Unacceptable Behaviour and Zero Tolerance Policy

Introduction 

As an employer, the practice has duty to care for the health and safety of its staff. The Practice also has a legal responsibility to provide a safe and secure working environment for staff. All patients are expected to behave in an acceptable manner and violent or abusive behaviour towards staff or other patients may result in removal from our practice list or even criminal proceedings. This policy aims to set out what behaviours/actions the practice deems as unacceptable and the actions that will be taken should they occur.

Policy 

We believe that patients have a right to be heard, understood and respected. We understand that people may act out of character in times of trouble of distress however we do not expect that these actions will become unacceptable or abusive. 

There are two processes in place for dealing with unacceptable or abusive behaviour; these are the unacceptable behaviour process and the removing violent patients’ process. 

The removing violent patients process will be followed if a patient is violent or exhibiting behaviour that makes staff or other patients fear for their safety. This will result in the police being contacted and immediate removal of the patient from the practice register. 

The unacceptable behaviour process will be followed if the practice feels a patient’s behaviour is unacceptable but does not warrant immediate removal from the practice register.

What actions/behaviours does the practice consider to be unacceptable? 

The following list is not exhaustive but is provided to explain the actions and behaviours that the practice considers to be unacceptable:

•	Violence (towards members of staff and/or other patients)
•	Excessive noise e.g. recurrent loud or intrusive conversation or shouting 
•	Threatening or abusive language involving swearing or offensive remarks 
•	Derogatory remarks regarding protected characteristics (e.g. racist, sexist or homophobic behaviour) 
•	Making inflammatory statements e.g. “You are incompetent and should be sacked” 
•	Derogatory, abusive or insulting comments made about staff online or in the media 
•	Harassing, abusing or threatening staff on their personal social networks 
•	Malicious allegations relating to members of staff, other patients or visitors 
•	Offensive sexual gestures or behaviours 
•	Abusing alcohol or drugs on practice premises 
•	Drug dealing on practice premises 
•	Willful damage to practice property 
•	Threats, threatening behaviour or intimidation 
•	Refusal to leave premises on request of staff (this is against the law)
•	Theft 
•	Abuse of practice processes/policy

The practice also considers unreasonable demands to be unacceptable. A demand becomes unacceptable when it starts to (or when complying with the demand would) impact substantially on the work of the Practice. Examples of actions grouped under this heading include: 

•	Repeatedly demanding responses within an unreasonable timescale 
•	Repeatedly requesting early supplies of medication 
•	Repeatedly requesting further supplies of stolen medication, without the required Police Incident number 
•	Repeatedly ordering prescriptions without enough notification 
•	Insisting on seeing or speaking to a particular member of staff when that is not possible 
•	Refusing to see or be managed by certain members of the practice team
•	Repeatedly changing the substance of an issue or complaint or raising unrelated concerns 
•	Repeatedly insisting on a course of medical treatment for which there is no clinical evidence

Unreasonable levels of contact 

Sometimes the volume and duration of contact made to our Practice by an individual cause’s problems. This can occur over a short period, for example, a number of calls in one day or one hour. It may occur over the lifespan of an issue when a patient repeatedly makes long telephone calls to us, or inundates us with letters or copies of information that have been sent already or that are irrelevant to the issue. We consider that the level of contact has become unacceptable when the amount of time spent talking to a patient on the telephone, or responding to, reviewing and filing emails or written correspondence impacts on our ability to deal with that issue, or with other Patients’ needs.

Unreasonable refusal to co-operate 

When we are looking at an issue or complaint, we will ask the patient to work with us. This can include agreeing with us the issues or complaint we will look at; providing us with further information, evidence or comments on request; or helping us by summarising their concerns or completing a form for us. 

Sometimes, a patient repeatedly refuses to cooperate, and this makes it difficult for us to proceed. We will always seek to assist someone if they have a specific, genuine difficulty complying with a request. However, we consider it is unreasonable to bring an issue to us and then not respond to reasonable requests.

Unreasonable use of the complaints process 

Individuals with complaints about the Practice have the right to pursue their concerns through a range of means. They also have the right to complain more than once about the Practice, if a subsequent incident occurs. This contact becomes unreasonable when the effect of the repeated complaints is to harass, or to prevent us from pursuing a legitimate aim or implementing a legitimate decision. We consider access to a complaints system to be important and it will only be in exceptional circumstances that we would consider such repeated use is unacceptable – but we reserve the right to do so in such cases.

