Assaults on NHS Staff

New figures released today show the reports made by the NHS of assaults on staff across the whole organisation and broken down by “sector”.  NHS Protect, a special business authority of the NHS across England, exists to protect NHS staff and assets on all areas from violence against staff, to counter-fraud and corruption that undermines the NHS as a whole.  They have published annual statistics for several years now, concerning incidents of violence against staff and they are worth examining —

Figures for 2012/13; for 2011/12; and for 2010/11

Overall, there has been a 5.8% rise in reported incidents and a 15.9% rise in sanctions compared to the previous year, but the first thing to say, is that the new 2012/13 data is not complete!

BROKEN DOWN BY SECTOR

The move from Primary Care Trusts to Clinical Commissioning Groups has thrown the report of assaults in primary care into disarray, so we can’t see that for this year.  I don’t know whether there are plans to publish that later or whether it’s lost forever!  So this year’s data is broken down by four areas: acute, ambulance, mental health and “special”.

This year, we learn that 70% of reported assaults on NHS staff occured within the mental health sector, 2% within the ambulance sector and most of the rest in the acute sector.  I admit to thinking, I’d like to know within the acute sector, the proportion of those that occured specifically in Accident & Emergency as it has always struck me as a particular area of concern.

When looking at the figures, you will see “assaults involving medical factors.”  This means the number of physical assaults “where the perpetrator did not know what they were doing, or did not know what they were doing was wrong due to medical illness, mental ill-health, severe learning disability or treatment administered.”  This is relatively new territory for the NHS.  They have reported staff assault figures for many years, but it is only in the last three that they have attempted to get to grips with assaultative behaviour which has a causal or contributory relationship to someone’s ill-health or treatment.  So for example, someone exhibiting distressed behaviour whilst suffering from dementia or after receiving a head injury who lashes out: this would be counted in the figures as “involving medical factors.”

A quick word on the assaults on paramedics:  there are 11 NHS ambulance trusts in England and they vary in size and in terms of staff numbers.  Yet if one examines the number of assaults experienced (see p8 of this year’s figures), we see a big discrepancy in the number of assaults experienced, the number of sanctions secured.  It does make me wonder about the factors that bring this about; whether they be cultural attitudes to assault in the NHS trust itself, to police responses as well the systemic features of paramedicine and criminal justice in the UK.

THE MENTAL HEALTH SECTOR

It has been the case since the commencement of figures that the mental health sector has contributed to the largest proportion of assaults against NHS staff and this covers assaults within inpatient settings as well as amongst community mental health teams.  70% during 2012/13, up slightly from 67% the previous year.  However, if we remember that the primary care figures missing from this year’s data, we would expect to see a modest rise in that overall percentage figure.

Something I wish I knew, was the proportion of those assaults that were reported to the police, so we could then make sense of the sanctions.  If you remember that 2% of assaults occured within the ambulance sector, also note that no mental health trust in the UK had more sanctions for assaults on staff than the ambulance service with the greatest success in this area.  I know from my previous work in my own force area, that one major mental health trust traditionally reported around 16% of their assaults to the police, so 7 in every 8 cases were never going to lead to a sanction, because the police were never informed.  This brings us on to “assaults involving medical factors” for the mental health sector.

If you look at pages 9 and 10 of this year’s or last year’s figures, you notice a number of mental health trusts who argue that all assaults against staff involve medical factors.  You’ll then notice one that thinks the opposite!  It seems safe to say that mental health trusts are struggling with this – the totals suggest that 82% involved medical factors and 18% do not.  But we can see significant differences in attitude.  Is there good reason to suppose that an NHS Trust in south-west London is dealing with such significantly different issues to a trust in north-east London or north-west London?  Overall, probably not.  And yet we see a very different attitude to “medical factors.”

The number of assaults reported is also of interest in itself.  Some of the smaller trusts have the higher number of assaults.  Research has suggested that levels of assaultative behaviour are contributed to by issues within the control of the care provider.  Things such as staffing levels, ward environment and so on.  But irrespective of that, given that it sits out of the control of the police, there are reasons to think that in some trust areas, they are under-reporting violent issues to the police where investigation and prosecution could do much to ensure a balance of treatment for individuals and safety for all.

I said something similar on Twitter today and was roundly criticised by a few individuals, but only earlier in the day, a senior police officer was talking about improving the confidence of rape victims to come forward and the need to improve the police response to reports of rape.  Why should it be any different in offending on mental health wards, whether that be offending behaviour by staff or by patients, against staff or other patients?  Surely it is everyone’s interests to make our NHS as safe as possible and we also know that the Mental Health Act has a significant interface with the criminal justice system and the potential for “therapeutic jurisprudence” via the courts is part of our legal framework:  only criminal courts can imposed certain kinds of orders and restrictions to achieve proper health outcomes and this does not always involve the criminal conviction of patients.

