GP practices are facing increasing physical, verbal and social media abuse. Eliza Parr looks at the consequences
There’s been no shortage of disturbing tales from GP practices about the rise in abuse towards staff in recent months. In May last year, a man was arrested for smashing up a practice in Northamptonshire, leaving one staff member needing stitches. At the end of the year, a practice pharmacist in Essex was hit in the head by a patient.
In January, a GP in Derby relayed to Pulse how she had seen her practice waiting room ‘torn apart’ by a frustrated patient, with police having to be called to the scene. Meanwhile, during the pandemic, the practice of Pulse columnist Dr Shaba Nabi was vandalised with anti-GP graffiti. At the time, Kent LMC chair Dr Gaurav Gupta said practices were being used as ‘a punching bag’.
This abusive and aggressive behaviour is indicative of a wider trend. Data provided to Pulse by police forces under the Freedom of Information Act show a 16% rise in crimes involving violence at GP surgeries since 2019, after a drop in incidents during the pandemic. Crimes involving public order offences and harassment went up by 15% and 61% respectively, while those associated with race or religion, such as assault or inciting fear increased by 100%.
In some areas, the uptick in incidents of abuse has been serious enough to be raised by police authorities. In Leicester, the police commissioner reached out to GP leaders to discuss ways to tackle the issue, suggesting to the LMC that GPs report ‘absolutely everything [to] make an example of it’. In February last year, Londonwide LMCs medical director Dr Elliott Singer told Pulse local GP leaders were working with the Met Police on guidance for minimising violence against staff.
For many GPs, there is little doubt that this is associated with the crisis in general practice. It coincides with a drop in patient satisfaction and problems with access. While these problems are born of an increase in demand and reduction in workforce, practices are taking the blame. This is not helped by parts of the media throwing fuel on the fire and a lack of support from ministers and NHS England.
But these isolated incidents of violence and criminal abuse, while devastating for those involved, are arguably not the most damaging issue for the profession as a whole. More worryingly, practices are dealing with constant low-level abuse. In a Pulse survey of 1,000 GPs carried out late last year, three-quarters of respondents said they and their staff experience verbal abuse from patients on a weekly basis, almost half said they or their staff have experienced physical abuse, while two-thirds reported abuse on social media. This has a real emotional impact on staff and forces some practices to change their processes to reduce the risks.
“I was called a Nazi”
‘He was posting daily – comments, abusive songs about us. He was very creative. He made things personal towards members of staff. I am the only manager in the practice, and he was personally describing me without mentioning my name, and likening me to the Nazis. It had become so extreme, he was saying he would love to just come down and smash the place up. Staff started to feel a bit on edge about who was coming in and the mood they were in – “Could this be him?” It messes with your head, I think’ Bex Cottey
‘It seems to be the go-to phrase that people have adopted: “Oh you Nazi”, “bl**dy Gestapo”. It’s very weird, really. It would be one thing to say “Oh you’re bl**dy useless”, or “you’re not listening to me”. But it’s such a hurtful, unpleasant thing to say. The terrible choice of language evokes war criminals and murderers, which is totally disproportionate – it’s really designed to hurt isn’t it?’ Dr David Coleman
Dr David Coleman and Bex Cottey, GP partner and practice manager at Conisbrough Group Practice, on a patient who was abusive to staff on social media
The emotional impact
RCGP chair Professor Kamila Hawthorne says Pulse’s findings are ‘deeply concerning as they show abuse is an increasingly common experience for GPs and practice staff who are working to their limits’. She adds: ‘We share our patients’ frustrations when they have difficulty accessing our services, but the vast majority appreciate that GPs and our teams are doing the best we can under intense workload and workforce pressures.’
Professor Hawthorne adds: ‘The reality is that having to work in these circumstances, with the additional worry that you may face abuse, sometimes on a daily basis, will have a significant impact on the mental health, wellbeing and morale of individual doctors and practice staff.’
One GP partner describes the confrontations with patients as ‘heartbreaking’. Dr Matt Curtis, who works at the Modality Partnership in Yorkshire, recalls an IT outage which led to a patient shouting ‘What if I die? It’ll be your fault’ at a member of staff. ‘The threat of physical violence is a constant possibility. Work is no longer a safe place,’ he says.
