Dr Gerard Panting explains how GPs can minimise the risk of violence against staff, and discusses the legal remedies available when faced with a violent patient

Violence is defined in the website of the national NHS zero tolerance zone campaign (www.nhs.uk/zerotolerance) as:

'Any incident where staff are abused, threatened or assaulted in circumstances related to !heir work, involving an explicit or implicit challenge to their safety, well-being or health.'

The website contains a range of useful materials. The aims of the campaign are:

  • To make it absolutely clear to the public that violence against staff working in, and for, the NHS is unacceptable, and that the Government and the NHS have made a commitment to stamp it out
  • To reassure all staff that violence and intimidation are unacceptable and are being tackled.

Under their existing Terms of Service, GPs can remove a patient from their list with immediate effect where a person has committed an act of violence against the doctor or behaved in such a way that the doctor has feared for his safety and has reported the incident to the police. No matter how gratifying it may be to see an assailant charged and convicted, it is much better to minimise the chances of violence in the first place.

Health Service Circular (HSC) 2000/001, Tackling Violence towards GPs and their Staff, states that the number of recorded incidents of violence that have resulted in GPs seeking to have patients removed from their list was 1081 in England for the year 1996-97. However, it also points out that this is considered to be an underestimate of the true scale of the problem. In addition, the 1996 British Crime Survey identified health professionals as being at greater risk from work-related violence than the general population.

HSC 2001/001 also states that health authorities are required to develop an action plan for combating violence, and to make resources available to encourage GPs to participate in local initiatives.1

To this end, the zero tolerance zone campaign website sets out advice on preventing violence. The DoH commissioned research into preventing violence in general practice. The research team developed a number of preventive strategies, aimed, in the first instance, at receptionists, as the research showed that it is they who take the brunt of verbal abuse and aggression. Its recommendations are set out in Figure 1 (below).

Figure 1: Strategies for preventing violence against staff

Recommended communication strategies towards patients include:

  • Trying to be positive, always offering the patient something rather than outright refusal
  • Referring the aggressive or aggrieved patient to a more senior member of staff, e.g. practice manager or doctor, rather than entering into arguments
  • Not exceeding one's responsibility by appearing to make inappropriate judgments about patients' needs
  • Respecting the dignity of all patients and 'befriending' the vulnerable ones.

Recommended organisation features include:

  • More than one receptionist on at all times. This allows for someone to 'take over' if an interaction appears to be getting out of hand, or for a senior member of staff to be discreetly summoned without leaving the desk unmanned
  • Established routines for unlocking and locking up premises at the beginning or end of the day (and not having to do these on one's own)
  • Being able to communicate quickly but discreetly with doctors during surgery to alert the doctor about an aggressive patient, e.g. via a dedicated phone or message posted on computer
  • Electronic signboards or monitors through which patients can easily be informed about doctors running late etc.

HSC 2000/001 also contains recommendations about the physical layout of premises and security features. The recommendations in this section are set out in Figure 2 (below).

Figure 2: Security features/physical layout
  • Panic buttons in consulting rooms, communicating with reception desks and administrative areas (and vice versa) were generally commended – with reception desk connection to police stations favoured in high-risk settings.
  • Considerations for this recommendation include:
  • Siting of panic buttons, e.g. out of reach of children while still easily accessible to staff
  • Regular testing of panic buttons, and of the planned response to them, is vital
  • Liaison with local police and protocols for circumstances in which police should be called
  • Loud noises and staff rushing about can exacerbate tense situations. Therefore, some practices prefer to use 'speaker' phones or 'codes' to alert colleagues to difficulties

Taking measures to prevent violence to staff is not just a matter of good practice – it is a legal obligation upon employers (including GPs). This is both a common law duty and a statutory duty under the Health and Safety at Work Act 1974. In short, the Regal duty is to ensure, insofar as it is reasonably possible, the health, safety and welfare at work of employed staff.

To comply with those responsibilities, employers are required to carry out risk assessments, to monitor and record violent incidents and to take appropriate action to prevent risk to staff.

The website lists factors that should be taken into account when assessing risk, and points out that risk assessment should be carried out by appropriately trained staff and information should be gathered from a number of sources. The factors identified are:

  • Being unable to get support
  • Being unable to trace staff
  • Staff under pressure
  • Noisy, cramped rooms
  • Working alone or being in the car alone
  • Potential weapons to hand
  • No staff available.

The risk control measures identified within the website include:

  • Staff training in talking to aggressive patients, including intoxicated patients
  • Ensuring that other staff are aware of what is happening
  • Avoiding being alone if possible, being able to get support if needed and removal of potential weapons
  • Approved training in recognition, defusing skills, disengagement and immobilisation
  • Summoning police if it becomes necessary.

When faced with a patient who is aggressive or violent, there are two legal remedies available to GPs and their staff:

  • Criminal prosecution
  • Civil action against the patient under the Protection from Harassment Act 1997.

Violent incidents reported to the police will be investigated, and where there is sufficient evidence against individuals they will be charged unless the police decide to issue a warning or formally caution the perpetrator instead.

Cautions can only be issued where the offence is admitted and the person responsible agrees to be cautioned. Although this may seem like a soft option, cautions are recorded and may influence sentencing in any subsequent conviction.

If someone is charged with an offence it is up to the Crown Prosecution Service (CPS) to decide whether there is sufficient evidence to bring the case to trial. The test applied is whether there is a realistic prospect of conviction and whether the prosecution is in the public interest – which is almost certainly the case where the victim is working in the healthcare sector.

The criminal courts can, in addition to sentencing an individual, award limited compensation for personal injury provided that the defendant has the means to pay.

Injunctions forbidding an individual from entering specific premises or contacting particular persons may be granted under the common law or under the Protection from Harassment Act 1997.

Under the Act, a person can apply to the courts for an injunction on the grounds that he or she has been in fear of violence from a specific individual on at least two occasions. Should that individual then break the terms of the injunction, he or she would be guilty of a criminal offence and may be imprisoned, fined, or both.

As applications under the Protection of Harassment Act 1997 are civil actions decided on the balance of probabilities, an application for an injunction can be made, even where the CPS has declined to prosecute.

Each year, the Medical Protection Society takes out a number of injunctions on behalf of members who have been subjected to harassment. In one case, a GP had been receiving poison-pen letters from an ex-patient.

The letters (which the ex-patient had been pinning to the surgery door) were extremely offensive – they attacked the doctor's physical appearance, his morals and his clinical competence. Some were obscene and others contained racist overtones. The author had only been a patient of his for a matter of months some years earlier; the GP had no recollection of her or of the one consultation she had attended.

The doctor asked for the MPS's help and we immediately applied for an injunction, which was granted 3 days later. Unfortunately, the GP's persecutor was not deterred by the injunction and only increased her activities.

Our solicitor had several discussions with a local CID officer, who told him that he was taking the matter very seriously. The patient was arrested and charged with criminal damage, sending malicious communications and behaving in a racially aggravated manner.

She pleaded guilty, was placed on 12 months' probation with the proviso that she comply with treatment, and a restriction order was issued prohibiting her from 'directly or indirectly contacting, molesting, pestering, harassing or otherwise interfering' with the GP. She was also ordered to stay away from his surgery or any other premises in which he may work.

  1. DoH. Tackling Violence towards GPs and their Staff. Health Service Circular 2000/001

Guidelines in Practice, December 2001, Volume 4(12)
© 2001 MGP Ltd
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