Violence in General Practice - Guidance for General Practitioners

Introduction

The Terms of Service have always allowed GPs to remove a violent patient from their list.  Patients removed in this way were then allocated to the list of another GP and few if any attempts were made to deal with the source of the problem.

In January 2000 the Department of Health issued HSC 2000/01 instructing Health Authorities to introduce local initiatives as part of the Zero Tolerance Campaign.  In addition, an important change was introduced in December 1999 to the National Health Service (Choice of Medical Practitioner) Regulations 1998. This took away from patients, who had been removed from a GP’s list for violent behaviour, the right to be allocated to a GP near to their home and allowed the setting up of specialist centres to deal with these violent patients.

HSC 2000/01 established the following definition for violence:

Violence’ means: -

Any incident where a GP, or his or her staff are abused, threatened or assaulted in circumstances related to their work, involving an explicit or implicit challenge to their safety, wellbeing or health.

The definition does not define violence just as physical assault but also includes threats to challenge the “safety, well-being or health of staff”.

Staff and Doctors do not, therefore, have to tolerate behaviour that falls into the above definition whatever its cause.

How to Remove a Patient

Where a patient’s behaviour falls into the above definition, GPs can remove a patient IMMEDIATELY from their list. To do so GPs must do the following:

1.  Call the Police

If the incident is taking place and the patient is posing a threat to staff or other patients call the police immediately.  GPs should be aware that the police response time will vary depending on the location of the surgery and the circumstances at the time.  The response time may be up to 10 minutes in urban areas and 20 minutes in rural areas.  If a GP believes there is a threat to life or serious injury this should be explained to the operator. Once the police have resolved the problem they will give you an incident or a crime number.

2.   Informing the Police

If the patient has left the premises and there is no immediate danger the Police must be notified of the incident.  There is no necessity for a GP to obtain a crime or incident number. It is preferable to advise the police of the incident in writing setting out the name of the patient, address, date of birth and a brief description of the incident.  The police will take no further action unless the incident was serious and the GP wishes to take legal action.  The police may, however, record on their intelligence database the details of the patient who caused the incident.  Alternatively the GP can inform the police by phone or fax, but a record must be kept of the incident.

3.   Notification to Primary Care Support England (PCSE)

Notification of immediate removals should go to PCSE using their FORM

The information provided must include:

• The patient’s name, address and date of birth
• Brief details of the incident that led to the request
• Confirmation that the police were notified of the incident or were called to the incident.

There should be no delay in notifying PCSE as the removal takes effect from the time the notification is received.  Immediate removals may not be accepted if reported some days after the incident unless there is very good reason for the delay. 

4.  Where the doctor wishes to immediately remove a temporary resident

The procedure will be the same as if the person were on the list.

5.   Notification to the Patient

The practice must take immediate steps to contact the patient informing them of the action that has been taken.  The patient should be informed in writing to their home address.  Although GPs are not obliged to give any reason the LMC would strongly advise GPs to do so and to be clear that the reason is due to the patient’s violent or intimidating behaviour.

6.     Relatives

Family and other household members cannot be removed immediately.  GPs must notify PCSE in writing and the removal will take place in the normal way on the eighth day after PCSE has received notification or when the patient has been accepted by another GP, whichever is the sooner.

It is not automatic that other members of the household should be removed at the same time. However, there may be circumstances where a GP believes that because of the possible need to visit patients at home or because the violent patient may accompany other family members to the practice, it is reasonable to terminate the responsibility for other members of the family or the entire household.

Only the patient who has actually been violent, will be referred to the Violent Patient Service, other family members will be allocated to other practices who will need to be made aware of the reasons for the removal.

It is advisable to write to the patient setting out the reason for their removal.

What happens after a patient has been removed?

All Kent CCGs provide schemes to allocate violent patients to a Violent Patient Service (VPS).

The patient will be informed of their allocation and the reasons by the CCG.  The patient will access services via a centrally operated call centre number operated by Primecare in Birmingham (Tel: 0845 6076624).  The patient will be allocated to one of the practices taking part in the scheme.  The patients will be seen by appointment only and at a location agreed by the GP. 

Patients who access Health Call out of hours are triaged by a nurse or doctor as appropriate and if the patient needs to be seen they will be directed to their nearest A & E Department.  Out of Hours Co-operatives will be informed of the patients who have been allocated to the VPS, as will surrounding practices if there is reason to believe that a patient might seek emergency or immediately necessary treatment rather than using the VPS.  Other practices should refuse to see such patients and are not obliged to provide immediate and necessary or emergency treatment.

After a patient has been removed, practices will be asked to complete a reporting form (see Appendix 1) and will probably be contacted by phone by the VPS doctor to whom they have been allocated.  Please co-operate with these procedures.  The intention of the scheme is not to create a ‘sin bin’ but to try to resolve the patient’s problems and to return them, within 1 year to ordinary general medical services.

The CCG reporting form should also help the practice identify any lessons that can be learned from the incident.

Legal Action

HSC 2000/01 sets out what powers the Police have and what happens when there is sufficient evidence to mount a prosecution.  Practices will be encouraged to ask the police to press criminal charges to provide a strong message to the public that violent and abusive behaviour will not be tolerated.  The LMC will assist practices with advice on the appropriate action.

Primary Care Support England (PCSE)

On receipt of the email from the surgery, PCSE will immediately take the following action:

Notify local practices that the patient has been put on the VPS for their information should the patient attempt to obtain treatment or to register elsewhere.

• Send a letter to the patient informing him/her of the immediate removal and explaining how he/she can access General Medical Services in the future.
• Send a letter to the GP operating the Violent Patient Service informing him/her of the assignment of the patient and enclosing a copy of the letter sent to the patient and also a copy of the letter from the previous GP explaining the reason for removal.
• Send a letter to the previous GP confirming that the patient has been immediately removed from his/her list and enclosing a copy of the letter sent to the patient.
• Notify Out of Hours providers when patients are entered on the Violent Patient Service list or removed from it.