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Thursday 24 January 2019
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Protecting practice staff against abusive patients: ‘there is still room for improvement'

Following a government announcement of a ‘zero-tolerance’ policy on violence against healthcare staff, Beth Gault speaks to three practice managers about their experiences of verbal and physical abuse. 
 
Dealing with challenging patients who might be emotional and distressed is often part of the job for practice managers and their teams. At times, however, patients can become not only challenging but also violent and abusive.
 
In October, health and social care secretary Matt Hancock announced that the NHS was collaborating with police on a new zero-tolerance policy on violence against NHS staff.
 
As part of this, Mr Hancock pledged to better protect NHS staff against aggression, as well as helping them in coming forward and reporting attacks.
 
Incidences of written, verbal and physical abuse all increased last year, according to a survey of 1,897 primary care workers, including practice managers, GPs and practice nurses, carried out by MiP publisher Cogora.
 
The Primary Concerns 2017 survey found that three in every 10 healthcare professionals have experienced verbal abuse from a patient. Practice managers were the group at greatest risk, being four times more likely than a GP to have experienced physical abuse from a patient.
 
To better understand the reality of abuse in general practice, we interviewed three practice managers who have all been at the receiving end of threats or aggression from patients.
 
‘I’m going to hurt your children while you watch’

In June, a practice manager who wished to remain anonymous found herself in the middle of an abusive incident. A patient had called the practice for blood test results. The receptionist provided these, but was unable to tell him what to do next, which resulted in him becoming verbally abusive, she recalls.

‘He threatened to come and wait for the receptionist outside the surgery when she finished work and demanded to know her name.’ This led the receptionist to change her name on Facebook for fear that he would locate her.

The practice manager reported the incident to the police and removed the patient from their list. However, a few days later, the patient rang the practice to make an appointment. He was directed to the practice manager who informed him that he was no longer registered with them.

‘It proceeded with a barrage about how awful we were, and threats that he was going to come and wait for me after work,’ she says. ‘All of that I took. But when he said: “I’m going to find you when you’re with your children and hurt your children while you watch,” that was it, I broke down. I burst into tears and was shaking.’

She says it occurred to her that the patient’s children went to the same school as her children and that it ‘suddenly became very plausible that this could happen’.

At that point, a nurse practitioner came in, took the phone from her and ended the conversation, after which the police were called.

The practice manager was so shaken by the episode that she took her children out of school early and took the rest of the day off work. The patient was given immediate notice not to come back to the practice but, in the end, the practice manager did not press charges.

‘I get abuse day in day out from patients who don’t get what they want. But when they threaten to hurt my children, that’sa trigger. I don’t think you should have to take that in any job,’ she says.

She adds that the situation is definitely getting worse and that in her three and a half years as practice manager, the practice has sent out a growing number of warning letters.

Afterwards, the practice manager met with one of the partners to discuss the incident, and she would recommend anyone who has been through a similar experience to do the same. Moving forward, she thinks there should be a better standard in place for when to take action on abusive patients.
 
‘With verbal abuse, it’s really difficult to ascertain at what point it’s significant enough for us to take a patient off our list,’ she says.
 
'It’s hard passing on aggressive patients to another practice’

Kay Keane, practice manager at Alvanley Family Practice, Stockport, says the abuse she and her staff have suffered is often a result of a discrepancy between what the patient thinks will happen and the reality.

‘The answer isn’t necessarily “yes, you can have a GP appointment,” it’s more “can you tell me what the problem is and I’ll book you in with the right person”, and some don’t like that,’ she explains.

Ms Keane says in one incident a female patient jumped over the counter and ‘almost held the GP and receptionist hostage’ to try and get additional medication. The police were called and arrested the patient ‘She was removed from [the list] immediately, but of course she’s then just going to go somewhere else.

It’s hard passing on patients that are aggressive because you know they’re going to be that way with the next practice too. So we don’t really throw people off our list unless they really, really overstep the line.’

Another patient who was removed from the list was given multiple chances to change his behaviour after a series of verbally aggressive incidents. In the end, Ms Keane says she had a heated discussion with him in the middle of the waiting room about a warning
letter he received.

He threatened her, saying she would not be safe when she walked outside, and that he knew what car she drove. Ms Keane says that as practice manager, she has to judge which situations are so serious that they require the police, and which ones can be dealt with internally.

The practice also has strict procedures in place to ensure the safety of staff. This includes making sure no one is alone in the building, testing the emergency procedures every three months, and recording each abusive occurrence to try and learn from it.
 
The practice has also appointed a wellbeing navigator to help preempt these incidents. ‘Sometimes it’s about something we have no control of [such as] a problem with the patient’s benefi ts,’ Ms Keane says.

The wellbeing navigator can discuss these issues with the patients, which she says is working well. However, she adds it’s also important to look at the role of the receptionist.

‘They’re underpaid for what they have to see and listen to. They’re not just receptionists; they’re almost patient care coordinators.’
 
He took a swing for me and hit me across the chin’

Steve Williams, co-chair of the Practice Management Network, says improvements have been made in the way abusive situations are responded to in the 15 years since he was physically assaulted by a patient.

At the time, it took three months to reach a resolution after a patient hit him when his request to pick up his repeat prescription was denied because he needed a review with his GP first. 
 
‘I asked him to move away from the reception and as I went to escort him away he pushed his hand against my shoulder,’ Mr Williams says. ‘So I put my hand up and asked him to please not touch me, at which point he pushed me.’

Mr Williams escorted the patient outside, and the patient hit him. ‘He took a swing at me and hit me just across the base of the chin,’ he says. The police were called but the patient was not removed from the practice list and, six weeks later, he returned and was again abusive towards staff – this time verbally.

Once more, the police were called but Mr Williams says the only step that could be taken was civil action. He says it ended in a civil suit, with the patient told he could not come
within 50m of the practice premises.
 
‘In the end the patient was taken off the list but it probably took about three months to resolve the issue,’ Mr Williams says. ‘We’ve really got the same problem today; there is still a delay. It’s better but it can still take 24 to 48 hours to get a patient removed, and it’s that time that’s the most dangerous for the practice.’