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Seven reasons that 'zero tolerance' doesn't work

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Mention on social media that you have had an unpleasant experience with an abusive patient and I can guarantee that other GPs will rally round offering much needed comfort. You are also likely to hear the term ‘zero tolerance’ and be given the seemingly sound advice that you should not put up with any form of abuse and the offending patient should be struck from your list without a second thought.

I like to see GPs looking out for each other, but these online conversations leave me deeply troubled. My efforts to offer a contrary view have not gone down well.

While I share the belief that we should take any form of abuse in the NHS very seriously, I have major reservations about zero tolerance. In my view it is a blunt, ineffective instrument that makes us more vulnerable, not less, and strikes at the heart of what it means to be a GP.

I know many hard-working caring GPs will disagree with me, and the NHS gives its staff the right to practise zero tolerance should they wish.

And you can accuse me of being an idealist – I am incurable in that regard and fully intend to stay one - but please don’t call me naive. After 23 years in the ‘doctoring’ business, I have sufficient grey hair to refuse to accept that label.

There are seven main reasons I’m so against zero tolerance:

1 Zero tolerance means ducking your responsibility. Getting rid of all your badly behaved patients simply passes the problem on to neighbouring practices. We all have patients who kick off at times and we all need to take our fair share of the load. Refer them to the Violent Patient Scheme? For the violent patients, yes, but for every patient who screams and shouts? They just wouldn’t accept them, and it isn’t a practical solution in most cases.

2 Punitive measures are a poor way to bring about change. Throwing a patient off your list is not an effective way to bring about behavioural change. Quite the opposite, it is likely to enforce the belief that doctors are part of an establishment to fight rather than a support to value.

3 Opposing zero tolerance does not mean condoning bad behaviour. Abusive behaviour is serious whether it is physical or not and should be properly challenged. However, it is possible to care for someone without condoning their behaviour, and to stand firm against abuse without the knee-jerk reaction of throwing someone off your list.

4 Zero tolerance means refusing to listen. Showing a willingness to listen is often the best way to calm someone down. Once someone has been listened to, they often apologise spontaneously and you can challenge them to behave differently next time. It should be about helping someone to want to work with you, because they know you are on their side rather than doling out punitive threats.

5 Zero tolerance contradicts the unique spirit of general practice. What makes general practice truly remarkable is that we never discharge our patients. We never say ‘that’s not our specialty’, or ‘you’re too old’. We don’t judge and we carry on caring for our patients whether or not they listen to our advice or even whether we like them. Where else can people get that level of support? It’s why our patients are so doggedly loyal, despite the best efforts of the government and the Daily Mail. Throwing a patient off your list is the antithesis of this spirit, and should only be used as a last resort.

6 Restoring a good relationship with a difficult patient is rewarding. We teach our registrars how to handle an angry patient, why should we be reluctant to do it ourselves? GPs are some of the best communicators in the country. It takes a bit of time, but the investment is worth it in the end, results in fewer complaints and may just help us sleep better at night.

7 You don’t need zero tolerance to protect healthcare workers from violence. You don’t need tolerance to be set at zero to know that staff safety is paramount. If staff feel physically threatened by a patient, call the police; if there is a danger it will happen again, remove them from your list by all means.

However, at the other end of the spectrum, for patients who will never be violent but who have been verbally abusive, is zero tolerance really our only response?

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.

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Readers' comments (57)

  • We live in a world where the cart in in front of the horse, and we are punished needlessly.

    Just yesterday I spent my time and did my best for a patient but the outcome was not what he wanted. He left but returned to berate me for smiling as he left.

    He continued to verbally abuse me, for my attitude, my physical appearance, my skills as a doctor, and was shouting to the point half the practice came to see what the problem was. He only left when the police were going to be called.

    He returned to make a formal complaint.

    This is the world we live in - where you get abused, but then have to defend yourself against a complaint, supported by one of the new quangos who's sole purpose in life is to help patients in their complaints against GPs.

    Just another reason why you wonder if it is still all worth it.

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  • I feel the writers comments although well meaning are a little out of date.

    Commendable but quaint sentiments.

    However there are paid for quangos such as CQC , GMC and Healthwatch whose sole purpose is to destroy dr's lives. Just look at the weasel words from the GMC with respect to dr's suicides.

    The world has changed and we have to change with it. Being simple nice but dim will destroy us.

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  • This article is a long apology for poor patient behaviour - we should never have to accept physical or verbal abuse, as much as patients should expect their doctor to be polite and welcoming. We have so few areas that we can control in our working lives and so many ways for patients to complain and it is depressing to find the attitude that we should always try to understand patient's motives and be resilient to abuse, even accept it as part of being a doctor.

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  • This is what you get when you expect and encourage a Liberal society.

    Where every sign of "nastiness" in human beings is given a clinical diagnosis of some sort.

    This then excuses the "bad" behavior and gives people the excuse they need to no longer act in a responsible and human like way.

    For some people zero tolerance is the only way. Punishment, not treatment, is what a lot of people are lacking.

    We need to accept that some people are just bad, not ill and they must be treated accordingly. It is no coincidence that since we stopped punishment as a society the prisons have become fuller and fuller and crime against the person continues to rise.

    Before the criticism starts flooding in, I am not advocating bringing back the birch, hanging nor drawing and quartering merely that, without boundaries and basic discipline, the human race reverts to animal instinct and that goes for some patients who believe that they can have whatever they want and that General Practice, and every other "Public Service" is merely a slave to their demands.

    "If you don't give me what I am entitled to (Want) I will make your life hell until you do and guess what?" "I don't care because there are no consequences."

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  • Some close minded patients need a reality check of respect, dignity and how to talk to people. If you dont respect GPs and hospital staff why do you care if you wait 3 weeks to see us? And then why do you want to see us in the 1st place. Go to medical school there's a recruitment crisis.

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  • Dr Brunet

    Do you have any self respect at all?

    I could not disagree with you more.

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  • Dr Brunet can you tell us what vacancy rates you have on the local Guildford VTS scheme you run?

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  • Good points in spite of the "abusive" Readers' Comments. Perhaps this is where Zero Tolerance should be applied?

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  • "Abusive" Reader's Comments.... LOL

    He is willing to listen after all.

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  • Sorry this is nonsense. Zero tolerance is just that and is the only protection NHS staff have against the small but very loud and over bearing minority of patients. We need to use it at every opportunity to get rid of patients and look after our staff and very importantly ourselves. Sorry Dr. Brunet you are just WRONG!

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