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23 January 2019

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In an ideal world, all patient interaction would be easy and we would get on well with everyone registered at our practice.
However, this isn’t always the case and when practice staff encounter patients whose behaviour is difficult to deal with, it can be tricky to know how to respond as Dr Ellie Mein, medico-legal advisor at the Medical Defence Union (MDU), explains.

Practice staff interact with a large number of patients every day. The vast majority will be polite and courteous, but occasionally a particularly difficult or aggressive patient will leave team members unsure of how to respond.
The MDU opened about 300 case files over a recent five-year period to support members on how best to manage difficult interactions with patients, and we also receive hundreds of calls a year from members on this topic.
Why do patients become challenging?

There are a number of reasons why patients may become challenging. For example:

  • If they are unwell
  • If they are in pain
  • Due to drink or substance misuse
  • If they are scared, anxious or distressed
  • Frustration that they are not being listened to or taken seriously, or the feeling that they are being made to wait too long
  • Guilt that they did not seek help sooner, especially if the challenging behaviour is coming from a friend or relative of a patient.

What form can challenging behaviour take?

A 2017 report in the BMJ looking at crime figures obtained from police forces across the UK showed a 9% rise in the overall number of recorded crimes committed on the premises of GP surgeries and health centres – from 1,974 crimes in 2015-16 to 2,147 in 2016-17.
The figures showed a rise in assaults, harassment and threatening behaviour, illustrating that physical attacks can be just the tip of the iceberg when it comes to dealing with challenging behaviour.
Practice staff may be faced with challenging behaviour in many forms. A patient might be demanding or controlling, unwilling to listen or uncooperative, verbally abusive or threatening or in extreme cases physically violent against people or property.
Anticipating challenging behaviour

Being aware of the possibility of a situation escalating, even in patients with no history of challenging behaviour, is the first step. Observe a patient’s manner, what they say and how they say it.
Acknowledging that a patient is unhappy or frustrated and indicating you wish to understand why and to help, if possible, may help de-escalate the situation.

Showing a willingness to listen, asking open-ended questions and avoiding encroaching on the patient’s personal space may also help calm the situation. Give careful thought to the layout of consulting rooms, or the use of panic alarms. 

NICE guidance also recommends that staff working in primary care should be trained in methods of avoiding confrontations with violent or aggressive patients, including anticipation, prevention, de-escalation and breakaway techniques. 

Dealing with aggressive behaviour during a home visit can be particularly challenging given the unfamiliar setting and lack of backup and support.
Trying to defuse the situation is one option, but it is also acceptable to end a consultation and leave, particularly if there seems to be an imminent risk of physical aggression from the patient or a relative/carer. 
What action can be taken?

The MDU recommends that you have a clear policy in place, setting out how abusive and threatening behaviour from patients will be treated. The policy should be readily available, for example a notice at reception or on the practice website. 

If you feel you can no longer treat a patient your thoughts should be discussed in a practice meeting and the decision must be reasoned, reasonable, proportionate and comply with both your contractual obligations and GMC guidance. 

The GMC and the standard GP contract usually require a warning to have been issued before a patient is removed from a practice list.
Decisions should be communicated sensitively to the patient and arrangements made for their ongoing care. This can reduce the chances of the patient making a complaint to the GMC, the Ombudsman or the media. 

If there has been a threat of violence, or actual violence, it is appropriate to call the police and removal from the practice list without prior warning may be possible.
If you are considering removing a patient from the practice list it can often be helpful to discuss your plan with your medical defence organisation in advance of acting on it.
Although removing a challenging patient from the practice list may seem like a solution, it isn’t always warranted or a viable option. It is also important to remember that patients must not be denied necessary treatment, even if they are aggressive or violent.
Treatment must be based upon clinical need, however demanding the patient is. Nevertheless, you should assess and minimise the risks to yourself, the patient and to others. In some cases it may be reasonable and necessary to consider alternative arrangements for treatment. 

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