Policy Framework for the Facilitation of Managing Violence in GP Surgeries

Policy Framework for the Facilitation of Managing Violence in GP Surgeries

NHS North of Tyne

Primary Care Organisations in Northumberland, Tyne and Wear in collaboration with Northumbria Police

Document Control

Owner / NHS North of Tyne
Version / 2.0
Approval Body
Issue Date / August 2010
Review Frequency
Next Review Date
Author / Northumberland Tyne & Wear SHA Tackling Violence Working Group on behalf of Primary Care Organisations in Northumberland Tyne and Wear

Revision History

Date of this revision:August2010

Date of Next revision:

Revision Date / Version / Summary of Changes / Changes Section
03.08.2010 / 1.0 / PCO Framework for Managing Violence in GP Practices
03.08.2010 / 2.0 / NHS NoT General updates to names of organisations including provision of the Violent Patient Scheme by a service provider

Distribution

This document has been distributed to:

Name / Title / Organisation / Date of Issue / Version

Warning! References to Primary Care Trust, PCOs, FHSA and other NHS Organisations are subject to change as the current organisational process is concluded
Policy framework for the facilitation of

managing violence in GP surgeries

1Introduction

2Responsibilities

3Training

4Protocol for handling incidents.

5PCO/FHSA Procedure for Removal, Re-allocation and Marking Records of Violent Patients

6Secure Premises

7Violent Patients working arrangements

8Templates

Appendix 1.Developing a Practice Strategy

Appendix 2.Risk Assessment Guidance

Appendix 3.Expected Responses

Appendix 4.What happens after a case is reported to the Police

Appendix 5.Treatment of Patients

APPENDIX6.CCTV Code of Conduct in relation to Data Protection Act 1998………………………………………… 42

Appendix 7.POSTER Expected Standards of Behaviour

Appendix 8.Training Strategy

1Introduction

The information included in this policy is intended to support the protocol between Northumbria Police and Northumberland, Tyne and Wear Strategic Health Authority and Primary Care Organisations.

The documents outline arrangements that GP surgeries can undertake to prevent violence taking place, and where violence does take place, to minimise harm to the victims and take action to prevent repetition in future.

Northumberland, Tyne and Wear Strategic Health Authority and Primary Care Organisationsare signed up to the NHS Zero Tolerance Zone campaign.

The NHS Zero Tolerance Zone campaign has two principal aims:

• to communicate to the public that violence against staff working in the NHS is unacceptable and the Government (and the NHS) is determined to stamp it out; and
• to communicate to all staff that violence and intimidation is unacceptable will not be tolerated and is being actively tackled.

The definition of work related violence:

“Any incident where staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, well-being or health.”

While a threatening act or an assault is relatively easy to define, abuse may b

more difficult. Based on the expected standards of behaviour in the NHS Zero Tolerance Campaign the following actions should be considered to be abusive when directed toward practice staff, other patients or members of the public and would fall within the definition of a violent incident:

• Abusive language e.g. swearing or offensive remarks
• Racist or sexist remarks
• Offensive sexual gestures or behaviour
• Malicious allegations relating to members of staff, patients or visitors
• Excessive noise e.g. loud or intrusive conversation or shouting
• Threats or threatening behaviour
• Abusing alcohol or drugs in practice premises, (However, all medically identified substance misuse problems will be treated appropriately)
• Drug dealing
• Theft from other patients, staff or theft of equipment
• Vandalism to the building, furniture or equipment

2Responsibilities

2.1GP and other employers’ responsibilities

It is the responsibility of all employers to assess the health and safety risks to their staff that arise from the activities they are involved in. Employers must take all practicable steps to remove, reduce and control the risks to their staff and others who might be affected (e.g. other patients). A legal duty of care is placed on them to do so. Breach of this duty of care may place employers at risk of subsequent litigation. Violence is accepted as a health and safety risk.

