Another epidemic: abuse and violence towards healthcare staff

In the context of COVID-19, persistent abuse of NHS doctors compounds the emotional toll on staff, damages morale, and threatens patient safety. Plans to stem the tide may be insufficient, as Kathy Oxtoby reports

CREDIT: This is an edited version of an article that originally appeared on The BMJ

Nearly 15% of respondents to the latest NHS Staff Survey, covering 2020, reported experiencing at least one episode of violence from patients, their relatives, or other members of the public; this is similar to 2019. Over a third of staff who had frequent face-to-face contact with service-users reported experiencing at least one incident of bullying, harassment or abuse from patients, relatives or the public in the past year.

As the COVID-19 pandemic places unprecedented pressures on healthcare services and staff, anecdotes have brought the problem of abuse to the fore. “One doctor told us they had experienced more unpleasantness in six months than in all their previous 50 years of working in healthcare,” says Pallavi Bradshaw, medicolegal lead for risk prevention at the Medical Protection Society (MPS), which protects and supports the professional interests of healthcare staff.

Of 1,251 doctors who responded to an MPS survey last September and October, 375 (30%) had been verbally abused by patients or relatives while at work during the pandemic. Another 63 (5%) had experienced physical abuse, and 88 (seven per cent) had experienced abuse outside the workplace, such as when using an NHS queue at a supermarket.

Samantha Batt-Rawden, president of the grassroots campaigning organisation the Doctors’ Association UK (DAUK), told The BMJ that doctors continued to receive abuse despite “risking their lives since March 2020.” In a recent survey, DAUK’s members reported verbal and physical abuse including insults, racism, death threats and violence. “Physical abuse is a regular part of being an emergency medicine doctor,” one respondent told the campaign. “I have been hit and bruised by many patients, for a variety of reasons. All staff have a story to tell, and it’s rare that patients ever have to face any consequences.”

The problem is not confined to secondary care. “There’s a perception that GPs aren’t offering enough face-to-face appointments, despite face-to-face appointments increasing in recent months” Bradshaw says, “and this has resulted in complaints, frustration, and abusive behaviour.”

One practice in Bristol was painted with offensive graffiti, and it’s hard to know the true extent of the problem. However, much abuse goes unreported, and national annual data on physical assaults against NHS staff are no longer published. Almost half of NHS staff surveyed had not reported an incident of harassment, bullying, or abuse in the past year. Batt-Rawden told The BMJ that three quarters (111) of 150 respondents to the DAUK survey had experienced abuse, but not reported it.

One common misperception is that violence from patients is to be expected, and is just another part of the job. Doctors may “try to rationalise and excuse, to a degree, patients’ angst,” says Ellie Mein, medicolegal adviser for the Medical Defence Union. They may attribute a patient’s violent or aggressive behaviour to physical or mental health problems, and decide not to report it.

Stress, anxiety and dependence on drugs or alcohol are often factors when patients and relatives are abusive, says Ian Higginson, vice president of the Royal College of Emergency Medicine. “The patient may have had a psychotic episode, have a behavioural personality disorder, or dementia,” he tells The BMJ. Sometimes “it’s difficult to draw a line between what is deliberate abusive behaviour and what is the result of illness.”

As well as the emotional toll on individuals, abuse can damage the morale of the entire workforce, and patient safety may suffer. “It makes doctors stressed, and affects our performance, even to the extent of not being able to give the right diagnosis and treatment,” says Chris Turner, a consultant in emergency medicine based in the West Midlands, and co-founder of Civility Saves Lives, an organisation promoting civility in medicine.

Employers must protect staff

“It is not enough simply to clap once a week for NHS staff,” as the public were doing in the first lockdown of 2020, says Batt-Rawden. “We have to create a protected workplace that doesn’t leave them at risk of abuse.”

Martin Marshall, chair of the Royal College of General Practitioners, says that any abuse of staff is “simply unacceptable.” General practices can remove abusive patients from their lists without warning if the police have been involved, he told The BMJ.

The government introduced an NHS violence reduction strategy in 2018, aiming to ‘help victims give evidence and get prosecutions’. Building on this strategy, in December, NHS England and NHS Improvement published a national Violence Prevention and Reduction Standard for NHS organisations to encourage ‘a safe and secure working environment for NHS staff, safeguarding them against abuse, aggression and violence’. Developed with the Social Partnership Forum—which includes NHS Employers, trades unions, and the Department of Health and Social Care—the standard requires organisations to assess and manage risks, implement change, involve staff and other stakeholders, and provide resources and training.

For GPs, David Wrigley, deputy chair of council at the BMA, says that clinical commissioning groups should introduce consistent, system-wide approaches to deal with abusive behaviour – and he wants NHS England and NHS Improvement to provide occupational health services for all staff so that victims get the help they need.