More Assaults on NHS Staff

A short post, because it’s just updated data on topics I’ve written about before, where the same issues prevail.  NHS Protect issued its 2015/16 data for assaults on NHS staff and the headlines are –

  • Assaults are up by over 2,500 to 70,555 in the last full year.
  • That covers the whole NHS: the figures further break down to –
  • 52,704 assaults involved what NHS Protect calls ‘medical factors‘ – see below.
  • 17,851 assaults did not involved medical factors.
  • MH professionals are two, three or four times more likely to be assaulted at work than the ‘average’ for the NHS as a whole.
  • I’m not sure we know how many NHS patients were assaulted, whether by other patients or by NHS staff (yes, it does happen). NHS Protect don’t record (or at least don’t appear to publish) those data.

Within the various sectors of the NHS –

  • 46,107 assaults occured within the mental health sector of the NHS – 35,440 of those involving ‘medical factors’.
  • 2,300 assaults occured within the ambulance sector – 712 involving ‘medical factors’.
  • 20,018 assaults within the acute sector – 14,780 involving ‘medical factors’.

MEDICAL FACTORS

I’ve written about this elsewhere and for detail, I’d encourage you to read the previous post. Suffice to say here, that medical factors are defined as relevant to an offence if “the person did not know what they were doing or did not know what they were doing was wrong, because of injury, illness or treatment.” This is, more or less, the legal definition of insanity, so it is quite a high threshold to meet. There are very few insanity findings in criminal courts in any given year, yet the NHS records that more than 5 in every 7 of the assaults on their staff were at the hands of patients who meet that description.  This seems unlikely to me – it strikes me as a massive over-representation given what we know from other sources that insanity pleas are few and far between. We also know from research for NICE Guidelines that fewer than 10% of people who offend whilst mentally ill are offending because they were mentally ill. There is little direct, causal relationship between illness and offending, it seems.

Little appears to have changed in terms of certain inconsistencies that needed pointing out in my previous post – we need to debate what they mean. Nottinghamshire Healthcare Trust and Oxleas NHS Foundation Trust (south-east London) both recorded that none of their assaults involved medical factors. No-one at all in those areas – not even one person – was so unwell because of illness or injury that they lacked all insight in to their actions. And yet just down the road from those two, in Derbyshire Healthcare NHS Foundation Trust and in West London Mental Health Trust, ALL of the patients were so unwell they were, essentially, insane. I’ve worked as an operational police inspector in both Birmingham and in the Black Country: look at the figures for BSMHfT and the BCPT, above: one thinks that just over 20% of assaults were due to medical factors; the other thinks that just under 20% weren’t. I know Birmingham and the Black Country fiercely defend their cultural and various other differences but take it from me as a neutral (a Geordie) who has lived and worked in both places for over twenty years overall: I can assure there is not that much difference!

It strikes me again and again, neither of these extremes is likely to reflect the medical or legal realities in those areas. Just for completeness, there are two MH trusts data missing from the header image because of the page layout so I’ve highlighted them below because they also tell another story: why do MH trusts with a 1:2 ratio of staffing when compared to each other have roughly similar levels of assaults? You are twice as likely to be assaulted at work if you’re a mental health nurse in Ealing than if you work in Middlesbrough.


Of course, trusts differ in the services they provide – only some provide medium secure services; only some run learning disabilities or children’s mental health services; and only three trusts in England provide High Secure services and (West London is one of them) … but this all needs untangling if we are to make sense of data that is superficially confusing because it doesn’t compare apples with apples.

RISING LEVELS OF CRIME

What’s missing are the reporting levels to local police services. One MH trust told me that they report around 15% or 1-in-8 assaults on the staff to the police, because of their assessment of ‘medical factors’ and their consideration of victim’s views plus a guess at the public interest test for prosecution. So they determine that a report is not needed 7 times out of 8. Yet in a recently developed MoU between NHS Protect and the police service, NHS are requesting trusts to report 100% of incidents recorded in these data to the police. With what purpose in mind? – of course, anyone who is assaulted is entitled to report that to the police, but I’m wondering what the motivation would be for doing so if the suspect was an 89yr old degenerative dementia patient who has pushed a nurse causing no injury during the provision of personal care?

