Patient Behaviour, Mutual Respect and Violence Prevention Policy

1. Introduction and purpose

This practice is committed to providing high-quality healthcare in a safe, respectful and supportive environment for patients, visitors and staff.

Patients have the right to be heard, understood and treated with dignity and respect. The practice recognises that people contacting healthcare services may be worried, distressed, unwell, frightened or frustrated, and we will make reasonable efforts to understand and respond appropriately to individual circumstances.

The practice also has a responsibility to protect the physical and psychological safety and wellbeing of its staff, patients and visitors. Violence, threats, harassment, discrimination and abusive behaviour are not acceptable.

This policy sets out:

• the standards of behaviour expected from patients, representatives, relatives, carers and visitors.
• how the practice will respond to inappropriate or unacceptable behaviour.
• how reasonable adjustments, medical conditions, mental health, neurodiversity, capacity and safeguarding considerations will be taken into account.
• when warnings or contact arrangements may be introduced; and
• the circumstances in which removal from the practice list may be considered.

NHS England recommends that general practices manage behaviour which challenges healthcare staff using principles of mutual respect, violence prevention and reduction, proportionality and preservation of access to healthcare wherever reasonably possible.

Nothing within this policy is intended to prevent a patient from making a legitimate complaint, expressing dissatisfaction, disagreeing with clinical advice, requesting a second opinion, declining a proposed treatment, or requesting a reasonable adjustment. These actions will not in themselves be regarded as unacceptable behaviour.

2. Our commitment to patients

Patients can expect the practice to:

• provide care to an appropriate professional standard.
• treat patients with dignity, courtesy and respect.
• provide care that takes account of individual clinical needs and circumstances.
• protect confidentiality in accordance with legal and professional requirements.
• provide access to medical records in accordance with applicable legislation and subject to lawful exemptions.
• communicate as clearly and respectfully as possible.
• consider reasonable adjustments for disability, communication needs and other relevant circumstances.
• provide an accessible complaints process and investigate complaints appropriately.
• ensure that making a complaint does not adversely affect the care provided to a patient.

CQC requires providers to operate an effective and accessible system for receiving, investigating and responding to complaints, and NHS providers have duties to consider reasonable adjustments for disabled people.

3. What we ask of patients and visitors

Healthcare works best as a partnership based on mutual respect.

We ask patients, representatives and visitors to:

• treat staff and other patients courteously and respectfully.
• attend appointments on time where possible.
• cancel appointments they no longer need, preferably with as much notice as possible.
• use urgent and emergency appointments responsibly.
• request repeat prescriptions with appropriate notice.
• use the practice’s recognised telephone, online, written and face-to-face communication channels.
• provide information reasonably required to enable the practice to provide safe care.
• understand that appointments may occasionally run late because another patient requires urgent clinical attention.
• recognise that the practice cannot always provide an appointment with a preferred individual clinician.
• respect the privacy, dignity and safety of other patients and staff.

Reasonable adjustments will be considered where a disability, medical condition, communication difficulty or other relevant circumstance makes standard access arrangements unsuitable.

4. Violence, threats, abuse and harassment

The practice will not tolerate violence, credible threats of violence, intimidation, harassment, discriminatory abuse or other behaviour which places staff, patients or visitors at risk.

This may include:

• physical violence or attempted violence.
• threats of violence.
• threatening or intimidating behaviour.
• racial abuse.
• sexual harassment or sexually inappropriate behaviour.
• discriminatory abuse relating to disability, race, religion or belief, sex, sexual orientation, gender reassignment, age, pregnancy or maternity, marriage or civil partnership.
• deliberately degrading, humiliating or intimidating verbal or written abuse.
• persistent serious swearing or personally abusive language directed towards staff or other patients.
• offensive or threatening gestures.
• deliberate damage to property.
• theft.
• fraudulent attempts to obtain medication or healthcare.
• behaviour creating a reasonable fear for the safety of staff, patients or visitors.

NHS England specifically recognises offensive language, racial abuse, sexual harassment, unnecessarily persistent or unrealistic demands causing disruption, property damage, theft and fraudulent acquisition of medicines or services as examples of behaviour requiring management. It distinguishes these from violence and threatening behaviour requiring the Special Allocation Scheme process.

Where a crime may have been committed or a person reasonably fears for their safety, the practice may contact the police. Where an incident connected with the regulated service is reported to or investigated by the police, the practice will also make any statutory CQC notification required.

5. Other unacceptable or unreasonable behaviour

5.1 Unreasonable demands

A patient’s request does not become unacceptable simply because the practice cannot meet it.

However, behaviour may be considered unreasonable where demands are persistent, disproportionate and substantially interfere with the practice’s ability to provide care to that patient or to others.