Chair of the BMA GP Committee for England Dr Farah Jameel, speaking to Pulse in a personal capacity, says she has carried a rape alarm since an incident in 2018, when she and two receptionists became trapped in the practice with a threatening patient who refused to leave without a prescription.
‘I had never felt so vulnerable in my life, and I never wanted to ever be in such a vulnerable environment again,’ Dr Jameel says. ‘You cannot pay me enough, you cannot look after me enough, to put me in that kind of working environment – it’s unacceptable.
‘And that’s what’s happening to a lot of doctors. We’ve got an unstable work environment where anyone can walk through our doors, we’ve got no security, no ability to feel safe by removing members of the public who behave in such a way.’
“When I stepped back, they kept coming”
‘What they wanted done was not something I would have been able to do, but they wanted it done there and then. When I tried to explain that, they stood up and started to get aggressive, and literally started coming at me. The body language was aggressive and they were coming towards me. So every time I stepped back, they kept coming.
‘I don’t know if they’d have actually done anything physical. But the sad thing is that if something like that happens, you think “even though I can do self-defence, I wouldn’t be able to”. GPs mostly get the blame for things. I don’t want that.’
A locum GP working in Bedfordshire in 2021 describes the threatening patient behaviour that led to her leaving the practice
A locum GP, who wishes to remain anonymous, says she left her Bedfordshire practice in 2021 after ‘three strikes’ of threatening patient behaviour. During one incident, when a patient started towards her as if to attack, she felt ‘unsure and unsafe’. She says: ‘As a female I didn’t feel comfortable, and I’m not leaving my house to experience this kind of thing every day. Feeling threatened at work – no.’
Last year, a GP trainee in the South West changed her route to work following an assault from a patient who became angry after waiting only five minutes. When she asked the patient to leave due to his verbal abuse, he stood up, grabbed her by the collar and pulled her towards him. ‘I think it will stay with me. It’s made me a lot more guarded and made me feel really exposed – people knowing how you get to work and recognising you around.’
“He grabbed me by my collar”
‘His body language was very aggressive so I stood up and opened the door and said “I’m inviting you to leave”. He then stood up and grabbed me by the collar of my scrub top and pulled me towards him, calling me a variety of names.
‘When the practice manager called him to tell him he was off-listed, he said he was going to “get me”, so it was quite worrisome for quite a while actually. It made me a bit fearful and made me look at people’s body language as they’re walking towards my room.’
A GP trainee in south-west England on a patient assaulting her during a consultation last year
Why is this happening?
Liverpool LMC secretary Dr Rob Barnett describes ‘a gradual increase in abuse’ in his area, of both verbal and aggressive behaviour, with non-clinical staff taking the ‘brunt’ of it. ‘The problem is: why are we getting into situations where patients are feeling so frustrated and so helpless?’ Dr Barnett believes the cost-of-living crisis exacerbates patient frustrations, but also says the NHS is broken.
In response to the attack on her practice, Dr Nabi said the public was being ‘fed a diet’ of anti-GP coverage by the media. Dr Asif Ghauri, whose practice pharmacist in Essex was attacked, said GPs were being ‘scapegoated for wider problems in the NHS, and the Government is going along with that narrative because it best suits their purposes now’.
Staff at other practices say patient expectation is a major problem. Managing partner at the Kingswood Health Centre in Bristol and director at the Institute of General Practice Management (IGPM) Robyn Clark argues that people are ‘used to getting an Amazon Prime level of service in many aspects of life’ and therefore expect the same from healthcare. When patients don’t get what they want, they ‘lash out’ at the first person they see, which is usually a receptionist.
“She said I caused her mother’s death”
‘The patient came to the front desk asking for her mother’s death certificate. When I said it would be sent to the registrar, the patient got incredibly angry. Her voice was raised, and she stated in a very loud voice that I had a bad attitude. She then turned to the other patients in the waiting room, saying the receptionists at this surgery deal with everything themselves, and are actually the cause of her mother’s death. It was because of us that her mother died of pneumonia. I felt totally embarrassed, and I did cry, which is not normal for me. I have worked here for nearly 14 years and this was probably one of the worst situations to deal with.’
An experienced receptionist in Yorkshire, on a patient who was verbally abusive earlier this year
The problems in secondary care can also increase patient frustration with general practice, even when the GP can’t do anything about it. Walsall LMC medical secretary Dr Uzma Ahmad believes ‘the system is not helping’ the issue of rising abuse. ‘Patients are experiencing long waiting times for outpatient appointments, for routine appointments in some specialties. That of course increases the pressure on general practice and patient expectation for things to be resolved – things that cannot be resolved in primary care,’ she says.
