The NHS operate a zero tolerance policy with regard to violence and abuse and the practice has the right to remove violent patients from the list with immediate effect in order to safeguard practice staff, patients and other persons. Violence in this context includes actual or threatened physical violence or verbal abuse which leads to fear for a person’s safety. This also includes behaviours that are transphobic, biphobic and homophobic. In this situation we will notify the patient in writing of their removal from the list and record in the patient’s medical records the fact of the removal and the circumstances leading to it.

Introduction

NHS staff should be able to come to work without fear of violence, abuse or harassment from patients or their relatives.

In most cases, patients and their relatives will be appreciative towards those who treat them but a minority of people are abusive or violent towards staff. The NHS is committed to dealing with this problem.

The NHS has had a ‘zero tolerance’ attitude towards violence since 1999 and there has been a significant increase in the numbers of offenders being prosecuted since 2003, when the Counter Fraud and Security Management Service (CFSMS) was set up. The NHS CFSMS split its responsibilities early in 2009 and the NHS Security Management Service (NHS SMS) now deals with the security of people and property across the NHS in England.

It is clear that some staff groups are more at risk than others. This may depend on the part of the NHS in which they work and whether they are frontline staff or not. For information on lone working see the chapter on lone working.

The 2008 staff survey carried out for the Healthcare Commission showed that 12 per cent of staff across all trusts reported being physically assaulted by patients over the previous 12 months. This figure has remained relatively unchanged over the past four years.

Among frontline staff, 28 per cent said they experienced this abuse from patients or their relatives, a fall from 32 per cent in 2007. Staff who said they had received training in the prevention or handling of violence and aggression made up 53 per cent, an increase from 49 per cent in 2007.

The staff survey reports an overall 5 per cent increase in the reporting of violence and abuse and a 3 per cent increase of staff who feel that their trust would take effective action if staff were physically attached by patients, relatives or other members of the public.

These figures suggest that, despite the progress of the past few years, violence and abuse remains an issue for NHS trusts and their staff.

The legal position

NHS organisations can’t ignore or dismiss the chances of violence towards their staff and expect to get the support of the courts. Employers have a duty ‘so far as it is reasonably practical’ to protect the health, safety and welfare of staff members under the 1974 Health and Safety at Work etc Act.

In practical terms, that includes assessing the risk of violence and taking steps to reduce it as required under the Management of Health and Safety at Work Regulations 1999.

Employers also need to establish procedures to be followed in the event of serious or imminent danger, and provide information and training on health and safety risks and control measures.

There have been several prosecutions of NHS organisations for failing to adequately follow these procedures. In one of the most significant, St George’s Mental Health NHS trust in South London was fined £28,000 with £14,000 costs after a nurse was killed by a psychiatric patient.

The junior member of staff was working alone at some distance from other staff members, without clear procedures and with inadequate measures to check on his safety.

In other cases trusts have been fined for not adequately assessing risks and failing to implement procedures.

Staff members who are the victims of an assault may also sue their employers for compensation. In one case, a healthcare assistant sued after she was attacked by a psychiatric patient while she delivered coffee to colleagues in a seclusion suite. The court heard that the risk to her could have been lessened by not letting the man out of his room.

The NHS SMS Legal Protection Unit helps trusts with:

• guidance on patient confidentiality and the Data Protection Act
• advice on issues such as withholding of treatment
• legal advice on the most appropriate sanctions and redress available for specific cases
• advice in cases of physical and non-physical assaults.

The unit’s work has included prosecuting individuals for assault, injunctions such as prohibiting an individual from contacting the ambulance services, and even anti-social behaviour orders.

What is violence at work?

The Health and Safety Executive (HSE) defines violence at work as “any incident in which an employee is abused, threatened or assaulted in circumstances relating to their work.” This covers the serious or persistent use of verbal abuse which the HSE says can add to stress or anxiety, thereby damaging an employee’s health. It also covers staff who are assaulted or abused outside their place of work – for example, while going home, while working in the community or while travelling as long as the incident relates to their work. Unacceptable behaviours also include any action perceived as transphobia, homophobia or biphobia.

The definition of physical assault used in the 2003 directions to the NHS from the secretary of state was “the intentional application of force against the person of another without lawful justification, resulting in physical injury or personal discomfort.”

Nuisance behaviour

The Department of Health also consulted in 2006 on whether additional powers were needed to enable the NHS to deal with patients or their relatives who were a nuisance or created a disturbance but could not be appropriately dealt with under existing laws. The consultation envisaged a new offence of causing a nuisance or disturbance on NHS premises and power for certain NHS employees to remove those involved. This has not yet been passed into legislation.

The 2003 and 2004 directions to NHS bodies

Every NHS trust needs to be aware of these directions – which have statutory force – which are outlined in a CFSMS document Tackling Violence Against Staff.