Unacceptable behaviour process 

This process will be followed when the actions/behaviour of a patient are unacceptable but do not warrant immediate removal from the practice list. The process consists of an internal review to investigate the circumstances of the behaviour/actions to decide on further action. Patients will be sent a warning letter and any repeat instances of unacceptable behaviour within 12 months of the first letter will result in removal from the practice register.

The situation review agrees that the behaviour was unacceptable.

Send a written notice to the PCO or NHS England, giving the patient’s name, address, date of birth and NHS number, requesting removal of the patient.  The removal will take effect on the eighth day after the request is received.

Patient is sent a warning letter (appendix 1), explaining the reasons and that similar situations in the future may result in removal from the practice

Patient is sent a second letter (appendix 2), explain the reasons and that they are being removed from the practice register.

No action to be taken against patient.  The reasons for the decision will be explained to the member of staff who raised the concerns.

Patient’s first offence within the last 12 months.

Patient’s second offence within the last 12 months.

The situation review agrees that the behaviour did not meet the threshold for further action.  The reasons for this decision will be explained to the member of staff who raised the concern

The situation is reviewed by senior team

Members of staff identifies unacceptable incident from a patient and reports this to the management team.

Removing Violent Patients 

This process will be followed if a patient commits an act of violence or behaves in such a way that makes staff or other patients fear for their safety. Such behaviour includes, but are not limited to: 

 Assault 
 Threatening behaviour 
 Behaviour resulting in damage to property 

All such instances will be reported into the police. This process has been designed to adhere to the requirements of removing patients under the NHS Special Allocation Scheme. Any individual who receives injury, no matter how small, should be the subject of an entry in the Accident Book and should always be strongly advised to be examined by a doctor before they leave the premises.

Patient commits an act of violence or behaves in such a way that makes staff or other patients fear for their safety.

End of process.

Notify the CQC ‘without delay’. Either while a registered activity is provided or as a consequence of it being provided, including incidents involving the police.

Inform the patient of the removal, as long as it would not be harmful to the patient’s mental or physical health or put any of the people listed above at risk.

As soon as possible after the incident notify NHS England about the incident and provide them with the patient details for the removal.  NHSE can be contacted on 0333 014 2884 or pcse.patientremoval@nhs.net.  The removal takes effect at the time at which the practice contact PCSE.

Where possible, such actions should be reported to the duty doctor, management team or other supervisor.  This individual will contact the police to report the incident and if necessary, request police attendance.

Please note:  If one of the above individuals is unavailable or reporting to them will delay contacting police and/or may result in harm coming to any individual present the police should be contact immediately.

	

Further Guidance 

This policy and the embedded processes have been developed in line with the NHS Constitution and advice and guidance from the Citizens Advice Bureau and the British Medical Association (BMA). 

Further information and guidance can be found in the following places: 

BMA: 

https://www.bma.org.uk/advice-and-support/gp-practices/managing-your-practice-list/removing-patients-from-your-practice-list 

https://www.bma.org.uk/advice-and-support/gp-practices/managing-your-practice-list/removing-violent-patients-and-the-special-allocation-scheme 

Citizens Advice Bureau 

https://www.citizensadvice.org.uk/health/nhs-healthcare/nhs-patients-rights/#h-gp-removes-patient-from-register 

GOV.UK (Information on the NHS Constitution) 

https://www.gov.uk/government/publications/the-nhs-constitution-for-england/the-nhs-constitution-for-england#patients-and-the-public-your-responsibilities

Appendix 1 – Content of first letter to patient - warning 

Dear Patient 

I am writing to you following an incident in the practice on *insert date*.

While we appreciate that the events leading to the incident may have caused you to feel some upset and anger we feel the actions you took/behaviour that was displayed *delete as appropriate* was unacceptable. We have a strict policy on unacceptable behaviour and this will NOT be tolerated. 

*Insert description of actions and reasons why unacceptable*. 

If there are any further instances of unacceptable behaviour within 12 months from this letter the practice will remove you from our practice register and you will be required to register with an alternative practice.

Yours sincerely… 

Appendix 2 – Content of second letter to patient – removal from practice list 

Dear Patient 

I am writing to you following an incident in the practice on *insert date*.

While we appreciate that the events leading to the incident may have caused you to feel some upset and anger, we feel the actions you took/behaviour that was displayed *delete as appropriate* was unacceptable. We have a strict policy on unacceptable behaviour, and this will NOT be tolerated.

 *Insert description of actions and reasons why unacceptable*. 

Our records show that you have previously been warned about such behaviour on *insert date here*. The letter sent on this date explained that repeat instances would result in your removal from the practice register. We have now requested that you are removed from our patient register. This will take place eight days after NHS England receive our request. You will now have to register at an alternative practice. 

Yours sincerely…