The Practice has a zero tolerance policy to all violence and aggression. This policy is for the protection of all Practice staff and Patients and visitors etc to the Practice premises. In order to ensure that this zero tolerance approach is adhered to, it is essential to have robust policies and procedures in place. In General Practice, this will need to cover a variety of situations in which incidents could occur. Generally speaking the majority of Patients behave in acceptable or manageable ways, however the incidence of excessively aggressive or violent attacks in Practices is increasing.

 

The Practice recognises that there can be contributory reasons for Patients behaving in difficult or challenging ways, however, where this tips over into aggression or violence, the Practice will adopt a zero tolerance approach.

 

The Practice aims to provide high quality healthcare and we will treat all patients with respect and dignity. In return we expect all our staff to be treated with respect. We will not tolerate abusive language or threatening behaviour against any member of staff. Such behaviour may result in the offender being denied access to the doctor and/or further measures as appropriate.

 

1.1 Communication

The Practice will communicate this policy by a variety of communication mediums e.g. a clear policy on the web site and the Practice shared drive.

 

2.0 Aims and Objectives

The aims and objectives of this policy are as follows:

 

• To ensure adequate processes are in place for the protection of staff and patients

• To ensure staff are fully aware of their responsibilities when dealing with violent or aggressive patients

• To ensure that staff are fully aware of their rights when they have to deal with such incidents

 

3.0 Aggressive Patient

What is an aggressive patient? The Health & Safety Executive1 defines work-related violence as: ‘Any incident in which a person is abused, threatened or assaulted in circumstances relating to their work.’

This could be from a patient (carer/ relative/ friend) who exhibits one or more of the following patterns of behaviour:

• Verbally abusive, offensive or intimidating in their behaviour towards staff

• Threatening physical violence

• Making excessive demands and/or maintaining certain expectations and failing to accept that these are unreasonable (e.g. wanting an immediate appointment and becoming aggressive when this is not possible)

• insisting that a member of staff is dismissed

• insisting that treatment is carried out on demand

• constantly requesting a different GP

• demands to see a particular member of staff/clinician

 

 

 

 

3.1 Risk assessment

The HSE2 recommends a proactive approach to the assessment of risk from aggressive or violent patients. This could involve the Practice team “walking through” the logistics of the reception area, identifying an escape plan(s), panic button protocol, security personnel support etc. The Practice may wish to undertake a generic risk assessment which should consider the overall needs of the organisation, for example:

• general risks to staff from patients, service users and their relatives or visitors

• risks associated with the design of the work environment, i.e. layout of rooms, lockable doors, escape routes, alarm systems, access to car parks at night

• risks associated with lone working, whether working in the community or alone in work premises (the NHS guidance on lone working can be found at http://www.nhsbsa.nhs.uk/2460.aspx)

• identification and testing of appropriate instructions, information and training

• identification, agreement and testing of security support arrangements.

 

4.0 Dealing with an Aggressive Patient

Patients can become aggressive for a variety of reasons, and it is always advisable to try to calm down the situation as early as possible, as this may prevent an incident. Being observant of patients/relatives is often the first sign that a difficult/tense situation is imminent.

 

4.1 Recognising the signs of an impending aggressive incident

The use of appropriate inter-personal skills in potentially difficult situations is essential.

Observation of the patient/client can help in predicting when aggression may occur. The following are some of the signs to look for:

• Staring, unblinking, uncomfortable gaze.

• Muscles tensed, jawline tensed.

• Facial expression

• Person balanced to move quickly

• Fingers or eyelids twitching

• Pacing about, uncomfortable stance, alternate sitting/standing

• Withdrawn on approach

• Voice-change of pitch or tone, use of insults, obscenities or threats

• Sweating

• Increase in rate of breathing

• Tears (crying)

• Offensive weapon carried or visible

 

4.2 Proactively diffusing a recognised condition

Having recognised such signs and assessed the potential of violence occurring, staff may feel they are able to diffuse the situation by using some of the following behaviours:

• Adopt an empathic, understanding approach, and attempt to show some affinity with the other person’s position – “I can see why you are upset about that”

• Use active NLP (neuro linguistic programming) – saying a small portion of a sentence back to the patient in the patient’s own words

• Avoid confrontation, do not argue but do not agree to reward their bad behaviour

• Speak and stand calmly with an open posture, but always remain balanced and ready to move away

• Do not move closer to the patient, even if they are speaking in whispers

• Try to distract the person from the immediate cause of concern by changing the course of the conversation – buy time to think, to plan, to obtain assistance – if possible ask the patient to have a seat “while I go to see what I can do to help you” – this buys time and allows you to think of your options.