Guidance on developing a practice strategy to reduce the risk of violent incidents is provided in Appendix 1

There is no single solution to preventing violence, but there should be, as a minimum, a full assessment of the risks. Risk assessment should be comprehensive and carried out by the appropriately trained staff. Guidance on performing risk assessments is included in Appendix 2.

2.2 Practice managers responsibilities

Managers have a key role to play in tackling violence in the NHS. Appendices

1 and 2 identify some of the things that can be done to reduce the risk of violence and aggression against staff and explain how to deal effectively with violent incidents when they occurEstablishing procedures for dealing with violent situations will help members of the practice gain the confidence to handle such incidents.

2.3Employee responsibilities

Staff working in the NHS should report all violent or abusive incidents to their

managers and, where appropriate, incidents should be reported to the police.

Above all, staff should not feel that they have to cope alone with violence, that

it is part of the job, or that they do not have the support of their employer or

local Primary Care Organisation.

3Training

Staff safety must be the paramount concern. They should not be knowingly put in situations that make them feel unsafe. However, if they are, they need to know how to deal with them.

Appropriate staff training is therefore crucial. Managers should assess the risks to staff and analyse their training needs. In doing so it will be possible to gauge the sort of training they require according to their roles and ensure that this is appropriate to the degree of risk an individual employee faces.

Support staff should not be overlooked in this process, includingcaretakers andcleaners.

3.1 Context and content of training

The theory behind violence at work is to understand:

• why it occurs and how any individual could be a potential aggressor given a certain set of circumstances.
• how staff actions may contribute to or exacerbate a violent situation.
• Provide the ability to recognise a potential violent incident in the making and to take appropriate actions to counter this.
• Diffusion or de-escalation training is the most suitable approach for equipping staff to deal with the frustration and aggression of patients, family, friends and bystanders.

A risk assessment (see Appendix 1) will identify whether other types of training, including training in physical techniques, are appropriate. Ideally, managers should receive the same training as their staff to ensure continuity.

3.2 Training provision

Primary Care Organisations will support employers in the implementation of

this policy by providing appropriate training on all aspects of violence in GP

Surgeries. This will be undertaken as part of their overall Training Strategies.

See Appendix 8 for guidance on training approaches and appropriate training.

4Protocol for handling incidents

The protocol does not seek to outline every option/avenue that staff at GP surgeries could be faced with; it merely seeks to highlight the considerations available. In particular, in respect of risk assessments and action plans, each situation will need to be addressed according to the circumstances; the considerations listed merely being a starting point.

4.1 Standards of behaviour

The following are examples of behaviour that are not acceptable:

• Physical assault, attempted physical assault or threat of physical assault
• Abusive language e.g. swearing or offensive remarks
• Racist or sexist remarks
• Offensive sexual gestures or behaviour
• Malicious allegations relating to members of staff, patients or visitors
• Excessive noise e.g. loud or intrusive conversation or shouting
• Threats or threatening behaviour Abusing alcohol or drugs in practice premises (However, all medically identified substances misuse problems will be treated appropriately)
• Drug dealing
• Theft from other patients, staff or theft of equipment
• Vandalism to the building, furniture or equipment

A poster format of these standards is included as Appendix 7

4.2 Classification of unacceptable behaviour

Level 1 / General nuisance: Excessive noise e.g. loud or intrusive conversation or shouting,offensive gestures or behaviour (sexual or otherwise).
Verbal Abuse: Swearing or other offensive remarks e.g. racist or sexist remarks or malicious allegations in relation to members of staff, patients or visitors.
Level 2 / Criminal Damage/Vandalism: Deliberate damage or vandalism to the building, furniture or equipment.
Theft: Theft from other patients, staff or theft of equipment.
Other inappropriate behaviour: e.g. Abusing alcohol or drugs in practice premises, drug dealing.
Level 3 / Threatening Behaviour
Level 4 / Violent Behaviour
Level 5 / Physical assault or attempted physical assault
Level 6 / Dealing with patients referred to the scheme

