“If I Die It’s On You” – How Abuse from Patients is Threatening the NHS’s Recovery and Resilience

Even in 2019, before the Coronavirus pandemic hit, the annual State of Primary Care report published by healthcare marketers Cogora was reporting that 74% of Primary Care staff had experienced some form of abuse from patients. The issue stretches back many more years than that and is not one likely to go away anytime soon. Unfortunately, Practice Managers seemed to be worst affected, with a staggering 90% having to deal with abusive patients. Pharmacists were also in the firing line – 82% had experienced abuse.

It’s fair to say that the findings for 2020 are unlikely to show a much-improved picture. This is borne out in more recent data from a May 2021 survey conducted by the Institute for General Practice Management (IGPM) which found that 83% of Practice Managers had had to remove a patient due to repeated abusive behaviours, and two-thirds had needed to call the police following such behaviour.

The anecdotal evidence from PMs suggests that some of the most recent problematic behaviours come from a lack of knowledge and/or understanding amongst patients around the vaccine roll-out, despite efforts to communicate how the process works and manage expectations around timescales. Earlier in the pandemic, however, problems often arose when a patient found themselves unable to see a particular GP or had to swap a face-to-face appointment with an online one. As has often been the case, the situation was exacerbated by inaccurate media reports, which sometimes misrepresented the work of GPs in seeing patients in person, even during the worst days of the virus. The recent letter from NHS England ‘reminding’ practices to start offering in-person appointments then reopened old arguments again.

There have also been calls for the Government to do much more to tackle racist behaviour in particular, which is increasingly being directed towards GPs and surgery staff. A motion was passed at the May 2021 Local Medical Committees (LMC) conference, which urged that ministers should ‘publicly and repeatedly’ tell patients they cannot decline care based on a clinician’s ethnicity, and that racist behaviour should be identified and called out by ministers. This comes after recent figures showed more than half of all BAME (black, Asian, and minority ethnic) primary care staff have been subjected to racist behaviour at work – from patients but also sometimes from colleagues.

Practice Managers have continued to be typically resilient and resourceful, finding for example that video records of their work can win more hearts and minds than written or spoken responses. Understanding how and why people behave as they do is also critical in preventing the situations and circumstances which allow abusive behaviour to occur. As restrictions have eased, spikes in aggression can sometimes be attributed to patients releasing their anxieties, trying to re-assert control when they feel it has been taken from them or trying to ensure they are at the ‘front of the queue’ to assuage their anxiety about ‘missing out’ or being deprioritised in some way.

But understanding the reasons behind abusive behaviour is only part of the solution – patient responsibility, clarity of communication, skill in managing expectations, and creativity in finding alternative solutions to new and challenging situations are all important ways to minimise the chance of encountering abusive behaviour.

For those patients exhibiting more serious abusive behaviour (assaults, threats, damaging property), removal and referral to the Special Allocation Scheme should be considered. A call to 999 should be made, then notification given to NHS England or the Primary Care Support England, followed by notifying the CQC, and then the patient, of what will happen to them. But there are many levels of everyday problematic behaviour which may not meet this threshold or take place online or on the phone, which has just as serious an impact on staff as violent behaviour but are harder to call out and address.

The costs of not acting to combat this issue are mounting; reports say that over a third of GPs are considering early retirement within the next 12 months due to the stresses of the job. Some have suggested that the government should implement the same sort of mental health support for NHS staff as it does for war veterans, especially in light of the trauma that Covid-19 brought. Many in Primary Care say that the NHS as a whole needs to support them more – and understand them better – if things are to really change. The NHS’s 2020/21 People Plan promises ‘action for us all’, but is in danger of lacking the funding and strategic insight it needs to make this a reality.

First Practice Management members can download a sample Violence and Aggression Policy now by heading to our Policies and Procedures Library.




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