples include the Specialties Assessment Program (College of Physicians and Surgeons of Ontario) and the Professional Practice Enhancement (College des Medecins du Quebec) (Humphrey 2010). These assessments are intended to identify performance concerns in practitioners, as well as provide remediation (Humphrey 2010). While geared towards problems of competence, these programs also have regular contact with impaired practitioners (Humphrey 2010). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 52 ACIL ALLEN CONSULTING 14.4 Education Providers The literature identified the roles of education providers, particularly universities, in the management of impaired practitioners. Some examples are included below. Education: Inclusion of information about practitioner impairment – including definition, prevention, causes, consequences recognition and responses – is included in the curricula of many health practitioner training courses (Moss and Smith 2009). For example, a study of the associate deans of 71 medical schools across Canada and the US found that practitioner impairment (95.8 per cent) and wellness (77.5 per cent) were addressed to some extent in their curricula (Moss and Smith 2009). It has been suggested that teaching wellness strategies to health practitioner students will help prevent or lessen distress or impairment, including into the future (Estabrook 2008). There is no research to date on the effectiveness of wellness programs in preventing future impairment, but students who partake in these programs report experiencing benefits (Rosenzweig, Reibel et al. 2003, Estabrook 2008). Support services: University-wide (and sometimes faculty-specific) support services are available at universities that educate and train health practitioner students. Some of these are particularly relevant to the management of impairment – such as counselling services, chaplaincy, student welfare coordinators, health services and mentoring programs (Melbourne Medical School 2013, The University of Sydney - Sydney Medical School 2013). However, a recent beyondblue survey found that medical students were hesitant to use universityprovided services to seek help for mental health or substance misuse issues, possibly due to fear of being ‘found out’ and reported to senior staff or AHPRA (beyondblue 2013). Referral and reporting: In Australia, education providers are subject to mandatory reporting laws, including in cases where the suspected impaired person is a health profession students (Australian Health Practitioner Regulation Agency, 2014b). Education providers are also able to formally or informally refer students to an appropriate health program. Assessments: An international survey found that a number of universities administer assessment programs for practitioners with suspected performance problems (Humphrey 2010). Examples include the Remediation and Enhancement Program (University of Saskatchewan, Canada), Physician Assessment and Clinical Education (California, US) and Individual Support Program (Cardiff, UK) (Humphrey 2010). These assessments are intended to identify performance concerns, but also have regular contact with impaired practitioners (Humphrey 2010). ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 53 ACIL ALLEN CONSULTING 15 Conclusions This literature review aimed to provide broad evidence and insights regarding Australian and international models for the referral, assessment, treatment and rehabilitation of health practitioners with impairment, and the corresponding roles of health profession regulators in these approaches. Evidence of problem There is an abundance of evidence that health practitioners experience health conditions that may lead to impairment of their professional performance. Risks of practitioner impairment discussed in the literature include risks to the practitioner, their patients and their professions. While anecdotal reports and legal cases abound, formal research directly correlating practitioner impairment to patient harm is scarce. Further evidence of such harm and how it comes about are required to better guide approaches to managing practitioner impairment. Types of programs and services This review identified four broad categories of services and programs for supporting and managing impaired practitioners. These are phone support lines, support services, case management and regulator management approaches. Regulator interaction with programs and services Regulators interact with these services and programs for supporting and managing impaired practitioners in five main ways: public promotion and endorsement, cross-referral, funding, formal agreement and program provision. Different Australian and international models utilise various combinations of these. Alignment with best practice principles Of the program and service types identified, an analysis of the literature showed that the case management approach aligns most closely with principles of best practice. It also has the greatest volume and quality of evidence for its efficacy. Regulator management has the next greatest alignment with best practice principles, but scarce evidence of its efficacy. As a result, this review focused in detail on four models of case management, and one of regulator management. Tensions From both an operational and regulatory perspective, tensions arise between best practice principles, and the goals and methods of these programs and services. These include potential clashes between the pursuit of public protection, and goals such as encouraging help-seeking, workforce retention and anti-discrimination concerns. Ethical matters regarding coercion as a method of encouraging program compliance are also an issue. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 54 ACIL ALLEN CONSULTING International trends – program type International best practice trends are moving away from punitive and disciplinary approaches in the first instance, to models which encourage engagement with alternative-to-discipline health programs as a first option for impaired practitioners. The most highly regarded international programs adopt a case management approach, via practitioner health programs which run at arms-length from the regulator. Several well-regarded programs provide services across a range of health professions, rather than limiting themselves to one health profession. In most models, the health program plays only a minimal role in clinical treatment and rehabilitation. Instead they utilise treatment contracts or plans (with varying levels of coercion attached) to manage referral to external clinical services, and coordinate assessment, monitoring, ‘voluntary’ work restrictions, return-to-work provisions and other case management matters. International trends - assessment With respect to assessment, most case management models utilise external clinical experts to assess the health status and impairment of practitioners. Assessments to determine the existence of health issues and performance issues are fairly well established separately. However, techniques and standards for connecting a health issue with a performance problem – thus establishing impairment – are more contentious. More literature is needed to improve clarity in this area. International trends – information-sharing and regulator contact Worldwide, health programs have varying arrangements regarding informationsharing between the regulator and the program. A major element that distinguishes different models is whether a formal agreement is in place regarding informationsharing, reporting and referral. Furthermore, major differences are seen in the nature of such agreements, including provisions regarding mandatory reporting, sharing of client information with the regulator, coercion and ‘shielding’ of practitioners. The literature shows that it is common for health programs to have limited contact with a regulator as long as a practitioner is compliant with treatment contracts and/or program recommendations. In some models, this is formalised through a ‘shielding’ provision. In other cases, it occurred informally, through people choosing not to report practitioners to the regulator if they are compliant with health programs. Costs, benefits and outcomes Data on the outcomes of different program and services models is difficult to compare, as it is not reported against standard measures. It is also not widely reported. Outcomes of relevance include practitioner recovery, licence and registration outcomes, program completion, and work status in health profession following completion. What is known is that practitioner health programs produce ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 55 ACIL ALLEN CONSULTING far higher recovery rates for substance misuse than do mainstream treatments available to the general population. Data on the cost-effectiveness of health programs are also scarce and difficult to compare. Detailed reviews on the costs and benefits of these programs, based on well-evidenced estimates where hard data are not available, are needed. However, types of costs associated with practitioner health impairment include those associated with absenteeism, presenteeism, suspensions, legal and disciplinary costs, as well as early retirement and/or loss of health workforce members. Some costs associated with the disciplinary approach to impairment remain similar when health programs are used as a first port of call instead, while others are shifted or reduced. Clients of health programs often face very high personal costs associated with their participation. ATTACHMENT A: HEALTH IMPAIRMENT PROGRAMS REVIEW OF THE LITERATURE ON REFERRAL, ASSESSMENT, TREATMENT AND REHABILITATION SERVICE FOR REGULATED HEALTH PROFESSIONALS 56 ACIL ALLEN CONSULTING Appendix 1 Methodology This literature review, guided by the research questions and pre-determined framework, was undertaken using an exploratory, iterative approach. As such, the review utilised a wide but not exhaustive selection of resources to provide an overview of: the regulatory roles of Australian and international health profession regulators regarding the referral, assessment, treatment and rehabilitation of health practitioners with impairment, and the assessment, treatment and rehabilitation models that support and manage regulated health practitioners with impairment. Our approach was directed towards achieving four main consecutive goals which guided selection of the most useful material from the large volume available. These consecutive goals were to: identify important issues and varying features of approaches to managing impaired practitioners, and impaired practitioner regulation identify an array of exemplar programs that represent an informative breadth of approaches to the issues and features identified above identify (where possible) comparable information about these features and issues for the exemplar programs, and actively seek out information to fill any gaps from initial searches, and to identify supplementary literature that may help in interrogating and analysing the regulatory and program differences identified, for the purposes of determining their relative strengths and weaknesses. Preliminary search The preliminary search was conducted using four online databases: Medline/PUBMed, Scopus (Elsevier), Google Scholar and Web of Science. This search, and all future searches, were limited to publications from the year 2000 and beyond, to ensure contemporary relevance. Searches were also limited to English language papers. The search terms in Table A were used in varying combinations (and derivatives – for example regulator/regulate/regulation). Some search terms were added to the initial planned list, based on useful terminology found in the first few papers found. For example, ‘physician’ was added to better capture papers written by American authors. The initial searches yielded 1,763 papers. Citations for all of these papers were all downloaded into Endnote for further analysis. Review of the literature on referral, assessment, treatment and rehabilitation service for regulated health professionals 57 ACIL ALLEN CONSULTING Table 9 Search terms Regulation/ Profession Impairment policies Higher hit rate: Regulator Registration Licensing Board Referral Reporting Mandatory reporting Fitness-to-practice Lower hit rate: Medical Board Nursing Board Authority Treatment/support/ Evaluations rehabilitation Higher hit rate: Nurses Midwives Doctors Physicians Dentists Anaesthetists Pharmacists Lower hit rate: Medical Practitioners Psychologists Physiotherapists Chiropractors Occupational therapists Podiatrists Optometrists Higher hit rate: Impairment Addiction Substance abuse Substance misuses Substance abuse disorders Mental health Mental illness Depression Anxiety Suicide Alcohol Drugs Aging Cognition Disability Higher hit rate: Health program Treatment Rehabilitation Counselling Therapy Management Recovery Peer support