ISSUES FOR POLICING

I have said for years, that whenever police officers sit around bemoaning the fact that service provision in the mental health sector of our NHS is not where they’d hope it would be – lack of s136 services, difficulties accessing beds leading to massive, sometimes illegal, delays in custody, etc., etc.. – they fail to see some areas where we, the police, fall short.

I have written on this blog that we need to improve the investigation of criminal offences involving suspects who are mentally ill, move past the (overly) simplistic notions about the relationship between mental ill-health and crime.  There is much to learn about the potential of the criminal justice system to support the health system.

We need to ensure that where staff or patients report being assaulted by someone with a mental health problem, even if that accused person is detained in hospital under the Mental Health Act, we don’t just dismiss it as “not in the public interest” or assume that because someone us a s3 patient they may never be held to account through the justice system.  This is far from being true, and even in cases where it were true, prosecution may still occur for serious offences, in order that courts can consider the use of (restricted) hospital orders to balance off people’s right to treatment with the publics right to protection.  Prosecution is not just about the individual, but also the victim and the public.

If you are a police officer, please take the time to read some of the blogs I have written on investigation and prosecution – a feeling amongst NHS staff of not being protected by the justice system and not being able to seek redress where staff have become victims sits behind much reluctance by staff and managers to do some of the things that we complain about in private.  Also, be aware that there is a formal agreement in place nationally between the police, the CPS and NHS Protect about basic standards to be expected during investigation / prosecution.  You can help to break the catch-22 by ensuring that if you receive reports from NHS staff or patients that they have been assaulted, that it obtains a meaningful response.  Think of it somewhat like domestic violence: we know in DV matters that the first report to the police will not be likely to be the first act of violence by the accused person.  Well, in mental health we need to remember that for every report we receive, about 7 other incidents were not reported and that there will probably be a particular reason or a particular history behind the report being made.  Let’s find it out and act accordingly!

To see the extent of this problem, consider the recent case in Taunton of Ronald ASHWORTH:  he was prosecuted for causing actual bodily harm in a private prosecution brought by NHS Protect after he punched and knocked out a member of staff, breaking their jaw.  This private prosecution followed the Crown Prosecution Service deciding “not to prosecute a related matter”.

We need to step up our record in this area of policing, to keep vulnerable people, our health colleagues and our NHS safe.


IMG_0053IMG_0052Winner of the President’s Medal from
the Royal College of Psychiatrists.

Winner of the Mind Digital Media Award.


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3 thoughts on “Assaults on NHS Staff

  1. I suspect the differences in ambulance trusts is largely accounted for by the level of reporting and the culture of reporting rather than one trust having more aggression problems than another. Whilst we are told to report all verbal and physical aggression, it is not generally the norm to report every Friday night drunk who swears at us, or to report being grabbed at by a dementia patient.

    It may be some trusts have genuinely got a zero tolerance policy where all these things are reported, or that in some trusts practically no assaults are reported unless the police become involved.

