How to respond to difficult patients

A handful of awkward patients can make life a misery for a practice. It's worth having procedures in place in case problems arise, says MDU adviser Dr Michael Devlin

GPs may have a good relationship with most of their patients, but there will generally be a few who can be rather more awkward. It is very easy for their appearance in the surgery to bring disruption to GPs, staff and other patients.

There were nearly 3,500 physical assaults reported by NHS staff in 2008/9, and a Medical Defence Union survey published last year found 58% of GPs and hospital doctors said they had been physically or verbally assaulted in the past five years [1,2 ].

Only a minority of patients are abusive or aggressive, but 81% of the respondents to the MDU's survey had encountered a patient making what they considered to be ‘unreasonable' demands.

Managing violent or aggressive patients may be seen as part of the job, but GPs and practice staff can understandably feel vulnerable. However, practices can prepare their staff and look at the surgery environment to try to reduce or minimise the opportunities for aggressive or violent behaviour. Here I look at how.

Assessing risk

Look at any risks posed by the physical location of the premises and its security. It is possible to seek advice from your local police station or the NHS Security Management Service about the security of the premises and measures such as installing CCTV or panic buttons.

Consider which staff and which areas are at high risk. GPs and nurses are particularly at risk because they see patients one to one. But receptionists are often the first person an aggrieved patient will see. Consider training staff in conflict resolution.

Outside the surgery, it's a good idea to devise a protocol for staff carrying out home visits. This should include taking special precautions with any patient who has a history of violence, such as trying to avoid seeing them alone or at their home.

Ideally, the primary care organisation will have arrangements in place so the patient can be seen at a suitable, safe location. If this is not possible, try to arrange for the GP to be accompanied by a colleague and make sure practice staff know their whereabouts.

Training staff

Incidents where patients become aggressive rarely happen out of the blue. Staff should be trained to recognise problems, defuse difficult situations and protect themselves.

Long waiting times, patients feeling their concerns are not being taken seriously or disappointment with treatment outcomes can all be triggers for anger or aggression.

Advise your staff to watch for outward signs a patient may be losing control. These include raising the pitch and volume of their voice, becoming red in the face, clenching fists or pointing, encroaching on personal space, using threats, refusing to communicate or becoming restless.

Suggest simple techniques to calm the patient such as listening to what they are saying, maintaining (but not prolonging) eye contact, asking open-ended questions and acknowledging grievances.

If the situation is escalating, the member of staff should maintain an adequate distance from patients – but keep away from corners – and try to keep between the door and the patient. If appropriate, use the panic button, call for help or leave the room and seek help from security or the police.

Since 2003, PCOs have been responsible for ensuring strategies are in place to tackle violence against staff, including training in conflict resolution. Your PCO may be in a position to arrange suitable initial training.

There are other techniques staff can learn and the NHS Security Management Service website [3] may be a good source of material with which to train your staff.

Encourage junior staff to come to senior colleagues to discuss any problems.

Responding to difficult behaviour

It's important the practice's response to difficult behaviour is measured and proportionate, bearing in mind that in some cases the patient's behaviour may be influenced by their condition.

The most appropriate initial response is usually to write to the patient, explaining why their behaviour was unacceptable and the effect it has had on other patients.

It may be occasionally be appropriate to invite a patient in to discuss their needs and how they can be accommodated.

Unless a patient has been violent or aggressive (see below), only consider ending a professional relationship where the doctor-patient relationship has irretrievably broken down, despite reasonable efforts to rectify the situation.

The last resort

Practices are usually contractually obliged to give the patient a warning in the 12 months before removing them from the list. The GMC says you must be satisfied your decision is fair (Good Medical Practice, paragraph 39). GPs should keep clear and detailed notes of any incidents, steps taken to resolve the situation, reasons for the removal and the process followed.

If a patient has been violent and you decide to remove them, report the incident to the police and get an incident number before informing the PCO. If information needs to be disclosed to the police, it should be the minimum necessary (rarely medical information) to allow for full investigation.

Notify the PCO in writing within seven days in order to comply with contractual commitments. When a patient has been violent and you fear further violence, it will be the responsibility of the PCO to arrange primary care for them. Such incidents should also be reported to the NHS Security Management Service.

Dr Michael Devlin is deputy head of advisory services at the Medical Defence Union. The MDU offers free practice-based seminars in this area and others – see www.the-mdu.com