Support group Assessment Higher hit rate: Funding Evaluation Benefits Outcomes Success Lower hit rate: Cost-benefit Cost-effective Costs Lower hit rate: Phone line Support line Lower hit rate: Degenerative Vision impairment Hearing impairment Dependence Filtering – titles First, the complete Endnote list was scanned to remove duplicates. Second, the title of all articles was scanned to determine which papers were likely relevant to the research questions. Following these steps, 382 papers broadly met the inclusion criteria. The citations for these papers were then sorted into Endnote ‘groups’ (folders) which reflected the research questions they were likely to address, using their titles as a guide. The titles within each group were then re-scanned to determine which papers would be most helpful to answering the research questions. Examining the papers in this grouped manner allowed their relative suitability and usefulness to be compared against other papers on similar topics. Using the titles as guides, papers were weighted based on the following criteria: relevance to research question recentness (i.e. weight given for recentness) study/paper type (e.g. weight given to large studies, systematic reviews) relevance to countries of most interest (i.e. weight given to Australia, New Zealand, UK, US and Canada), and relevance to professions of most interest (i.e. weight given to nurses, midwives). For example, in some cases, evaluations of certain programs were published every few years. In such cases, papers for the most recent two evaluations were kept, while all others were discarded. In another example, some papers focused on professions that were not regulated health professions in the relevant country (such as counsellors, paramedics or massage therapists). These papers were also excluded. Based on the above factors, the least relevant papers in each group were set aside. Where titles did not provide sufficient information to make a judgement, the paper was progressed to the next stage. At the end of Review of the literature on referral, assessment, treatment and rehabilitation service for regulated health professionals 58 ACIL ALLEN CONSULTING this stage, 161 papers remained, which we anticipated would be most valuable in addressing the research questions. Filtering – abstracts Where they were not already available in the EndNote entries, abstracts were then obtained for the remaining papers. The abstracts were then reviewed for alignment with the selection criteria, and relevance to the research questions. Papers were sorted in tables by country, profession and research question/topic. This helped to determine the balance of papers that had been obtained, and identify any gluts or gaps which needed to be addressed. Papers were excluded if: they were case studies based on single individuals they detailed regulatory frameworks, health programs or systems which have been superseded by newer version for more than five years they were solely about non-work-related risk factors for substance abuse or mental illness in practitioners (such as genetic factors and childhood trauma) or they fell into a ‘glut’ section of the tables, and largely duplicated data presented by other papers in the list. Examination of the abstracts revealed that there was significant overlap between papers, as well as substantial variation in their likely usefulness and rigour. As such, due to the sheer volume of literature on the topic, and the limited timeframe, not all papers included at this stage could proceed to the final literature list. Inclusion of papers was subsequently determined on a priority-based system. Papers were afforded priority ‘points’ for each of the following criteria that applied: relevant to the professions of most interest published in or after 2009 (previous five years) large studies (for example, large number of participants or programs covered) systematic studies or reviews relevant to countries of interest novel ideas or approaches presented comprehensive evaluations of whole programs filled a gap (i.e. sole paper, or one of only a small number of papers, covering a relevant topic/country combination) quantitative data provided (especially about costs and outcomes) pointed relevance to a specific research question. Only papers which obtained a ‘score’ of four or higher on this priority scale were retained. Following the application of these filtering processes, 103 papers remained. Filtering – full text The remaining 103 articles were obtained in full text version and manually reviewed before a final decision was made on their inclusion. All were determined to meet the criteria for inclusion. Additions – sourced from scholarly literature Throughout reading of the remaining articles, relevant references were followed up. From this process, 34 more scholarly articles, and 50 other references (for example websites, government reports and consultant reports) being identified as relevant to the review. Review of the literature on referral, assessment, treatment and rehabilitation service for regulated health professionals 59 ACIL ALLEN CONSULTING Additions – sourced from grey literature searches Based on information in the academic papers, exemplar models were chosen that best represented the diversity of features and issues of regulatory interest in the management of impaired practitioners. Once these exemplar models were chosen, and outlines of the tables published in this review were decided upon, we identified gaps in information not able to be located in the scholarly literature. This information was then specifically sought from grey literature sources, identified by the use of pointed Google searches. This was also done where particular information was necessary to provide context for information identified in the scholarly literature. Examples of grey literature that was included in the review in this manner include health program websites, government data, inquiry hearings, consultant reports, organisational position statements and newspaper articles. References identified by this process made up the remaining 28 references included in the bibliography. Review of the literature on referral, assessment, treatment and rehabilitation service for regulated health professionals 60 ACIL ALLEN CONSULTING References ACT Health. (2013). "Policy - employee assistance program." from http://health.act.gov.au/c/health?a=dlpubpoldoc&document=2832. 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