4.3 Recommended actions

First Incident / Subsequent Incidents
Level 1/2 /

• Verbal Warning from practice manager or GP

• Report to police if appropriate

• Record incident

• Consider written warning to patient

• Conduct risk assessment and implement recommendations

/

• Agree actions between the GP and PCO

• Consider removal from practice list

• Consider adding violent marker to patient record

Level 3/4/5 /

• Contact Police

• Record incident using the relevant incident form

• Conduct risk assessment and implement recommendations

• Agree actions between the GP and PCO

• Add violent marker to patient record

• Consider removal from practice list

4.3.1Verbal Warning

GP or other senior member of practice staff will explain to the patient that

his/ her behaviour is unacceptable and explain the expected standards

that should be observed in future. It should be made clear that the

patient may be removed from the list if there are further instances of

unacceptable behaviour.

4.3.2Report to police

If an immediate threat of violence is present, call the police using the

999 emergency call system. The Police will make every effort to respond

within the agreed Northumbria Police targets. If the immediate threat is

passed, call the local police station to report the incident. Obtain a

crime/incident reference number from the Police. If the immediate threat

has passed call the police using the non-emergency contact number.

4.3.3 Record incident

When considering how to counteract violence it is helpful to know the

extent of the problem. It is important that the number and nature of

incidents of violent or threatening behaviour in general practice are

highlighted. To this end a report from should be completed for each

incident of violence or abuse that happens in a practice (see section 8.2)

4.3.4 Written warning

Continued behaviour, outside the expected standards, should result in a

written warning detailing the conditions for future treatment (see template

letter, section 8.1)

4.3.5 Risk assessment

Prevention of violence at work must start with a full assessment of the

risks. Risk assessment should be conducted prior to or following an

incident to determine appropriate countermeasures to reduce the risk of

incident occurring/re-occurrence. Guidance on risk assessments can be

found in Appendix 2.

4.3.6 Agree action plan with PCO

Where a patient has demonstrated behaviour likely to be a risk to staff a

referral should be made to the Violent Patient Scheme Provider, Primary

Care North East based at Scotswood GP practice (PCNE). PCNE will

review the referral and feedback to the practice with two working days

and an action plan will be agreed.

Where there is clear evidence the patient has transgressed acceptable

behaviour standards, a warning may be displayed on the patients file and

communicated to other relevant professionals, specifying the risk posed

by the patient. This information should be shared with community

(nursing, mental health, social services etc) colleagues likely to come into

contact with the individual. The patient should be notified in writing and a

copy of this letter placed on the patients record.

Where the patient is being removed, the practice will notify the NEFHSA

using the Removal of Patient form (see section 8.5) and the appropriate

removal notices and patient record markers established. If it is felt that the

patients behaviour is such that it could be managed by another practice,

the NEFHSA will send the patient a list of practices where they can

re-register.

If this is not a suitable course of action, the patients will be dealt with via

the Violent Patient Scheme and allocated accordingly to the PCNE

service. PCNE will notify system partners of the acceptance of the patient

onto the VPS.

• Review/Removal of potentially violent warning

If no further incidents occur, the potentially violent classification will be reviewed in 12 months. Where the warning is retained, even though no incidents have occurred, reasons must be justified and a written copy kept with the patient medical record.

Where the warning marker is to be removed, the decision will be communicated in writing to the patient by North EastFamily HealthServices Agency. A copy of the letter must be kept with the patient medical record.All warning markers, on both manual and electronic records must be removed.

4.3.7 System Care Pathway

5.PCO/FHSA procedure for removal, re-allocation and marking records of violent patients

5.1 Role of the practice

The practice will be responsible for identifying the problem, carrying out a risk assessment and issuing the patient with an initial warning letter about their behaviour. If the problem persists or a Level 3, 4 and 5 incident occurs, the practice should in the first instance discuss the issue with the service provider.