  2. NHS Assault figures 2012/13
    The publication of figures for the number of reported physical assaults on NHS staff in England has been an annual event since 2005. Michael identifies that they are incomplete this year because they exclude the figures for Primary Care providers, which in 2011/12 were reported as being 1540. Arguably they have been incomplete each year. NHS Protect is at pains to identify these as PHYSICAL assaults on NHS staff (in the NHS Physical Assault has a very specific definition namely: The intentional application of force to the person of another, without lawful justification, resulting in physical injury or personal discomfort) however these figures end up being reported as the total number of assaults on NHS Staff, including all the verbal abuse and attempted assaults specifically excluded and of course all the incidents in Scotland, Wales & Northern Ireland.
    Michael asks above what proportion of the assaults in the Acute sector occur in A&E. I can’t provide figures for the sector as a whole, however in one acute Trust the number of assaults in A&E accounts for approximately 12 % of the total number for that Trust. So despite what the media tend to report the main problem of assaults on NHS staff is NOT caused by young men & women under the influence of alcohol in A&E on a Friday & Saturday Night. The figures show that the majority of assaults occur in Mental Health & Learning Disability settings but of those in Acute hospitals the vast majority occur on wards caring for older patients with a range of medical conditions. Unpalatable as it may be nurses are much more likely to be assaulted by a pensioner than by a person of their own age or younger.
    In Ambulance Trusts as in every trust local attitudes will play a part in the number of incidents that are formally reported, the time reporting takes, lack of support from management & the ongoing perception that it it’s “part of the job” prevail. Unfortunately so does the “Zero Tolerance” myth. It’s a myth because people do tolerate aggressive or assaultative behaviour from patients despite what well- meaning senior staff in Trust’s , professional bodies or Trade Unions may say. How do I know? because if I was punched and spat at by someone in the street or if I worked in a shop I’d be sure to report that assault to the police as well as my manager. I have been spat in the face and punched by an elderly patient I was preventing from leaving what he did not accept was a hospital ward, I reported it internally because assessing incident reports is what I do but I certainly didn’t report it to the police and many healthcare staff wouldn’t even have filled in the online reporting form that I did, because they tell me they don’t.
    Michael asks what proportion of assaults are reported to the police? In our example acute Trust of over 150 assaults less than 3% were reported to the police at the time. Michael is correct, a negative spiral can exist where staff won’t report incidents because when they have done previously no action was taken against their assailant. With no reports the police can’t act, and CPS can’t consider if there are advantages to the individual assailant or victim or the “community” of a prosecution. These spirals can be broken but it takes confidence from staff that the police will investigate, confidence from police officers they will get support from the NHS to unpick the issues around capacity/diagnosis/prognosis and the practicalities of interviewing individuals detained on S3 of MHA and confidnce from both that CPS will understand the public interest in pursuing cases of this sort. For Police Officers or Prosecutors reading this don’t forget each NHS Trust should have a Local Security Management Specialist (their actual title may vary from Trust to Trust) in post who is trained to help unpick the complexities of dealing with assaults on healthcare staff committed by patients.
    In order to identify why “clinical” assaults occur and how to reduce them it’s important to consider what these assaults actually are. This is the second year of NHS Protect’s figures detailing how many of these assaults are “clinical” and in the Trust I’m using as an example a survey of staff identified that the majority of these occurred while staff were in close proximity to patients delivering clinical or personal care and were caused by blows from hands and arms followed by pinching/scratching as the most common forms of assault. Many of these patients were described as being “confused” or having Dementia while a proportion had brain injury, were detoxing from alcohol or were combative in A&E during assessment either as a result of injury or intoxication.
    The question of the proportion spilt of assaults between A&E and other areas of the hospital Michael identified also merits investigating further with A&E being the location for approx. 25 % of all incidents reported to Security in our example Trust. A&E is also the location for 30% of the total number of Non Physical Assaults, 25% of restraint for clinical reason but only 12% of the physical assaults! Why is this? A combination of higher staffing levels, the fact that owing to 4 hr trolley wait targets people admitted intoxicated don’t tend to recover from that state until on a ward, may well account for some of this apparent discrepancy.
    What is disappointing in these figures and the reporting of them in the media is that NHS Protect have chosen to focus on the increase in criminal justice sanctions obtained when such a small proportion of the assaults don’t have a clinical component and are therefore suitable for prosecution. It’s also pertinent to note that a criminal sanction is not judged to include community resolutions or restorative justice approaches despite a drive by many police forces to adopt this approach for more minor criminal behaviour. This approach can be very effective in changing behaviours in acute & MH settings and where CPS are reluctant to authorise charge of individuals who are “unwell” either physically or mentally.
    So how can we tackle a broadly unchanging level of violence against healthcare staff committed by individuals who may be elderly, infirm, confused, psychotic, attempting to pull drains/catheters/IV lines etc out or simply leave hospital convinced they do not need to be in hospital or in fact are not in hospital at all? Much of the violence reported in the NHS Protect figures is I feel attributable to these patients attempting to communicate an unmet clinical need including, hunger, thirst, fear, pain or frustration. To tackle this we need to equip clinical staff with skills to identify underlying medical conditions and environmental and behavioural factors driving behaviour and skills to keep themselves and patients safe while these medical issues are addressed.
    There are training programmes out there that can do this, one adopted by the trust in question has seen a reduction in physical assaults of 11% Trust-wide and up to 60% in targeted areas with other benefits including a 10% reduction in clinical restraint, improved staff perceptions of safety and importantly for patients training that means clinical staff and their security colleagues trained together in techniques which unlike those used by the police do not depend on gaining compliance through the threat of or actual infliction of pain (this isn’t a criticism of police officer safety & control & restraint techniques and I acknowledge that no physical intervention is without risk but crucially the RCN is clear there is no therapeutic benefit to the infliction of pain and we are talking about health care settings). The training package described recently won the Training Initiative Category at the Security Excellence Awards and in these budget conscious times doesn’t need cost more than existing mandatory training programmes in conflict management.

    None of this is easy but continually rehashing the same headlines each year in response to broadly unchanging figures is not going to have any effect on improving the safety of NHS staff and their patients.

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