The new UK government pamphlet 'Your Guide to the NHS' opens with a mission statement about 'core principles' - 'universal', 'comprehensive', 'quality services', 'seamless services', 'reduce health inequalities', and other familiar pieties.
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On page two it gets down to business: 'your commitment to the NHS.' This means 'look after your own health', 'care for yourself when appropriate', 'listen carefully to advice', 'tell the doctor about any treatments you are already taking', 'keep your appointment', 'return any equipment that is no longer needed', 'pay prescription charges promptly'. The NHS guide does not specifically demand that you wash behind your ears, but you get the drift.
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'Your commitment' includes the injunction to 'treat NHS staff, fellow patients, carers and visitors politely, and with respect'. The NHS is no longer merely concerned with health - it is determined to improve the manners of the nation. Indeed, it is engaged on a wider crusade against prejudice and injustice: 'we will not accept violence, racial, sexual or verbal harassment.'
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The government's declaration of 'zero tolerance' of bad behaviour in the NHS is a fashionable posture that reflects the decline of trust in relations between the public and the health service. But this posture will have even more demoralising consequences for both health workers and their patients - as I know, from my personal experience of the impact of this policy on the ground.
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The Community Services Trust, which administers the health centre in which I work, has issued a poster under the heading 'Abusive Behaviour', threatening patients that it will take action against them if they are violent or abusive towards staff. Without any consultation, this has been displayed at several prominent positions around the health centre.
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At a practice meeting last week we discussed this poster in light of the fact that we have had very few incidents of violent or abusive behaviour in the health centre in recent years. A number of factors were thought to have contributed to this: a well-organised appointment system, high-quality reception staff, improvements to the waiting room, a new garden and an art display.
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Recognising that some patients are more inclined to be rude or hostile towards reception staff than they are towards doctors, we have asked receptionists to let us know when this occurs so that we can make it clear to individual patients that this is unacceptable. They have found that this is generally effective in deterring such behaviour. We have also installed a 'panic button' alarm system, but this has rarely been used in practice (though often by mistake).
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In short, we feel that our policy of treating our patients with respect has been reciprocated.
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 | | The 'abusive behaviour' poster offends everybody without protecting anybody |
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We registered two major objections to the poster: that it is offensive, and that it is ineffective. Displayed prominently around the health centre, it gives the impression that practice staff are experiencing such a wave of 'verbal abuse, harassment and violence' that it has become necessary to take decisive action against this. This is not only untrue - it is insulting to our patients, with whom we have built up relations of trust and affection, often over many years.
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Furthermore, the notion that this poster affords any protection to practice staff against the risk of abuse or assault is illusory. Somebody who is inclined towards violence, for whatever reason, is not going to be deterred by reading a poster which declares that such behaviour is unacceptable. The poster thus offends everybody without protecting anybody. The fact that the Community Services Trust considers this an appropriate gesture of concern for the welfare of practice staff reveals that it seems to be as cynical towards its employees as it is contemptuous of the public.
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Yet this poster - or some variant of it - is being promoted widely in the health service, in hospitals as well as in primary care. A glance at the weekly GP periodicals confirms that there is a widespread preoccupation with the threat of violence from patients and numerous proposals and schemes to deal with it. Indeed, such preoccupations appear to have become universal among professions exposed to the public, reflecting a wider breakdown of relations of trust in society.
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We can only state that, in our experience of a large, busy, inner-city health centre with a high prevalence of psychiatric illness, incidents of violence and abuse are so rare that they are of negligible importance in the day-to-day life of the practice. We are aware of widely reported (though mercifully rare) cases in which GPs and other practice staff have sustained serious injuries, and recognise that this is always a risk.
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In our view it would be a serious mistake to respond to this marginal risk by replacing relations of trust and respect in general practice with attitudes of fear and anger, which are expressed so powerfully in the GP press (and implicitly in the 'abusive behaviour' poster). Not only would this be profoundly damaging to doctor-patient relationships, it would also be counterproductive. If doctors start treating all patients as potential assailants, they are more likely to encourage than deter aggressive behaviour.
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We have written to the relevant authorities (shortly to be subsumed in a new Primary Care Trust) to suggest that the abandonment of the 'abusive behaviour' poster would be an important symbolic gesture for the new trust. It would indicate a decisive break from the traditions of poor management and lack of respect for the public that have been characteristic of the organisation and provision of healthcare in east London, as in the rest of the country.
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Overcoming the attitudes expressed in this poster will take time, especially as they are fully backed by the government, but tearing it down would mark a start. Readers watch this space!
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Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).
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