Pegasus Health Pastoral Care Programme

KEYWORDS: Pastoral care; primary health care; general practitioner

The Institute of Medicine in the United States of America has highlighted the link between patient safety, well-being of the doctor and organisational culture.¹ Doctors may be considered impaired when they are unable to practice medicine with reasonable skill and safety to their patients due to a mental or physical disability.²

In New Zealand, 41% of general practitioners (GPs) intend to retire by 2025.³ Increasing workforce shortages and other stressors are putting doctors at risk of stress and burnout, which in turn can put patients at risk of harm.¹

There is an emerging body of evidence suggesting that health professionals may experience a range of difficulties in their practice. Estimates vary on how many doctors are working while impaired mentally or physically. One to two percent may be unsafe, while 5–12 percent may not be practising at an acceptable level.^4–7 Minor degrees of burnout can affect approximately one-third of all doctors at some stage of their career.⁸ Rates of burnout are difficult to estimate due to under reporting.⁹

When a doctor is considered unsafe to work, it is generally a result of either physical^10–12 or mental health illness (including burnout and stress,^13–19 anxiety, depression and suicidal tendencies,^2,5,8,16,18 substance abuse and dependency,^14,20 or cognitive impairment).^21,22 An Australian review of complaints found that doctors with cognitive impairment started receiving complaints made against them and had inappropriately been prescribing drugs of abuse for ~10 years before the diagnosis of cognitive impairment is being made.²³ International evidence suggests the predictors of risk of stress and burnout include:

• Patient complaints and incidences^21,24

• Inappropriate prescribing^14,23,25

• Not being locally trained^26,27

• Not involved in continuing medical education²⁷

• Not from an English-speaking background²⁷

• Practising in a rural area^21,27

• In solo practice²⁷

• Being single²⁷

• Longer time after graduation^6,27

Where intervention, treatment and monitoring are initiated early, outcomes for the doctor are typically positive.^{13,19,27–32}

Pegasus Health is a primary care network in Canterbury, New Zealand that started 25 years ago. Pegasus Health strives for its health practioners to practice medicine with reasonable skill and safety. Support, education and organisation improvements are available to all members.

General practitioners can be supported by Pegasus Health through times of increased stress, burnout or personal problems. The Pegasus Health Pastoral Care Programme has been in existence since 2009. Pegasus Health aims to detect problems at an early stage and support doctors on an individualised basis.

The Senior Clinical Leader at Pegasus Health receives referrals, complaints or incidence reports through various means, as shown in Figure 1. The Senior Clinical Leader determines if the referral, complaint or incident deviates from best practice. Once the need for support has been identified, care needs to be individualised according to level of impairment, career stage, insight and motivation. GPs identified as needing assistance are offered individualised support and mentoring by one of five doctors in a pastoral care role. Support may involve a visit with a review of file notes. A formal practice review may be done in-house by a peer.

Figure 1. Flow diagram of Pegasus Health Pastoral Care Programme

The pastoral care person reports back to the Senior Clinical Leader (at a high level to maintain confidentiality) and a decision is made as to whether the matter has been resolved or whether further support is needed. The current capacity for this support is ~12 new cases per annum, but will vary depending on the level of input required per doctor. The programme can offer pastoral support to GPs who are dealing with a range of issues including depression, bereavement, anxiety or organisational issues.

Where appropriate, a case may be referred to the Pegasus Health membership committee. Appropriate cases may include cases with a patient safety issue, a person not responding to individual support and mentoring or posing a risk to Pegasus Health. Issues of competency or misconduct require a referral to the Medical Council. What constitutes a competency issue is first determined on a case-by-case basis by the Membership Committee.

The purpose of the Membership Committee is to assist the Chief Executive Officer (CEO) in the management of membership support and processes for the companies, Pegasus Health Membership and Pegasus Health (Charitable), and to advise the CEO on membership matters. Members of the Membership Committee include the Senior Clinical Leader and five GP members appointed by the Senior Clinical Leader for a minimum term of 2 years. The CEO and other senior executives are in attendance. Meetings are held up to bi-monthly.

The responsibilities of the Membership Committee include: managing entry and exit processes for Pegasus Health members, advising the CEO on all areas of membership risk, making recommendations on membership issues, and providing a governance support role in member care processes.

Pegasus Health sought to extend the pastoral care programme in a systematic way to help doctors before patient safety is affected. Until recently, the pastoral care programme has not included statistical analysis. Data collection provides a snapshot of the ‘‘psychological health’’ of doctors, including baseline risk factors, attendance at education sessions, complaints, prescribing, investigating and referral data. This latest development is hoped to provide much needed additional information to improve the quality of interventions and support.

