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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)

  • agree - under current situation

    clinician is always wrong hence guilty until proven innocent, multiple jeopardy etc and public is always right - hence support from state etc.

    try suing your solicitor to see a group of professionals who are on the ball with client - supplier contracts.

    the only way to resolve it is having an individual supplier-purchaser contract with rights/responsibilities. will it happen - never as the bleed-in hearts will rather General Practice be destroyed than agree. we are doomed i tell ya ... doomed.

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  • I work in oz, 0 tolerance is the norm - patients much more well behaved. Having worked 4 years in London as a Partner and 2 out here…Dr Brunet you are wrong, very wrong. You are actually part of the problem. Our profession needs to regain its dignity in the UK, your approach worsens it for all. Have some guts and stand up to poor behaviour

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  • Dr Brunet you are not out of date, in fact you are right on target. This problem will not go away and will only increase. You can't manage this with anger, disposal and dismissal or you will be on here still talking about it next year, year after......with a stress related illness. Invest in managing this and learn from your peers.

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  • Well said Anon 7.05pm. Dr Brunet is right on target. It is the dissenters who are have the Messiah Complex NOT Dr Brunet.

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  • Me thinks 705 and 731pm aren't gp's.....probably patients who have been rude!!! Should be 0 tolerance to trolls....

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  • I don't think Dr Brunet is being naive. He is simply advocating a "thought through" response. Kicking a patient off your list is very tempting, but leads to more work for colleagues at another practice. As a previous commentator said, it is rather like parenting - setting clear boundaries and trying to work through the problems. I do note he is not saying this approach is suitable for all patients, rather that zero tolerance should be a last resort.

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  • The problem is analogous to the various penal systems of the world. New York is far safer and people are better behaved since Mayor Giuliani's 'three strikes and you're out' policy.

    The problem is that it has become the norm for people to shout and complain everywhere. It is not just in primary care. We see it in Post Offices, Banks, Shops..

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  • There are some valid points made here with regard to tolerance and patient education. If that was the whole story, then i would agree wholly with the article. And of course, a degree of understanding and insight into the fact that fear may sometimes drive "out of character" behaviour is commendable.

    However, what seems to be entirely overlooked is the simple right of the professional not to be expected to tolerate abuse. If we accept abuse, we devalue ourselves, as well as the work which we do. And, not only are we highly trained professionals, but also human beings with feelings and and (arguably) a pretty fundamental right not to be subjected to any form of violence or abuse.

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  • Possibly the worst article I have ever read on Pulse. In answer:
    1) Don't care, off my list
    2) Don't care
    3) Irrelevant
    4) Really don't want to listen to abuse, thanks
    5) What???
    6) So is throwing them off the list
    7) But it helps

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  • Yes and another successful example of zero tolerance to rudeness and inappropriate behaviour is Singapore.

    I know Doctors who work there and find the job very enjoyable.

    Thirty years ago patients were well behaved in the UK, but not anymore. Enough is enough.

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