What is being done?
There has been some support. In October 2021, then health secretary Sajid Javid’s plan for GP access included pledges to help tackle abuse, such as a ‘zero-tolerance campaign’ and £5m to improve practice security. NHS England told Pulse in February it had developed national campaign materials, including posters and social media assets, to promote respect for all primary care staff, which had been downloaded 1,500 times since October 2021. But neither NHSE nor the Department of Health and Social Care would confirm whether this was the full extent of the ‘zero-tolerance campaign’.
ICBs have also taken action by launching communication campaigns to educate patients about the impact of abuse. West Yorkshire launched a ‘leaving a gap’ campaign asking patients to take a moment to think before speaking with staff, while Lancashire and South Cumbria ran a campaign called ‘Not in a Day’s Work’, aimed at reducing abuse. North Staffordshire LMC chair Dr Chandra Kanneganti says a joint social media campaign by the LMC and ICB has helped cut abuse in his area.
Some ICBs report uptake of the £5m security fund from Javid’s plan, with 49 practices in Northamptonshire receiving financial support, and 20 practices in Staffordshire and Stoke-on-Trent receiving a share of £95,000. New or improved security measures include CCTV, glass screens around reception, external lighting and access systems for internal doors.
But ministers seem to be moving away from targeted support. In March, when asked about abuse of GP staff at Prime Minister’s Questions, then-deputy PM Dominic Raab said the Government had ‘zero tolerance’ for abuse. But his solution focused on government efforts to improve GP access with ‘more support staff, and also the technology’. This ongoing fixation with access is clear in both the new GP contract for 2023/24, and the newly published GP recovery plan.
The BMA has criticised this aspect of the plan. In response to an incident in Nottingham, acting BMA GPC England chair Dr Kieran Sharrock wrote: ‘The GP Recovery Plan ramps expectations but delivers no support and patients get angry – no surprise. Another example of Steve Barclay and Rishi Sunak’s failings causing patient distress and doctor risk.’
The case Dr Sharrock was commenting on was indicative of the abuse practices are facing. GP principal Dr Paramjit Panesar had called the police when a patient behaved threateningly. He tweeted: ‘Waiting for the police to arrive on site as a patient has threatened my safety, has been into the building three times, found my car and photographed it. Does make you think, why this vocation.’
Practices taking their own measures
Perhaps the starkest consequence of the rising abuse is practices having to change their processes. One Doncaster practice lost seven staff members who reached breaking point over patients’ behaviour. Dr David Coleman, GP partner at Conisbrough Group Practice, says there was ‘a phase where there was someone in tears every day’.
‘Seven people have left, saying, “I can’t deal with people talking to me the way they’re talking to me”. Patients say things like “If I die it’ll be your fault”,’ he tells Pulse. The reception desk now closes for two hours a day, during which time staff communicate with patients by phone and online.
Dr Mike Holmes, chief executive and GP partner at the Haxby Group, says one of his practices, the Old Forge Surgery in Upper Poppleton, now closes at lunchtimes due to verbal abuse from patients and difficulties retaining staff. A young receptionist was called a ‘worthless person’ by an angry patient.
In the past 12 months, Ms Clark says her Bristol practice has issued 28 warning letters to patients, 90% related to abuse to the reception team.
Unfortunately, such measures are necessary. While patient demand is stoked by government access plans at the same time as GP numbers fall, it seems constant abuse will become yet another stress that comes with being part of a GP practice.
How to deal with abuse
The BMA advises that when a patient is violent or exhibiting behaviour that makes you fear for your safety, they should be immediately removed from the practice list. It’s also important to call 999 as soon as possible and get an incident number.
On social media abuse, the BMA says practices need a policy for dealing with it. This should include: keeping a record of instances (e.g. screenshots); reporting to the practice manager; writing to the patient; or discussing next steps with the LMC or a medical defence organisation. Removal should be a last resort.
Before an official warning letter, practices can write politely reminding a patient to behave appropriately. One practice sends a ‘Be Kind’ letters to patients who have become frustrated and rude with staff. These have been effective.
Practices can keep an incident log where they record instances of abuse to ensure they are acted on and any persistent abuse from particular patients is tracked.
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