It is our good fortune to work in the profession that has the highest respect in the country. We are not politicians, taxmen or estate agents – my respect goes out to them as they often start at a disadvantage. However, it cannot be assumed that every patient and relative is going to be pleasant and polite. Every GP has a story about angry patients threatening them or worse. Aggression is not something that any GP who cares about their patients or staff can ignore.
The following five steps are based on lessons from our experiences and should help ensure GPs and their staff feel safe and secure at work and on home visits.
1 Treat patients with respect and have a clear complaints procedure in place
Ensure that all staff treat all patients with dignity and respect at all times. My practice looks after ‘zero-tolerance’ patients in Liverpool, and I have heard many stories from patients about what had previously happened. Many of them have coping strategies that turn anxiety into anger.
At Great Homer Street Surgery we work on the basis that patients have come because they are concerned about their health. We in turn make addressing their health concerns our priority, whichever way the patient chooses to express those concerns. Over the years it has served us well and despite being the zero-tolerance practice and a practice with a very large drug-misuse service, we have few incidents.
Staff buy into the vision, but when something does go wrong we listen to their concerns and address the issues, so they feel listened to and supported too.
2 Train staff to stop incidents escalating
Practices need to ensure that if incidents occur they do not escalate into unmanageable situations. The angry patient, who is met with provocation or just ignored, can easily turn into a problem and cause substantial damage to a practice, whether to the physical welfare of staff and patients, the infrastructure of the building or just to the practice’s reputation and sense of security.
Training staff in conflict management is essential. De-escalation is a learnt skill. It is a natural tendency when under attack to become defensive. We all do it. But to have the confidence to lower your voice in response to aggression rather than raise it, to uncross your arms rather than cross them and to move back slightly rather than forward are all recognised de-escalation techniques. Don’t rise to the bait and don’t flee from the aggressor. It is about not panicking, and that requires training. In these times of change, accessing PCT training courses may be difficult, but most PCTs used to offer de-escalation training. If not, you could organise it yourself if you think it’s a good investment.
3 Make sure it’s easy for staff to get away from violent threats
When I did my de-escalation training several years ago, I found the common sense approach of the tutor enlightening. An ex-policeman and martial arts expert, he was clearly capable of beating any aggressor to a pulp, but instead chose to spend his time showing us puny office types how to change a conflict into a win–win outcome.
He sat me at my desk and talked through all the weapons I had on display that could be used against me by an aggressive patient – the pen for stabbing, the coffee for scalding, the computer screen for clubbing. It was not his advice to consult from a bare cell, but to be aware of potential risks and how to mitigate them. He was quite clear that despite my 6’ 3” height and 100kg weight, the best approach if a patient brandishes any sort of weapon is to evacuate immediately.
He reminded us that the clinician’s chair should always be nearer the door than the patient’s. Arranging consulting rooms so that you can get out without the patient blocking your exit is good contingency planning.
4 Show all staff, especially locums, how to use alarms
When we upgraded our intruder alarm, a panic button was installed in all patient-facing rooms. Each button was placed in a convenient location. The annual alarm service checks they work. In 15 years we have never used them but they are reassuring. The new staff induction includes advice about alarms. When triggered they create an enormous noise.
When our telephone system was upgraded, a silent panic button was included. Pressing it informs every member of staff with a phone where the alarm is going off.
5 Don’t let safety worries dominate premises design
We recently designed a new surgery. After detailed discussions and the provision of several sets of revised plans that began to meet our expectations, confidence and trust grew.
We began to see how our vision of a surgery built for the convenience and benefit of patients and staff could be translated into a safe and secure reality.
One of the early principles discussed and agreed was the building should be designed for the majority, not the minority. Shutters, bars, grilles and alarms could be present if essential, but not if a more aesthetically pleasing and user-friendly solution was available.
So the reception desk was designed to be wide with its front face sloping towards the patients. Sweet Mrs Lovely in her wheelchair can easily approach the receptionist as the footrests of her wheelchair partly tuck under the protruding desk.
When grumpy Mr Basher comes in and leans over in his intimidating way, his feet have no purchase on the edge of the desk and its width leaves plenty of space between him and the staff. There is a doorway directly behind so staff can evacuate if withdrawal is prudent.
Although security is paramount, it should not compromise the ability to serve the majority who are predominantly concerned about their health.
Dr Simon Abrams is a GP and Catherine Campbell the practice manager at Great Homer Street Surgery in Everton, Liverpool. Everton has one of the highest scores on the index of multiple deprivation in the country