Freelance Medical Journalist
Living on the Wirral, Elizabeth Gates is a national freelance medical journalist specialising in public and occupational health. She is also an expert in managing change. "I have to be," she says, "I'm a wife, mother and Labrador owner"
Beacon View Medical Centre is a special case. Three years ago, it was selected by Gateshead Primary Care Trust (PCT) as a designated practice for the PCT's reported violent patients. As such, practice manager Liz Mather says: "We've had a lot of support."
Enhanced support has meant strict protocols for the transfer of violent patients (10 such patients a year are transferred to the Beacon View practice – "not many in a practice handling 4,500", says Ms Mather) – the provision of extensive security equipment, and violence management training.
The results are good. As Ms Mather says: "Staff don't want to experience a violent incident but, if it does happen, they feel confident they can nip it in the bud. All I can say is: the system works."
But what happens elsewhere in general practice? When, as reported in the press, violence rears its ugly head, chairs are thrown and the machetes come out?
Violence management training "mandatory" for staff at risk
Faced with allegedly rising levels of violence to UK healthcare workers, government bodies are taking an interest. The NHS Security Management Service (SMS) has been briefed to establish, through PCT reporting systems, the true extent of violence and its significance.
If employees are obliged to deal with potentially violent or aggressive members of the public, the Health and Safety Executive (HSE) warns: "The law requires employers to provide them with adequate Health & Safety training."(1)
According to the HSE, good violence management training covers:
Department of Health (DH) regulations mean that violence management or conflict resolution training (CRT), based on a national syllabus designed by NHS SMS, is now mandatory for all NHS staff or contractors at risk from violent behaviour – including workers in general practice.
The NHS SMS also encourages practice managers – the "hub of the practice"(2) – to invest in this form of training. The benefits of this training, it says, include reduced violence, reduced costs attached to sick leave and damage to property, and reduced disruption.
Assessing and dealing with patients who may become violent
Risk assessment is complex. As Ms Mather explains: "Someone who perhaps has never been violent before can suddenly turn violent – because they're anxious, and poorly. On the other hand, so-called 'violent patients' can be gobsmacked they've been sent to us, with a police record and a marker on their files for 12 months. And we've only ever had one incident with a referral and that was minor. What's 'violence' for one person isn't necessarily 'violence' for another."
Staff attitude helps. As Ms Mather says: "We blame the behaviour, not the person. Even before we became the practice that takes violent patients, we had the most violent patient in Gateshead on our books. But, because we are always smiling, friendly and open, he's always been as nice as ninepence with us."
Good training, she adds, enhances this approach. Mentally ill patients or addicts, for example, may sometimes fail to abide by "guidelines" relating to violent behaviour (physical and verbal). But 30 years' experience and violence management training have enabled Ms Mather to take the necessary stand to protect her staff.
As she explains: "Ninety-nine percent of patients comply with our guidelines. They don't come here wanting to cause trouble. They come here because they feel poorly."
For some practice managers, this form of training is still a low priority. But for others, as violence management seems set to become "an annual agenda training item",(3) more central support and advice would be welcome. And a straw poll of practice manager members of the Institute of Healthcare Management (IHM) has revealed some interesting initiatives and deficiencies.
Training provision for practices
At present, after a violent incident – or "near miss" – many practice managers favour informal whole-team discussions. A practice manager in Kent comments: "Staff don't always want to be told what to do by their manager. They want to process their own ideas with the manager's facilitation."
A Kingston-based practice manager also warns against inertia: "Greater levels of interpractice cooperation, growing from practice-based commissioning (PbC), etc, may enable practice managers to achieve the critical mass required to make training events financially viable." However, she adds that, in her experience, "this remains to be seen".
Local provision varies. In some rural areas, such as Gloucestershire and South West Essex, the low risk of violence means that no formal training is available. Yet, ever since an incident in Lerwick, on the Shetland Islands, in which a hepatitis-C patient spat at a GP and was verbally aggressive to him and the reception staff, the Shetlands Health Board has offered violence management training to all general practice staff.
Providers also vary. In Kingston, private and charitable organisations – such as the Suzy Lamplugh Trust – offer training that has to be paid for by the practice or the individual. In Shoreham, West Sussex, and Bromley, Kent, practice managers use inhouse training offered by drug companies. And, at one practice in the Highlands, annual self-defence refreshers are run by a patient who is a former policeman.
Government-supported training providers do exist. The NHS SMS offers "well received"2 – but seemingly little-publicised – courses nationwide. And one practice in Wales has been able to join seminars and training run for local council staff. Staff here have also been encouraged to complete the Health of Wales Information Service's (HOWIS) online Health & Safety training (see Resources).
Says Ms Mather: "We supplement the national vocational qualification in Customer Care, which includes a section on handling difficult patients, with additional training put on by Gateshead PCT for all their staff."
Developed in collaboration with crime prevention officers, this training involves situation-specific risk assessments. Receptionists are taught, for example, not to leave cups of coffee on the counter within the reach of patients who may
Adds Ms Mather: "If someone leaps over the desk, you also need to know how to break away and where to go. And you need to know this in advance."
A funding battle
But, decimated by local budget deficits, other PCTs appear too strapped to help general practice colleagues. Then practice managers feel they must address the issue – assessing risk and preparing staff.
In the view of IHM practice managers, violence is increasingly an NHS-wide issue. Violence management training, with annual refreshers, is seen as necessary, even though what is learned may never be used. But many practice managers are convinced that being prepared will pay dividends. A Shoreham practice manager says: "I would feel I had failed my staff if I had not prepared them for such events."
Yet funding remains the greatest barrier to providing this preparation. The Department of Health (DH) recognises that no money has been ring-fenced for violence management training in the new GP contract. But the Quality and Outcomes Framework (QOF) offers incentives to practices, giving induction training on practice codes, standards and regulations, including Health & Safety. This, it says, may cover violence management. And, in 2005/06, induction training earned practices four points at £124.60 each – approximately £500.
However, the DH warns: "The Department doesn't micromanage individual practices' training budgets. So this would be a matter for the practice management."
The NHS SMS adds that CRT is "good value – compared with standard continuing professional development (CPD) courses."
1. Health and Safety Executive (HSE) spokesperson.
2. NHS Security Management Service (SMS) press office.
3. Response to the Institute of Healthcare Management (IHM) enquiry.
NHS SMS Conflict Resolution Team
Health of Wales Information Service
Violence and Aggression in General Practice – Guidance on Assessment and Management
London: Health Development Agency; 2001 (Recommended by the HSE). Available from: www.nice.org.uk/download.aspx?o=502103