• Speak clearly, evenly and slowly and do not necessarily stop talking because the other person does not answer

• Even if the other person is very loud, do not raise your voice

• Try to identify the source (nub of their problem) of concern, acknowledge this and offer to help if possible

• Do not disagree where it is not necessary

• Do not give orders or use status or authority as a threat, remember your body language

• Never make promises which cannot be kept

• Never reward aggressive behaviour

• Do not make threats

• Be alert and send for assistance where necessary

• Be prepared to leave the situation if necessary to avoid injury

 

4.3 If the incident escalates further

If the aggressor continues or becomes more verbally aggressive, then the following process should be followed:

 

• If they continue with their aggressive behaviour, the receptionist should be clear in telling them that they will not be dealt with until they calm down.

“I am sorry (use aggressor’s name here if it is known), we do not deal with people who are being aggressive or abusive. I will try to help you but must *stop shouting/ *stop swearing/*stop being aggressive or I will not be able to deal with you.

• Remain calm and clear and keep repeating that the behaviour is unacceptable. Insist that you are trying to help, but cannot do so until they calm down. Remember immediately giving the aggressor what they have asked for just to end the situation, or the Clinician agreeing to see the patient just “to keep them quiet” just sets a precedent which will repeat in the future and sets a poor example to on-lookers. If the Patient continues/ does not desist, in the interests of safety, it is best to have another member of staff come to assist. Staff should never isolate themselves with a potentially violent patient. The second member of staff may ask other patients (in queue) to step back while the current patient is being dealt with.

• If it is deemed appropriate, get a more senior member of staff to speak to the patient, again keeping calm and stressing that you are trying to help. If possible move the patient to a side of the desk whilst being mindful about not isolating the member of staff or allowing the patient access to the receptionist/ reception area.

• If the aggressor refuses to calm down or refuses to leave when requested to do so, the risk assessment at 3.1 should have identified the additional security arrangements which will come into place at this point.

 

4.4 Repeated Incidents

If there are repeated incidents from a particular patient, then the Practice should write to the patient warning them that no other incidents will be tolerated, and the Patient will be removed from the list if this happens again.

Note that it is important to carry out this action once it has been written down. If the Patient continues with this behaviour, even after the written warning, then they should be removed from the list for the sake of staff and other Patients.

 

5.0 Violent Patients

Dealing with a violent Patient requires a much more immediate response. It is good Practice to test these procedures on a regular basis. As soon as a Patient turns violent, then immediate action must be taken, as follows:

• Step back from the Patient.

• If in Reception lock the door (may consider this door is locked as a matter or course)

• If the aggressive behaviour continues employ the additional security measures as described in 3.1

• If the patient is in the consulting room with a clinician, then the correct procedure should implemented (see app 2)

• Phone the police. Once violence occurs, it becomes a crime.

• If there are other patients in the vicinity, then there is a duty to protect them. If possible remove/instruct other Patients in the vicinity to move to another part of the waiting area or another room away from the situation. The logistics of this action should be tested in a “dummy” run and the policy updated. If this is not possible then this should be discussed in the Practice meeting at least on an annual basis.

 

5.1 Staff support following a violent incident

• Staff directly involved in the incident should talk through the incident on a one-to one basis with the manager/partners/nurse

• Staff not involved in the incident should be briefed about the incident

• If the person affected is not employed by the practice then inform their line manager immediately after the incident

• The policy should be reviewed in light of the incident to update it with any additional learning points/changes necessary

• Following an incident of violence, the practice should hold a significant event meeting to decide if the patient should be removed from the list.

• If the patient is to be removed from the list, then the practice should now follow the procedure for the removal of patients.

 

5.2 Accepting a known violent patient

(see appendix 3)

 

6. Following an Incident

Every incident of violence or aggression should be recorded in the patient’s notes and additionally in a log specifically used for this purpose. This log should contain the following information:

• Patient ID (eg NHS number)

• Time and date of incident

• Nature of incident – particularly the trigger point (eg not able to get appointment)

• Perspective of staff member dealing with the incident,

• Names and statement of any witnesses

• Record of any actions taken

 

7.0 Removal of Patient from Practice List

In Good Medical Practice, the GMC states that: the trust between you and a patient may break down, and you may find it necessary to end the professional relationship. For example, this may occur if a patient has been violent to you or a colleague, has stolen from the premises, or has persistently acted inconsiderately or unreasonably.”