The main points include:

• the need to report physical assaults through NHS SMS
• police involvement in physical assaults
• appointment of a security management director in each trust
• the development of local security management specialists.

The business case for action

The 2003 National Audit Office (NAO) report1 found that research demonstrated clear links between violence and aggression, and staff sickness, turnover and lost productivity.

UNISON also points out that there are costs associated with compensating workers, bad publicity and low morale.

Reducing the risk of violence

A key part of any NHS trust’s approach has to be risk assessment and devising solutions to eliminate the risk of violence or reduce that risk to an acceptable level.

The HSE highlights some risk factors for violent behaviour:

• impatience
• frustration
• anxiety
• resentment
• drink, drugs and inherent aggression/mental health problems

The NAO also points out that rising activity levels and staff workload may lead to increased risks.

However, staff will have differing risk levels as well. Those working alone may feel themselves to be at particular risk (see the chapter on lone working). Those who make the first contact with a patient may also be at risk not least because they may be going into a situation about which little is known – for example, ambulance staff. The Healthcare Commission staff survey also showed different staff groups at increased risk.

However, that does not mean the risk of violence to other groups should be discounted. The staff survey suggests that violence occurs throughout the NHS and may be surprisingly high among some staff groups who would not fit into any stereotypical view of those at risk.

There are many ways to reduce the risk of violence. The HSE suggests:

• providing suitable training and information to staff
• improving the design of the working environment
• making changes to aspects of staff roles
• recording incidents of physical assault or verbal abuse so that patterns can be discerned. Any employer must notify their health and safety enforcing authority if an act of violence at work results in death, serious injury on incapacity for normal work for three or more days.

However, looking at the way departments work could help to address some of the factors which prompt individuals to commit abusive or violent behaviour. This could include looking at the way patients are given information on as waiting times and what will happen to them, especially in areas such as A&E.

Treating violent and abusive patients

Many NHS organisations will know of people with a history of violence or abuse who are seen as being a threat to NHS staff who are caring for them. Yet it would be unethical to deny those people care altogether – and many healthcare professionals would feel duty bound to care for them, at least in an emergency.

The Government’s 2001 health service circular, Withholding treatment from violent and abusive patients in NHS trusts, makes it clear that treatment can be withheld immediately in exceptional circumstances – although normally patients would be warned – but leaves it to trusts to formulate their own detailed policies.

Many trusts have policies on this which include warning systems (‘yellow cards’) when behaviour is felt to be unacceptable, alternative arrangements for treatment of persistent offenders (which may involve other local providers), and offering care only when security of staff can be guaranteed, while still recognising the need to treat the patient in the event of an emergency.

Any policy needs to take account of particular groups which may need to be handled differently – child patients, relatives of patients, people with mental health issues which may influence behaviour, and those who are considered not responsible for their behaviour for other reasons. Staff representatives are likely to have views on how proposed policies would operate in practice.

PCTs often provide violent patients with GP services through special payments under the direct enhanced services scheme.

The National Institute for Clinical Excellence also has guidelines for the short-term management of violent or disturbed behaviour.

Conflict resolution training

Many frontline staff will have undergone conflict resolution training (CRT), aimed at giving them the skills to defuse potentially aggressive situations. This has been developed by NHS SMS together with the BMA, RCN and Unison.

All existing NHS staff should have received CRT and trusts should have an ongoing programme to train their new staff.

Training can also be offered to staff at risk from of abusive telephone calls from patients and carers.

Designing out violence

There is growing interest in how health service buildings can be designed to reduce the risk of violence. This includes both ‘negative’ aspects designed to stop someone carrying out a violent act, and ‘positive’ aspects designed to stop them feeling angered and frustrated – and therefore prone to violence – in the first place.

Negative areas could include:

• barriers to reduce the risk of assault on reception staff
• consulting rooms designed so that staff cannot be trapped inside
• furniture which can’t be used as weapons – for example, because it is bolted down or designed with no sharp edges.

The more positive side includes:

• the use of colour and light to influence mood – for example, airy waiting rooms painted in pastel colours
• noise reduction
• information screens.

These measures need to be backed up by a system which treats patients in a timely and respectful manner, and provides them with adequate information.

The ‘secured by design’ initiative looks at various aspects of crime reduction and has a guide to creating a more secure hospital which deals with aspects of violence against staff. www.securedbydesign.com.

A research paper commissioned by NHS Estates in 2003, The Impact of the build environment on care within A&E departments (see www.intelligentdesign.com), also covers many factors that may influence patient behaviour. The effects of workplace design on work-related violence – a report by the Health and Safety Laboratory – is available on the HSE website.

More information

• Health and Safety Executive