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Independents' Day

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)

  • I don't think Martin is saying we should accept all sorts of verbal abuse. My understanding is that he is saying we shouldn't knee jerk throw them off the list, which I agree with.

    However, all dysfunctional behaviour should have consequences, otherwise it is simply reinforced. This could include DNAs, verbal abuse or personal attacks. Any of these things should be managed with warning letters clearly outlining what the practice policy is and what is and isnt unaceeptable behaviour (super nanny would be very good at this!)

    If behaviour continues, despite warnings, then action has to be taken and sometimes that action will be removal from a list. Without the follow through, the warnings are just empty threats and are meaningless.

    It's no different to raising kids, really!

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  • NB - when I write personal attacks - I dont mean physical but verbal

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  • This sounds like a very mature GP to me. Perhaps the dissenters should question whether they are really up to the job. I suspect Martin deals with difficult patients very well, and thumbs-up to him, for wanting to remain an idealist after 23years in the job.

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  • We are not allowed to remove patients from the list without good reason - this is considered prejudicial.

    1)The problem with accepting responsibility is that a malicious complaint can lead to responsibility to answer to the GMC. This is no longer the benign institution it once was - regrettably you have to protect your back. I wish it wasn't like this, but this is reality.
    2) Occasionally when it is pointed out that people are behaving irresponsibly the do apologize after reflecting on their behaviour (rare I know)
    3) It is difficult to care for someone when you are afraid what they will do next.
    4) 'Listening' is a weasel word which is often confounded with capitulation. There is a limit to how much abuse any one person can hear without it adversely affecting the care they give to others
    5) There is no 'unique spirit' in GP land - hospital doctors also aim to provide professional non-prejudiced, tolerant and friendly care. The public increasingly view us in terms of a consumer/provider relationship as demonstrated at last weeks vote.
    6) I think it's difficult to truly restore a relationship with someone who is threatening even if it is verbal. Vexatious complaints are very risky to doctors these days.
    7) Actually you do need zero tolerance to avoid violence because it usually arises from other forms of abuse. Sadly there are a group of people who know just how menacing they can be and get away with it but there is a risk they will lose control one day. Medical staff have actually been harmed by such patients - the risks are very real.

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  • Anonymous 11.01,
    You have my full support. We GPs are so accepting of patient behaviour. We are terrified of complaints and the yes sir, patient need, idea, expectation mantra has devoid us of all authoritative voice.

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  • Dr Brunet. I would hate to work in your practice.

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  • Quite a ridiculous article really - whilst trying to appear to take the moral high ground you have ended up looking silly and somewhat dangerous . Ask yourself maybe there is a reason why your opinions haven't gone down well ? Because you're simply wrong and don't have the insight to realise it yet.

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  • Is it sensible that this person runs a GPVTS scheme?

    The article is naive to say the least for reasons described above.

    I'm not sure it wouldn't have been overly simplistic in the 70's let alone now!

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  • So allow patients to shout at and verbally abuse you whilst we apologise for making them angry and say come back in a month?

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  • This comment has been moderated.

  • Another one with the messiah complex.Pity the muppets on his VTS scheme.

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