After full review of the evidence, available internal reports and databases, and consideration of the practical implications with key stakeholders, Pegasus Health elected to monitor major risk factors for stress and burnout, including patient complaints and incidents, and prescribing data. All patient complaints and incidences are reviewed. Critical incident debriefing is also undertaken at the Afterhours Surgery and is handled sensitively.

The knowledge management team in Pegasus Health were able to retrospectively review opiate and benzodiazepine data for all GP members over the preceding 10 years. A total of 20 drugs were included in the analysis from 2007 until 2016. Reporting is based on Ministry of Health Community Pharmacy Dispensing Data. Data are provided by unique head count and average milligrams per patient. These data are then drilled down by Medical Council number for Pegasus Health GPs to give an overview of individual GP prescribing over time and by each individual drug. GPs are ranked in relation to their peers by volumes dispensed. A detailed report is generated for the Senior Clinical Leader who discusses this with the GP concerned. Encrypted patient information can also be provided to the GP as there may be cases of one or two individual patients skewing data. A comparison can be made between real pastoral care cases and GPs considered to be prescribing appropriately.

Aside from these two major risk factors for stress and burnout, our internal databases can also be used to assess doctors for the other known risk factors identified in literature. Currently, there is not enough data available to develop models utilising weighted risk factors, or for model development using data analysis techniques. For example, not being locally trained was an issue because ~40% of our GPs were overseas trained, many from English-speaking backgrounds. Instead of including this as a risk factor, it was decided to take a broader approach to all GPs new to Canterbury whereby everyone receives induction information highlighting the differences in our local health system. New Pegasus members also receive a visit from a GP from the membership committee before being accepted.

Another group that appears to need more support includes GPs who are isolated either through being rural, solo practitioners or not involved in continuing medical education. All Pegasus members are monitored for attendance at small group education. Non-attenders are regularly encouraged to attend.

Risk factors outside of medicine may contribute to a doctor’s functioning, such as changes in marital status and life stressors. We did not have access to this information so we were not able to include these. Males and females appear to have a different set of risks, so we decided to exclude gender. Age alone was also not a strong enough risk factor due to the variability in functioning as people age. Existing research suggests that changes in prescribing data carry more validity than increasing age alone.

Over time, the data will be monitored for its validity, and individuals considered at risk will be assessed alongside randomly selected GPs for comparison. In the future, the tool will be used to regularly monitor at-risk doctors in a systematic way. Those doctors will then receive an assessment and individualised management plan. The results will be evaluated and will further inform any developments in the area.

Over the past 9 years, 32 doctors have been provided individualised support from Pegasus Health. There are currently 324 GP members. The level of need for pastoral care is consistent with national and international research. Where intervention, treatment and monitoring are initiated early, outcomes for the doctor are typically positive. Most GPs have been able to modify their practice and continue to work safely while under a mentoring programme. Where there have been concerns about cognitive impairment, a dignified retirement has been facilitated. The Medical Council has been notified of cases of involving health, competency or conduct issues.

The database has been reviewed using real cases. While the number of GPs involved in pastoral care to date is low, the data appear to be a useful tool for detecting doctors at risk. When considering prescribing data alone, the detection of at-risk doctors was strong in all but one case, which was unrelated to prescribing issues.

The numbers in the pastoral care programme are low and not necessarily representative of other areas in New Zealand. Care has been individualised on a case by case basis. Further details cannot be evaluated as this would breach confidentiality. It is not possible to analyse trends and make recommendations for other locations or parts of the health system.

Pastoral care is an important aspect of a mature primary care network. Pegasus Health is now in its 25^th year and has a well-developed pastoral care programme. There are several key features underpinning the success of the programme to date, as outlined below.

First, review of the evidence showed the topic to be both important and relevant, and helped to formulate a list of risk factors. This list was well researched, drawn from international and national literature and made more compelling with local data and expertise. Second, Pegasus Health has a long culture of peer support through regular peer-led education sessions and the use of free counselling and one-on-one individualised support. Finally, some cases have been successfully and delicately managed by the Senior Clinical Leader within Pegasus Health where outcomes have been positive and patient safety has been maintained. Reports from users of the pastoral care programme have been largely positive.

Pegasus Health sought to extend the Pastoral Care Programme in a systematic way to help doctors before patient safety is affected. By bringing together the evidence and various information systems available within Pegasus Health, a database has been developed. It is hoped that this tool will make a valuable contribution to the monitoring and support of at-risk doctors.

The organisation is considering expanding the programme to include other health professionals such as nurse practitioners, practice nurses and community pharmacists in a systematic way.

There are no potential, perceived, or real competing interests.