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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)

  • The tide has turned. GPs will not continue to tolerate abuse. Why should they or any others in society accept this as part of their job.

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  • Having to put up with abuse from patients or from professional bodies like the GMC, CQC etc is making the job of a GP totally intolerable. This is the cause of the GP recruitment crisis and has to be addressed quickly. If not there will be no GPs left.

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  • The GMC suggests that future Doctors should undergo 'resilience training' to cope with patient complaints.

    Why would any person wanting to be a traditional family GP choose to work in a job where, in order to survive, one needs 'resilience training' to cope with abuse?

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  • Dr Brunet you are wrong..no,no...

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  • Vinci Ho

    SIGH....Martin........
    Why do you want to write this article in the first place?
    I just wonder if it matters whether it is different in different practices in different areas these days??
    If the practice is constantly bombarded by problems like these ,we are all just human.......
    'When angry count to ten before you speak.If very angry,count to one hundred' Thomas Jefferson
    Problem is can you really get every angry person to do that???

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  • Vinci Ho

    If Terence Stephenson from GMC alluded to the assumption that doctors in NHS are like fighting in Afghanistan these days, would it mean we have to 'readjust' our traditional mentality as a doctor????
    A lot of 'soul searching'..........(just like this terminology at the moment)........

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  • gp's are tired stressed and burnt out - people like you are part of the problem - not the solution - encouraging more demanding patients to become more aggressive when they dont get their antibiotics for that 2 hour old sore throat.
    please place yourself on the same pedestal as that ridiculous nurse who suggested taking legal action against gps for missing dementia.

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  • This comment has been moderated.

  • Contrary to the consensus, I think this is a helpful article which actually landed after I had a difficult and heated consultation with a very demanding patient.
    In retrospect I feel I could have handled it better and found your article thought provoking.
    Well done!

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  • Dr Brunet,
    I disagree with you more or less completely: if people are aware that there are no consequences for bad behaviour a minority will behave badly. If they know that there will be consequences for verbal or physical abuse (be it off-listing, being moved onto a violent patients scheme or being arrested), they will be less likely to do it.

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  • If this GP had some experience outside the UK, he'd see how medicine can work when patients have (and therefore engender) respect. He'd easily see how wrong he is, despite his heart being in the right place.

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