Examples may include:

• repeatedly demanding access to a particular clinician where there is no clinical or reasonable adjustment requirement.
• repeatedly demanding same-day appointments for matters assessed as non-urgent.
• repeatedly demanding responses within unreasonable timescales despite the practice having explained when a response can reasonably be expected.
• repeatedly requesting medication early without an appropriate clinical reason.
• persistently demanding investigations, medication or treatment which clinicians consider inappropriate after the reasons have been explained.
• persistent refusal to use reasonable access arrangements where this substantially disrupts service delivery, unless an alternative is required as a reasonable adjustment.
• contacting individual staff members through their personal email addresses, telephone numbers or social-media accounts instead of practice communication channels.

A patient may request a particular clinician or type of clinician, and the practice will consider such requests where reasonably practicable. Declining an appointment with a particular clinician is not, by itself, unacceptable behaviour.

5.2 Unreasonable levels of contact

Contact may become unreasonable where its frequency, duration or nature disproportionately interferes with the care of other patients or the operation of the practice.

Examples include:

• excessive repeated telephone calls within short periods without a new clinical need.
• repeated prolonged calls covering the same matters after these have already been addressed.
• excessive repeated emails, online requests, letters or other correspondence.
• repeatedly submitting substantially identical requests after an appropriate response has been provided.
• deliberately inundating the practice with irrelevant or excessive documentation.
• contact which significantly prevents staff from attending to the needs of other patients.

The practice will distinguish persistent contact arising from genuine clinical deterioration, vulnerability, disability, safeguarding concerns or communication difficulties from behaviour which is genuinely unreasonable.

5.3 Communication and complaints

Patients have the right to raise concerns, challenge decisions and complain about their care.

The fact that an allegation cannot immediately be substantiated does not make it abusive or unacceptable.

However, the manner in which concerns are raised may become unacceptable if it involves threats, harassment, discriminatory abuse, intimidation or sustained personal abuse.

Where correspondence contains abusive material alongside a legitimate clinical, safeguarding or complaint issue, the practice may decline to engage with the abusive content while ensuring that the substantive issue is appropriately addressed. CQC requires complaints to be received and acted upon effectively and does not permit patients to be disadvantaged because they have complained.

5.4 Failure to cooperate

The practice may require reasonable information from patients to investigate concerns, manage care safely or respond to complaints.

Problems may arise where a patient persistently:

• refuses to provide information reasonably necessary to address the issue.
• refuses reasonable attempts to clarify what assistance is being requested.
• repeatedly changes the substance of a complaint or request in a way that prevents meaningful resolution.
• repeatedly raises the same matter after it has been fully considered without providing materially new information.

Before describing such behaviour as unreasonable, the practice will consider communication difficulties, disability, cognitive impairment, mental health, language needs and other relevant circumstances.

5.5 Alcohol, drugs and illegal activity

Patients will not automatically be refused healthcare because they appear to be under the influence of alcohol or another substance.

Clinical needs will be assessed appropriately.

However, violence, threats, intimidation or unsafe behaviour associated with intoxication will be managed in accordance with this policy.

Drug dealing, theft, deliberate property damage, fraudulent alteration of prescriptions and other suspected criminal activity may be reported to the police where appropriate.

6. Factors the practice will consider before taking formal action

Behaviour does not occur in isolation. Before taking formal action, and where it is safe and practicable to do so, the practice will consider whether the behaviour may have been influenced by:

• acute physical illness.
• mental health difficulties.
• dementia or cognitive impairment.
• learning disability.
• autism or other neurodivergence.
• communication difficulties.
• sensory impairment.
• medication effects.
• substance misuse.
• reduced or fluctuating mental capacity.
• significant distress, trauma or bereavement.
• safeguarding concerns.
• disability or another protected characteristic.
• cultural or language needs.
• previous experiences of healthcare.
• difficulties accessing or understanding services.

Reasonable adjustments and alternative communication arrangements will be considered where appropriate.

NHS England specifically requires practices considering removal to take account of mental health, clinical presentation, neurodiversity and other health conditions which may influence behaviour, and to ensure that protected characteristics do not improperly influence the decision. Removal should be exceptional.

The practice will also consider whether de-escalation, clarification, mediation, a discussion with the patient, additional support or a mutual behaviour agreement could resolve the problem before escalation.

7. Immediate management of incidents

Staff experiencing unacceptable behaviour may, according to the circumstances:

• clearly tell the person that the behaviour is unacceptable and ask them to stop.
• end a telephone call after giving an appropriate warning where safe to do so.
• discontinue an online or written exchange where communication has become abusive.
• obtain assistance from another member of staff.
• move themselves or other patients to a place of safety.
• ask a person to leave the premises where clinically and practically appropriate.
• activate practice safety arrangements.
• contact security or the police where there is a safety concern.
• call 999 where there is an immediate threat or emergency.