5.2 Role of the PCO

PCNE will discuss the problem with the practice and, together, decisions will

be made about future provision of General Medical Services to the patient

and whether their records should be marked to indicate that they are a violent

patient. PCNE, when notified, will conduct an assessment of patients moving

into the region who are on a Violent Patient Scheme in another PCO area.

They will also liaise with representatives from MAPPA / MARAC regarding

assessment of individuals subject to the MAPPA process.

5.3 Role of the FHSA

On being informed by the PCO, the FHSA Registration Manager will write to

the patient informing them why they are being removed from the practice they

are currently registered with and giving details of the practice they are being

allocated to. The letter will also inform the patient about their records being

marked and their rights in this situation. The FHSA will also arrange for the

patient’s records to be fast-tracked to the new practice on the same working

day.

5.4 Procedure

Practice identifies problem

• Practice carries out risk assessment

• Practice issues patient with warning letter if appropriate

Outcomes:

Situation resolved / No further action
Repeated levels 1 or 2 incidents / Practice contacts Nominated Lead at PCO to discuss appropriate action.
Escalation to Level 3, 4 or 5 incident
“Out of the blue” level 3, 4 or 5 incident

NB: Protocol with Northumbria Police should be followed with regard to

involvement of Criminal Justice System

5.4.1 Where a patient is removed but not assigned to the Violent Patient

Scheme

If the situation cannot be allowed to continue and the patient must be

removed from the practice, discussions will focus on the following

possibleoutcomes:

• If it is felt that the patient’s behaviour is such that it could be managed by another practice, the NEFHSA will provide details of alternative practices tothe patient.

• If itis felt that the patients behaviour is such that it could be managed by another practice but it is inappropriate fo the patient to select their own practice, the FHSA will work with the PSCA Commissioning lead to assign the patient to another practice.

Violent Patient Register

Decision to be made whether patient’s records to be marked to indicate

risk of violence. If a Level 3, 4 or 5 incident has taken place, this should

be automatic.

5.4.2 Action by the FHSA

Following notice from the practice and PCNE the Registration Manager

at the NEFHSA will ensure the registration system is properly updated.

• Allocation to another practice or the Violent Patient Scheme.

• Marking patient’s record to indicate risk of violence where appropriate.

• Letter to the patient on behalf ofPCNE, by registered post, indicating:

- the action that has been taken;

- how the patient can contact their new GP practice or the VPS.

• Details will also be provided of the date for review by the Service Provider of the violent warning marker and the patient’s right of appeal.

• NEFHSA Registration Manager arranges for the patient’s records to be transferred to the new practice or PCNE within 1 working day.

5.4.3 Further Action by the PCO

PCNE will agree directly with the removing practice acceptance of tients

deemed suitable for the scheme.

PCNE will, within their own procedures, inform other relevant agencies

and personnel of the violent warning marker, e.g. community staff,

social services, A&E and out-of-hours provider(s).

Where the service provider of VPS believes the patient is not suitable for

the scheme they should advise the practice to contact the FHSA to

request a seven day removal.

Where the NEFHSA believe it is necessary to callocate a patient subject

to seven day removal, rather than allowing them choice of practice, they

should work with the PCSA Commissioner to idebtify a practice and

ensure both former and new practice are aware of the change in

responsibilities.

5.4.4 Appeals Process

PCNE will ensure that any appeal by the patient against the violent

warning marker is handled according to locally agreed procedures.

The FHSA Registration Manager will remind PCNE when the date for

review of the violent warning marker is imminent. PCNE will then take

the matter to the appropriate review committee.

PCNE will carry out its own review of the patient’s progress with the

new service.

6. Premises

PCNE will ensure arrangements have been made for patients identified as being suitable for the Violent Patient Scheme to be registered with or treated at an appropriate location by staff whohave had additional training in managing potentially violent patients.

7. Violent Patients working arrangements