 

If Patients have been violent to any members of the practice staff or have threatened staff safety, the incident must be reported to the police straightaway. In these circumstances, the practice can notify the PCT and request immediate removal.

 

Even in these circumstances, the Practice should inform the patient of the reasons leading to removal from the Practice list, unless one or more of the following apply:

• it would be harmful to the mental or physical health of the Patient

• it would put Practice staff or patients at risk

• it would not be reasonably practicable to do so.

 

The Practice is required to record this in the patient’s records and set out the circumstances leading to removal. Family members should not be struck off GP lists, unless there is a threat to the Practice from the ex-patient as a result of keeping these patients on.

 

The RCGP states that: “Where violence has been an issue, the PCO has responsibility for ensuring that all Patients can receive primary care services, if necessary within a more secure setting.” These are often known as Special Allocation Scheme (SAS).

 

When it becomes necessary to remove the Patient from the practice list, for reasons of violent or aggressive behaviour, then a specific process should be followed.

 

Under schedule 6 of the NHS (GMS Contracts) Regulations (2004), the PCT would be required to remove a patient from the Practice list if it is informed by the Practice that the patient has committed an act of violence against anyone present on the Practice premises, or at any place where the services were provided to the Patient, or that the patient has behaved in such a way that any person has feared for his/her safety.

 

It is essential in all cases that the incident has been reported to the police, prior to the application to the PCT to remove the patient from the list. (See appendix 4 for an extract of the GP Contract)

 

8 Governance Arrangements

This policy will be approved by the Practice Manager. The Practice Manager will be responsible for notifying all staff of the process, ensuring all staff has up to date copies of the document and that the staff are following the processes documented within.

This policy will be reviewed 2 years from the date of publication

 

Appendix 1 (writing to a patient after aggressive/violent attack) – Suggested wording

 

In Confidence

To: …………………………………

……………………………………..

 

Dear

Following your visit to surgery on.............................. when (details of incident – factual)

…………………………………….…………………………………………………………………

………………….......................................................................................................................

 

We are writing to tell you that this behaviour is unacceptable.

 

It is my responsibility to point out to you that there is a zero tolerance policy in this Practice and across the NHS for Patients who are abusive and/or violent to staff.  The Practice takes this policy very seriously, and would not hesitate to remove Patients from the list who do not abide by the protocols of the Practice.

 

We are happy for you to remain with the Practice, but insist that you prohibit from violent, intimidating, aggressive or threatening behaviour .

 

We hope you understand that should such poor behaviour occur again, we will have no alternative other than to exercise our right to remove you from our List.

 

Yours sincerely,

 

Appendix 2 (aggressive attack in the clinical room)

Dealing with a violent or aggressive patient if the patient is in the consulting room with a Clinician requires an immediate response. As soon as a patient turns violent, then the correct procedure should implemented and immediate action must be taken, as follows:

 

·       If possible the Clinician should proceed to the door of the consulting room and request assistance from other staff/request additional security.

·       If unable to get to the door, press the panic button/employ a pre-agreed protocol immediately

·       Two members of staff (or security) must immediately respond to the clinic room to provide assistance

·       Another member of staff should call security to aid the removal of the patient from the premises

·       Phone the police. Once violence occurs, it becomes a crime.

·       If there are other patients in the vicinity, then there is a duty to protect them. If possible remove other patients in the vicinity to another part of the waiting area or another room away from the situation.

·       Following an incident of violence, the practice should hold a significant event meeting to decide if the patient should be removed from the list.

·       If the patient is to be removed from the list, then the practice should now follow the procedure for the removal of patients.

·       Following the incident, the main points should be recorded on a significant events

·       form

·       All incidents of violent and aggressive behaviour should be reported to the Practice Manager

·       Manager for noting as per point 6 in the policy.

 

Appendix 3 (accepting a known violent patient)

In Confidence

To: …………………………………

……………………………………..

Dear

 

Thank you for registering with  ***************

 

We are now in receipt of your full medical records.

 

We note, from these records, that you have a history of abusive and/or violent behaviour

at your previous Practice.

 

It is my responsibility to point out to you that we have a zero tolerance policy across the NHS for Patients who are abusive and/or violent to staff. At ************* we take this policy very seriously, and would not hesitate to remove patients from the list who do not abide by this policy.

We are happy for you to remain with the Practice, but insist that you abide by the above mentioned policy in all your dealings with the practice.

 

If you wish to discuss this matter further, then please do not hesitate to contact me.

Yours sincerely.

Practice Manager

 

Version 1.1

Author: Practice Manager. Surjit Kaur

Date April 2025

Review April 2026