General Medical Services provision - patients displaying violent behaviour: comparative review

Introduction

Violent behaviour in primary care

Within the current General Medical Services (GMS) contract, violence refers to 'actual or threatened physical violence or verbal abuse leading to fear for a person's safety'^[1]. While there is a lack of routine data collection regarding violent behaviour in primary care, and definitions of what constitutes violence vary, studies performed consistently demonstrate a significant prevalence of violent behaviour^[2-4]. In 2013, of the 68,683 reported assaults on NHS staff, 25% involved primary care staff^[5]. Annually, two-thirds of primary care staff report experiencing violence from patients, with only 4% of GPs reporting no such experience in a five-year period^[6-8]. Moreover, there is growing concern that violence is increasing with crime rates in primary care rising^[9]. This is echoed by concerns from 46% of GPs who believe patients are more violent than five-years ago, a change generally considered to reflect increasing pressures on primary care^[6,10]. Violence in primary care is therefore considered a key public health concern^[4].

Responses to violence in primary care – balancing zero-tolerance with a duty of care

In recognition of the potential physical and psychological impact of violence on healthcare staff and other patients, numerous government initiatives have been introduced, most notably the 1999 'zero-tolerance' policy which continues to underpin approaches to violence across the NHS^[11,12].

Consequently, where a patient is violent in primary care, GMS contractors are entitled to immediately remove the patient from their practice list, provided the incident is reported to the Police (or Procurator Fiscal in Scotland)^[1,13]. A Freedom of Information request to NHS Scotland's Practitioner Services Division revealed that in 2018 114 patients were subject to immediate removal across Scotland.

However, while individual contractors are entitled to remove patients from their practice list under these circumstances, such patients have a statutory right to ongoing care under the NHS Scotland Act (1978) which emphasises the universal right to primary healthcare^[12,14]. There is therefore an ongoing responsibility to ensure the provision of GMS for this patient group until they are deemed able to return to mainstream services.

Scotland's approach

In Scotland, each of the 14 Health Boards is individually responsible for ensuring ongoing provision of GMS for those subject to immediate removal in their area^[15]. Contractually, these arrangements are termed 'Violent Patient Schemes', although such terminology is controversial with the implication that these patients are inherently violent; the term 'Challenging Behaviour Services' (CBSs) is often used instead.

Each Health Board is free to decide how they will meet this responsibility. Consequently there is substantial variation in how CBSs are delivered across Scotland. Indeed, a 2009 review of Scottish CBSs highlighted this variation gathering responses to five broad questions (Box 1)^[16].

1. Details of the model used in your health board area.
2. How many patients are currently seen under these arrangements?
3. Cost per patient in the practice.
4. What is the process for 'rehabilitation'/risk assessment?
5. Describe the process for returning to mainstream general practice.

Box 1. Five questions addressed in 2009 review of Scottish Challenging Behaviour Services.

Review aims

CBSs are continually evolving and inter-board awareness of different approaches to delivery is currently limited. Given the importance and prevalence of violent behaviour in primary care, the present review therefore aims to update and extend the 2009 review.

Three key areas will be addressed:

1. How CBSs ensure ongoing provision of GMS.
2. How underlying issues are addressed with patients to facilitate long-term return to mainstream services.
3. How CBSs ensure a safe and supportive environment for staff and other patients.

The overarching aim is to establish current practice and inter-board variation, thus

creating a detailed resource to act as a platform for future discussions about the shape of Scottish CBSs, with the ultimate aim of improving care for this patient group. By highlighting challenges, areas of good practice and identifying possible solutions, it is also anticipated this resource will be valuable for individual CBSs seeking to improve.

Furthermore, there is a lack of discourse and research within published literature on the underlying causes of violence towards primary care staff and the role of CBSs. This review therefore also aims to capture current perspectives from those involved in delivering CBSs.