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

Discussion

This review provides a detailed overview of the current shape of CBSs in Scotland, highlighting key inter-board variations and challenges in caring for this patient group. Identified areas of good practice/possible solutions to challenges have also been collated as a further resource for consideration by individual services (Box 3).

Behavioural contracts both within CBSs and as a recommendation for referring practices.

Designated phone lines for service patients manned by limited number of trained staff.

Appropriate support and training for all staff who interact with patient, including administration staff.

Debrief with all staff who interact with a patient prior to appointment to share concerns and potential issues.

Scheduling appointments for quiet times/when no other patients present.

'Stepping down' patients who no longer require security present.

Restricting patient access to service outside appointment times.

Security advice on additional safety measures e.g. room layout.

Reimbursement of travel expenses on request.

Alerts on records to notify other services of patient status, n.b. ethical issues surrounding confidentiality must be considered in this approach and informing patients is recommended^[18].

Box 3. Identified areas of good practice/possible solutions to challenges faced.

At the outset it is imperative to appreciate that CBSs are continually evolving and this review only provides a snapshot of current services. Moreover, the responses presented are those of Primary Care Managers, not those directly involved in delivering CBSs, and the perspectives obtained are likely to reflect this. The questionnaire approach also imposes inherent constraints on the responses received; in some aspects apparent inter-service variation may reflect the detail of information provided rather than real-world differences.

Ensuring ongoing provision of GMS

Consistent with their contractual obligations, all Scottish CBSs ensure the ongoing provision of GMS for patients who are violent. However, across Scotland there are substantial variations in GMS accessibility relating to appointment times and location, both between Health Boards and in comparison to the general population. Such variations raise important questions about the rights of these patients in accessing GMS and therefore the shape of CBSs^[18]. The inclusion of patients who have not been subject to immediate removal within CBSs further adds to these questions. While the nature of needing designated CBSs means there will be inherent restrictions on access, this must be balanced with an approach that does not enhance the inequalities often already faced by this vulnerable group^[14,18]. Where possible, approaches to mitigate these differences, e.g. provision of travel expenses, should therefore be considered. Nevertheless, while the restricted service access is a source of complaint for some CBS patients, anecdotally many patients also prefer these designated services.

How underlying issues are addressed with patients to facilitate long-term return to mainstream services

Contractually the role of CBSs is simply GMS provision^[15]. Although it is difficult to capture the approach of services in questionnaire format, it is evident that the majority of services go beyond this, attempting to address the underlying causes of violent behaviour with a view to future violence prevention and successful long-term return to mainstream services. This important distinction raises the question of the need to contractually re-define the role of CBSs to encompass this; perhaps CBSs could be termed 'Challenging Behaviour Rehabilitation Services'. Such reconceptualisation may lead to a wider recognition of the value of these services within the broader public health framework of violence prevention^[14], not least when considering the funding made available to them.

The increasing inclusion of patients not subject to immediate removal within CBSs further challenges the current contract. However, while the capacity to offer care to others may be incredibly valuable, there is a need to be careful this doesn't lead to a situation whereby GPs attempt to 'offload' all difficult patients to CBSs. Thus, any such shift must be balanced by empowering mainstream GMS to deal appropriately with difficult behaviour; this review identifies a number of means by which this could be achieved.

Meaningful comparison of the current cost of each CBS is considered to be precluded by the substantial variation in services offered and approach taken. Moreover, the general lack of data collection, outcome data and service evaluation surrounding CBSs represents an important gap, precluding appropriate evaluation of the role and effectiveness of these services. In future there is therefore a need for a consistent and comprehensive approach to this across services cognisant of not placing undue burden on staff.

How CBSs ensure a safe and supportive environment for staff and other patients

Underlying the contractual entitlement to remove violent patients from mainstream GMS is the recognition of the need to protect staff and other patients. However, this should also extend to those delivering CBSs. In some CBSs it is clear that such protection is lacking, with security not always available and staff often facing the challenges of dealing with ongoing difficult behaviour. While to some extent these challenges are unavoidable, security must be ensured and appropriate staff support and training provided^[5]; at present this also appears to be lacking in some services. These factors may underlie some of the difficulties in recruiting practices to take on CBSs, although this is likely to be an ongoing challenge requiring further consideration and strategic planning^[17]. Consultation with those directly interacting with patients to understand their support and training needs would be valuable; crucially this must also extend to administrative staff who are often on the receiving end of continued verbal abuse and not just GPs.

Broader perspectives on violence in primary care and the role of CBSs

This review offers new insight into the causes of violence in primary care. While some of the causes identified are consistent with existing understandings of violence^[5,14], some of the dynamics identified are unique to the primary care setting thus contributing understanding to a previously unexplored area. It is however acknowledged that this initial exploration is limited and those involved in delivering CBSs have a unique perspective on causes of violence in primary care which remains under-utilised.

An additional role for CBSs could therefore lie in using their insight and expertise to help mainstream GMS with violence prevention. Indeed, the demand and nature of referrals faced by CBSs suggests many mainstream GMS are ill-equipped to manage difficult behaviour, echoing previous research^[2]. A greater understanding of the causes of violence may also engender a greater willingness to understand and engage with difficult patients, rather than seeking to remove them; although such a cultural shift within primary care would be difficult.

Alternative models of service delivery

With significant inter-service variation, an alternative approach would be adopting a uniform model across Health Boards thus ensuring a greater consistency. However, as this review highlights, individual services face unique demands and challenges and need the freedom to respond to these accordingly. While a uniform model may therefore be inappropriate, an ongoing central mechanism for sharing ideas and resources, alongside the central data collection and evaluation already proposed, would be an asset.

At present the majority of CBSs use a centralised model of care. While a dispersed model may overcome some of the challenges presented regarding accessibility^[17], this may magnify other challenges. It may be more difficult to ensure safety and provide appropriate support and training within a dispersed model. Moreover, recruitment of practices willing to offer CBSs may be prohibitive given the recruitment difficulties already faced. This review does not capture how CBSs have evolved since their inception and it may be that other models have been used previously; considering this evolution may therefore offer further insight into the challenges of different models when considering models for the future. Comparison with services across the rest of the UK may also prove beneficial, although a lack of reviews in this area makes this challenging.

Conclusions

Across Scotland there is significant variation in how CBSs are delivered. This review provides a detailed overview of current services to inform future discussions, highlighting many excellent examples of good practice and offering possible solutions to key challenges faced.

Crucially, current CBSs not only ensure the ongoing provision of GMS for those subject to immediate removal, they also provide services for other difficult patients and often engage in an active process of rehabilitation, suggesting a need to re-define their role to recognise their valuable contribution to violence prevention. At present, central data collection, evaluation and mechanisms to share ideas are lacking and this remains an important area for future improvement. CBSs also face significant challenges surrounding accessibility, safety, support and training and these must be addressed to ensure the ongoing availability and quality of these valuable services.