"The vast majority of patient consultations don't involve abusive or threatening behaviour, but almost every colleague I speak to has encountered it at some point in their working lives," says NHS GP and blogger Dr Zoe Norris.
Dealing with aggressive, abusive or violent patients is thankfully not a regular occurrence for most GPs, but it does happen.
It pays to have strategies and techniques in place in the event of such behaviour, to mitigate risks to GPs and their staff.
Banning Violent Patients
In extreme circumstances GPs can remove a patient from their practice list immediately if the person is violent, aggressive or behaves in a way that makes the GP fear for their safety or the safety of their staff.
"The GMC, and the standard GP contract usually require a warning to have been issued before a patient is removed from a practice list. However, if there has been a threat of violence, or actual violence, it is appropriate to call the police, and removal from the practice list without prior warning may be possible," says Dr Ellie Mein, medico-legal adviser for the Medical Defence Union (MDU).
They can be placed on the Special Allocation Scheme, previously called the Violent Patient or Zero Tolerance scheme. To get a patient 'banned', the practice should report the incident to the police. That patient will then be treated by an alternative, specific GP with prior notification.
Figures revealed in a freedom of information request by the BBC show that in 2018 more than 3000 violent or abusive patients in England were subject to the Special Allocation Scheme.
The British Medical Association says while this doesn't happen often it is still an important issue.
"When GPs are delivering over a million consultations every day, the number of incidents and number of patients involved are very, very small. However, one incident is one too many and we can't tolerate situations where patients are putting front line healthcare staff at risk," said Dr Richard Vautrey, chair of the BMA's GP Committee.
Zero Tolerance Approach
The NHS is committed to a violence reduction strategy which includes measures to better protect NHS staff and to prosecute offenders more easily.
It's a zero tolerance approach and includes improved training for staff and scrutiny of violent events by the Care Quality Commission as part of its inspection regime, identifying trusts that need extra help.
A report in the BMJ in 2017 found GPs and their staff are increasingly facing violence, harassment and threatening behaviour in their surgeries.
It found, in the space of a year, a 9% rise across the UK in the overall number of crimes committed at GP surgeries and health centres. There were 1974 in 2015-2016 compared with 2147 in 2016-17. The report showed an increase in assaults, harassment and a 90% rise in public order offences like threatening behaviour.
"Over a recent 5-year period, the MDU supported members in primary care with a little under 300 case files involving threatening, abusive, or aggressive behaviour directed at GPs or their staff. We also receive many hundreds of calls a year from members on this difficult dilemma," adds Dr Mein.
There have been some high profile cases of extreme violence against GPs who have been stabbed and injured by patients. A man has recently been jailed for attempted murder after shooting a GP with a crossbow.
The MDU says that in other instances, threats have been sent to the home addresses, personal emails, or mobiles of GPs and their staff.
Why Are Some Patients Violent or Aggressive?
Patients become violent or threatening for different reasons.
There are some patients who have a history of problematic behaviour. However, it may be mental illness or a learning disability that causes a patient to be violent and aggressive. Sometimes a physical problem makes a patient act out of character and turn nasty.
Frustration and unrealistic expectations can also be reasons why patients may turn aggressive or abusive.
"Most commonly this is in scenarios where the GP is saying no to something; often inappropriate prescribing or writing private letters or notes which are outside the NHS," explains Dr Norris.
"Experiences like this can cause such distress to GPs that they are unable to carry on seeing the rest of their patients that day, have to take time off work, access counselling services, or even leave the profession entirely," she adds.
MDU members' enquiries about inappropriate behaviour are varied.
"Queries ranged from how to deal with patients who become verbally abusive, often in response to their request for a particular treatment, prescription or sick note being declined because it wasn't clinically appropriate," says Dr Mein.
"At the other end of the spectrum were cases where GPs, nurses, or administration staff were subjected to rape or death threats, work or personal property was damaged, or actual physical assaults occurred. Some members asked about being subject to abuse or threats on home visits," she adds.
What Can Be Done to Mitigate Risks?
It helps to be aware that violence and threatening behaviour is always a possibility.
The National Institute for Health and Care Excellence (NICE) guidelines suggest offering staff training so they have the skills to defuse a potentially violent or aggressive situation. De-escalation training should help GPs and staff recognise the early warning signs of agitation and use techniques for distraction and calming.
"GPs cover dealing with threatening and abusive patients as part of our training, but on a practical level many of the suggestions, such as always making sure your chair is close to the door and that you have a panic alarm isn't practical," explains Dr Norris.
She suggests: "Knowing when to end a consultation and ask patients to leave is important; often opening the door and leaving the room yourself can make you feel safer as everyone's nightmare is to be trapped in this situation."
Adopt a zero tolerance approach in practice, and display highly visible signs in the practice to that effect.
"Have a clear policy within your practice and stick to it - any abusive behaviour to any member of staff will result in a formal warning; serious or a second breach of this will result in removal from the practice list," suggests Dr Norris.
Other ideas could be a system that records phone calls so that any verbally abusive behaviour can be recorded. Any behaviour that upsets a member of staff or makes them afraid should count as abusive.
The BBC reported in February 2019 that a GP practice in Halifax in West Yorkshire arranged for its staff to undergo self-defence training in response to rising levels of violence and abuse.
It's not alone; there are a number of self-defence courses operating across the country that are geared to NHS staff.
"GPs and our teams across the country are dedicated to delivering care to more than a million people every single day, and it's essential that we all feel safe in our workplace as we strive to do this, often in very difficult circumstances," says Prof Helen Stokes-Lampard, chair of the Royal College of GPs.
“GPs, like our emergency care colleagues, are often vulnerable in the environments we work in, which are open to the general public and were not always designed with safety in mind. It's therefore vital that efforts to minimise risks to our health and safety are redoubled right across the health service," adds Prof Stokes-Lampard.
If there are potentially problematic patients on a practice list GPs and their staff may want to consider their social media profiles and how much of their personal information and that of their families is in the public domain.