Ending an abusive interaction does not remove the practice’s responsibility to consider any outstanding urgent clinical or safeguarding need.

Frontline staff may take immediate steps necessary to protect themselves and others. Formal warnings, long-term contact restrictions and practice-list removal decisions will normally be considered by senior management or a GP partner rather than by an individual staff member acting alone.

8. Formal warnings and behaviour agreements

Where behaviour is unacceptable but does not justify immediate removal, the practice will normally seek to address the issue proportionately.

Possible actions include:

• discussing the incident with the patient.
• seeking clarification of the circumstances.
• giving the patient an opportunity to explain what occurred.
• offering mediation where appropriate.
• agreeing a mutual behaviour plan.
• issuing a formal written warning.

A written warning should:

• identify the behaviour giving rise to concern.
• explain why it is unacceptable.
• describe the behaviour expected in future.
• identify any reasonable adjustments or agreed communication arrangements.
• explain what may happen if the behaviour continues or recurs.
• provide an appropriate opportunity for the patient to respond.

Under NHS contractual arrangements, removal for non-violent behaviour may normally only be requested where the practice has issued a written warning within the preceding 12 months stating that the patient is at risk of removal and explaining why. There are limited circumstances in which a warning may not be appropriate or practicable, and the reasons must be recorded.

9. Contact arrangements and restrictions

Where repeated contact or behaviour is causing significant disruption but continued registration remains appropriate, the practice may introduce proportionate communication arrangements.

Examples may include:

• identifying a nominated member of staff as the main point of contact.
• requesting that routine communication is made in writing or through a defined channel.
• agreeing specific arrangements for non-urgent contacts.
• arranging planned clinical reviews rather than repeated unscheduled contacts.
• setting reasonable boundaries around repeated correspondence on matters already addressed.

Any restriction will:

• be based on the individual’s circumstances.
• be proportionate to the problem being managed.
• take account of reasonable adjustment requirements.
• not prevent access to urgent or clinically necessary healthcare.
• not prevent legitimate complaints or safeguarding disclosures.
• be documented.
• be reviewed periodically and removed or amended when no longer required.

10. Removal from the practice list

Removal from the practice list is a serious action and will generally be considered only where the relationship between the patient and practice has irretrievably broken down or where safety considerations require removal.

10.1 Non-violent behaviour – standard removal process

For inappropriate or unacceptable behaviour which does not meet the threshold for immediate removal, the practice will normally:

1. investigate and document the circumstances.
2. consider the patient’s medical, psychological, communication and social circumstances.
3. consider reasonable adjustments and safeguarding issues.
4. attempts proportionate measures to resolve the situation.
5. provide a written warning where required.
6. consider removal only if the behaviour subsequently continues or recurs and the relationship cannot reasonably be restored.

Where the contractual requirements are satisfied, the practice may request removal through PCSE. NHS England describes the standard process as appropriate for less serious circumstances and ordinarily involving 8 days’ notice once the required conditions have been met.

The practice will record the reasons and circumstances surrounding any removal decision. NHS England requires practices to retain records concerning patient removals and ordinarily requires a warning within the preceding 12 months.

10.2 Immediate removal following violence or threatening behaviour

Immediate removal is a separate process.

A practice may request immediate removal where a patient has committed an act of violence or behaved in such a way that practice staff, other patients or others present reasonably fear for their safety.

The incident giving rise to immediate removal must be reported to the police. The practice must then follow the NHS England/PCSE Special Allocation Scheme process. A police report by itself does not automatically mean that the threshold for immediate removal has been met; the circumstances and safety risk must support that course of action.

The practice will follow current PCSE requirements when requesting immediate removal and will provide any required written incident information to the commissioner.

10.3 Safeguarding and vulnerable patients

Before removal is requested, consideration must be given to safeguarding and continuity of care.

Particular care is required where the patient is:

• a child or young person.
• subject to a child protection plan or order.
• an adult with a learning disability.
• autistic.
• experiencing significant mental health difficulties.
• cognitively impaired.
• dependent on a formal carer.
• caring for children or vulnerable adults.
• otherwise considered vulnerable.

NHS England specifically requires safeguarding considerations during patient removals and emphasises continuity of primary care for children and vulnerable people. Where relevant, advice will be sought from the practice safeguarding lead and/or commissioner.

Where a parent or carer is removed because of violent or aggressive behaviour, consideration will be given to any implications for children or vulnerable people dependent upon them.

