Zero tolerance – can it work?

VIOLENCE against healthcare staff has been an increasing problem in the NHS. In October, Matt Hancock, Secretary of State for Health and Social Care, announced a new strategy to tackle the issue, including specific measures to better protect staff and prosecute offenders.

Key action points included: better collaborative working between the NHS and the Crown Prosecution Service to seek prosecutions and assist victims in giving evidence; improved training in dealing with workplace violence; improved psychological support for staff who are victims of work-related violence; and for the first time the Care Quality Commission (CQC) is to include the scrutiny of violent incidents as part of its inspection regime.

Results from the most recent ‘staff survey’ in England suggest that more than 15 per cent of NHS workers have experienced actual physical violence during the previous 12 months, which is the highest estimated figure for five years.

Part of the announcement also included a relaunch of the so-called ‘zero tolerance’ approach, which aims to protect the NHS workforce from deliberate violence and aggression from patients, their families and the public at large.

The new strategy acknowledges that a zero tolerance approach is indicated in cases where “deliberate violence” is used against NHS workers. This appears to be a subtle change from the original NHS zero-tolerance campaign, introduced throughout the UK in the 1990s, to reject all aggression and violence against NHS workers.The reality is that the triggers for violence are complex and multi-faceted and it quickly became clear that such a basic approach to its management was in some cases unhelpful and unworkable.

It is fairly easy to justify taking substantive action, such as removal from the practice list, against an individual who has behaved in an unacceptable manner through the use of personal abuse, threats and aggression or violent assault. But this becomes more problematic where there is an underlying illness or condition present, or circumstances where someone's behaviour is out of character, or they lack insight into their actions.

The original NHS zero tolerance strategy gradually made way for the development of more flexible and circumstance-driven ‘unacceptable behaviour polices’, which attempt to mitigate where appropriate but also allow for decisive action to be taken in circumstances where aggression and violence is pre-meditated and deliberate.

At MDDUS we regularly receive calls from members seeking advice on the removal of patients from practice lists, and the use of aggressive and violent behaviour against workers is certainly a compelling reason for doing so. However, we would encourage members to carefully consider each case on its own merits rather than simply relying on a blanket ‘zero tolerance’ policy. Be sure to follow the GMC's guidance on Ending your professional relationship with a patient, which highlights the importance of steps such as warning the patient of your intentions in writing, and contact our advice line for specific help.

ACTIONS

• Adopt a risk assessment approach to the management of workplace violence and aggression that fully considers both the prevailing circumstances and any mitigating factors.
• Ensure that all incidents of work-related violence are recorded and reported through appropriate health and safety systems, and, if appropriate, to the police.
• Have a clear and comprehensive policy in place for dealing with aggressive or violent patients, including the steps to be taken when considering removing such patients from a practice list.