RECENT research published by the BMJ shows a nine per cent increase in recorded crimes on GP premises and health centres. This is against a backdrop of a rise in overall recorded crime of ten per cent and so is not, in itself, a cause for undue alarm. It is, however, a timely reminder to think about what appropriate action should be taken to ensure safe practice premises for staff and patients.
Given the thousands of patients visiting GP premises and health centres every day, the actual numbers of recorded crimes are relatively low. In 2016/17, there were 2,147 incidents, 339 assaults, 55 cases of harassment and 321 public order offences such as threatening behaviour. For the individual victims, of course, the effect may be life-changing. Managing difficult patients can also be challenging for a practice but there are effective ways to help protect staff.
The obligations on a practice to address such issues will arise from various sources and from its roles as employer, service provider and owner (or tenant) of a premises.
Key relevant legal obligations include:
- ensuring as far as is reasonably practicable the health and safety of employees, patients and visitors to the premises (Health and Safety at Work etc Act 1974)
- security arrangements to make sure that people are safe while receiving care (CQC Fundamental Standards Regulation 15)
- sufficiently trained staff (CQC Regulation 8).
As with many health and safety obligations, the starting point in addressing required and recommended actions is to conduct an adequate risk assessment. The basic purpose of the risk assessment is to identify hazards, evaluate risks and implement, monitor and review measures to reduce the risks – in this case potential aggressive behaviour to staff and other patients. The Health and Safety Executive (HSE) even has specific guidance on assessing workplace violence in a health and social care setting.
The followings areas are likely to be of note in a risk assessment for GP premises:
- The physical environment. Are access ways well-lit and visible? Are there good lines of sight? There is various guidance showing how the impact of colour palette, signage and layout can help reduce and better manage the risk of patient violence. One study reported a 50 per cent reduction in violent incidents in A&E as a result of design and signage changes.
- Do you have lone workers or those conducting visits? What reasonably practicable measures can be put in place to address additional risks?
- Do staff receive appropriate training, such as basic techniques in managing challenging behaviour or de-escalation, with greater training for those in higher risk situations?
- Are there appropriate policies and procedures in place for handling incidents, emergencies and particular high-risk patients, and dealing with threatening patients, such as warning letters and acceptable behaviour agreements?
- Is appropriate equipment available, such as panic buttons or alarms?
Failure to have adequate systems in place can have serious consequences. For example, a staff member injured by a patient could bring a claim for financial compensation for harm, or in an employment tribunal. The employer could also face a health and safety prosecution.
Although a criminal prosecution normally follows an incident in which someone is harmed, an employer or service provider can be charged for simply creating a risk of harm. Following a change in sentencing guidelines, fines for health and safety breaches are now based on an organisation’s turnover and can, in certain circumstances, run into hundreds of thousands of pounds. There have been a number of prosecutions, for example, of NHS trusts failing to take adequate steps to protect staff who have then been the victim of serious, or even fatal, injuries from patients.
Commonly, issues arise from the systems around assessment or treatment of mental health patients. Whilst the risks may be less prevalent in general practice, isolated violence and sustained aggressive behaviour do occur.
DEALING WITH SERIOUS THREATS
Cases of stalking of a GP by a patient are thankfully rare but not unknown. In recent years a male patient was imprisoned for a campaign of harassment against a female GP which led to serious mental health consequences.
A common sense approach to dealing with violent incidents includes contacting the police as a first port of call. It is also important to keep a log of events in case the acts become repeated by a particular individual and evidence is needed to pursue formal action, or patterns emerge which can be assessed to help reduce risk.
Interestingly, the Criminal Justice and Immigration Act 2008 created an offence and power to remove from certain NHS premises those creating a nuisance. The legislation does not cover GP premises but rather hospital and other facilities operated by an NHS Trust or Foundation Trust. Options that GPs do have include removing an individual from the practice list if certain criteria are met. There is a careful process to follow but violent or threatening behaviour can be grounds to justify removal of a patient from the list.
Practices should have a policy on dealing with difficult behaviour, such as escalating correspondence and setting out how decisions will be taken, including clinical input. These steps often act as a pre-cursor to removing a patient and help establish a clear and reasonable process for the practice to follow.
In cases of harassment or violence, the police have a range of powers that can be used and there are various criminal offences. Liaising with MDDUS and police would be the first recommendation. In certain circumstances, a practice might consider taking action itself. The Protection from Harassment Act 1997, which creates a criminal offence of harassment, also gives a civil court the power to issue an injunction (a court order) preventing someone from carrying out acts of harassment against other specified individuals.
The threshold for acts that constitute harassment is relatively high and to obtain an injunction it is necessary to show a course of conduct causing alarm or distress. In 2012, that Act was updated to include specific offences and remedies in relation to stalking. Whilst seeking an injunction from the court comes as something of a last resort, Capsticks have successfully obtained them: for example in regard to the release from a psychiatric unit of a patient known to be fixated on a former healthcare professional still living in the area.
WHAT TO TAKE AWAY Here are some key tips to consider for protecting practice staff and complying with legal obligations:
- Have the environment and staff procedures been risk assessed and identified actions completed?
- Can the physical environment be adapted to be safer?
- Ensure policies are up-to-date (dealing with violent patients, lone working etc).
- Make sure staff are trained in how to respond.
- Are appropriate equipment and safeguards in place?
- Keep a record of any incidents that take place, and consider ‘debriefing’ staff.
- Where appropriate, report incidents to the police.
- Seek further advice if necessary.
Daniel Kirk is an associate in the litigation division and member of the dedicated GP team at Capsticks Solicitors LLP