11. Decision-making and governance

Immediate safety measures may be taken by any member of staff where necessary.

Formal decisions regarding:

• written warnings.
• behaviour agreements.
• significant ongoing communication restrictions; or
• removal from the practice list

will normally be made or ratified by senior practice management and/or GP partners.

Consideration will include:

• nature and severity of the incident.
• frequency and pattern of behaviour.
• impact on individual members of staff.
• impact on other patients and service delivery.
• any immediate or continuing safety risk.
• previous warnings or interventions.
• the patient’s explanation.
• medical and psychological circumstances.
• disability and reasonable adjustments.
• mental capacity where relevant.
• learning disability or neurodivergence.
• protected characteristics.
• safeguarding considerations.
• whether a less restrictive response could safely resolve the matter.

Decisions must be proportionate, defensible and based on objective evidence rather than assumptions about the patient.

12. Recording incidents

Incidents of significant unacceptable behaviour should be documented appropriately.

Records should be factual and objective and, where relevant, include:

• date, time and location.
• individuals involved.
• what was said or done.
• relevant context.
• impact or perceived safety risk.
• action taken at the time.
• whether police or other agencies were contacted.
• any injuries or damage.
• relevant clinical, communication or safeguarding considerations.
• reasonable adjustments considered.
• subsequent warning, behaviour plan or other action.
• review arrangements.

Subjective or unnecessarily judgemental terminology should be avoided.

Where clinically appropriate, relevant alerts may be added to the patient’s clinical record to protect staff and facilitate safe care, in accordance with information governance requirements.

13. Review of warnings and restrictions

Warnings, behaviour agreements and communication restrictions should not remain indefinitely without review.

The practice senior management team will review active restrictions at appropriate intervals and at least quarterly where practicable.

The review should consider whether:

• the behaviour has continued.
• circumstances have changed.
• restrictions remain proportionate.
• reasonable adjustments remain appropriate.
• restrictions can safely be reduced or removed.

15. Internal review and patient representations

A patient who disagrees with a formal warning, behaviour restriction or non-violent removal decision may ask the practice to review the decision.

Requests should preferably be made in writing, although reasonable adjustments will be made where written communication is difficult.

Where practicable, the review should be undertaken by a senior person who was not primarily responsible for the original decision.

The patient may explain, for example, that:

• the incident has been misunderstood.
• relevant circumstances were not considered.
• the response was disproportionate.
• reasonable adjustments were required.
• additional information should be considered.

An internal review does not prevent the practice from taking immediate steps necessary to maintain safety.

Immediate removal through the Special Allocation Scheme is governed by the applicable NHS England/PCSE process, which includes an appeals mechanism.

15. Complaints and alternative routes

A patient who is dissatisfied with the service is encouraged to raise their concerns through the practice’s formal complaints procedure.

Patients may alternatively contact the relevant Integrated Care Board regarding a complaint about NHS primary care services where the ICB is the appropriate commissioner. Responsibility for commissioner-level primary care complaints transferred from NHS England to ICBs.

Following completion of the applicable NHS complaints process, patients may also have the right to approach the Parliamentary and Health Service Ombudsman.

A complaint made in good faith will not affect the standard of clinical care provided to the patient.

Patients remain free to register voluntarily with another GP practice in accordance with normal NHS registration arrangements.

16. Practice access and resources

The practice has a finite number of appointments and staff resources and must use them fairly and safely across the registered population.

Patients may therefore be offered assessment or treatment by an appropriately qualified member of the multidisciplinary practice team rather than specifically by a GP.

Requests for a particular GP or clinician will be considered where practicable, particularly where continuity of care or a reasonable adjustment is clinically important, but a particular clinician cannot always be guaranteed.

Clinically urgent needs will continue to be assessed and managed according to clinical priority.

17. Equality, dignity and reasonable adjustments

This policy will be applied fairly and without unlawful discrimination.

The practice will make reasonable adjustments for disabled people where required and will consider communication, sensory, cognitive and accessibility needs when applying this policy. The Equality Act 2010 places duties on service providers to make reasonable adjustments where disabled people would otherwise be substantially disadvantaged.

Behaviour will be assessed according to its nature, context and impact rather than on the basis of a person’s diagnosis, disability, protected characteristic or social circumstances.

18. Policy review

This policy will be reviewed periodically and sooner where there are:

• changes to legislation.
• changes to NHS England or PCSE policy.
• changes to CQC requirements.
• significant incidents highlighting a need for amendment.
• relevant learning from complaints or staff feedback.

The practice will use the current NHS England Primary Medical Services Policy and Guidance Manual and PCSE patient-removal processes when considering removal from the practice list.

Policy owner: Practice Manager / GP Partners