This approach should be even more interesting in those trusts which report 100% ‘medical factors’ – because they are asking the police to criminal investigate the liability of someone that professionals themselves are already assessing as unlikely to be convicted, ever. That having been said, in those thankfully rarer cases of more serious crime, the potential that someone is unfit to stand trial or likely to be found not guilty by reason of insanity is not sufficient reason, in itself, not to prosecute. The criminal courts in this country have powers under the MHA that no doctors have to balance off the issues where treatment needs to be considered alongside public protection. So we do need that debate about when it is right to prosecute a very vulnerable person who has offended. We know the answer is not ‘never’, so it begs the question, ‘when?’

Does a rise of 2,500 reported assaults comes from greater recording of incidents previously not reported because of a lack of time to do so or a belief that nothing worthwhile would result; or from a genuine rise in the levels of crime? … we don’t know! I’ve heard anecdote recently for each of those explanations and from professionals I know well and would trust; but it should be borne in mind the violent crime in society generally is rising and demand on the NHS is rising at a time when resources are being rationalised. It would not be unexpected if we saw numbers rising even just allowing for rising levels of offending. We need more data … much more data. We also need a clearer understanding of what ‘medical factors’ should mean and how this is being interpreted across the NHS. We need much more analysis and discussion of yet more data. 

We don’t know what we’re doing so we don’t know whether what we’re doing is wrong.

This should be on our to-do list for 2017 — Happy New Year!


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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11 thoughts on “More Assaults on NHS Staff

  1. I would say that i feel that it may be down to specifics on set ups to reporting within West London Mental Health Trust, also please bear in mind that WLMHT is spread across three london boroughs – not just Ealing.
    @ Micheal Brown – please feel free to email me direct for more information.

  2. Like you said not comparing apples with apples. My local Trust which was originally a mental health trust now runs community services like district nurses, pain clinics, GP surgeries, out of hours GPs., community hospital as well so the incident per staff ratio is an unreliable measure.

    1. A point I’ve made to NHS Protect several times! Given that Health & Safety obligations extend to patients using services as well as staff working there, I would have thought as much attention would be required to assaults on patients by other patients and, as you say, by staff. I know NHS staff can find that discussion difficult, but we know that nurses and healthcare assistants have been convicted of offences on several occasions, in addition to being more likely to be victims of crime than any other professionals in the NHS. Of course, in reality, these issues are connected!

      1. A good point indeed. I have been assaulted as an inpatient by other patients. Also assaulted by a member of staff in the community – both safeguarding and police investigation on that one. Pretty sure neither will be shown in a chart or reported in detail.

  3. per thousand patient “units” would be a better measure of the cost to staff and sufferer of how the service provided, if we could agree what a patient “unit” of service is e.g. per admission, per in-patient day, per outpatient contact, per … ?

  4. Just with regard to the ‘insanity’ discussion point, it is clearly a bit of a catch all however I do not think that this represents the issue of ‘insanity’ rather the issue of capacity. One of the challenges for MH staff is that there is a significant chance of them being assaulted but a decreased chance of the police taking action, because usually the understandable stumbling block becomes the issue of the patient’s capacity. I think this is an issue for two reasons a) because such ‘crimes’ are challenging to pursue and likely to result in the CPS declining to proceed – the problem is that this situation can essentially make some patients immune from prosecution, which makes little sense to staff and for those patients who would benefit from reality confrontation. b) and this is largely just an interesting technical point; often MH professionals and police can misunderstand each other in relation to ‘capacity’ as MH staff know capacity in relation to the Capacity Act, whilst for the police it relates to the ability to form mens rea. Personally I have sympathy with both professions in this entangled area.

    1. Absolutely spot on – totally agree with you and have said this for years. Although I also think officers misunderstand what is required to form mens rea – it’s not always what people think it is and this comes back to training investigators.

  5. We shouldn’t worry too much , after all – “its’ all part of the job” isn’t it?. This issue has been endemic to the caring profession since time immemorial The data is compromised by unhelpful ,subjective perception, our legal system does not support victims, those who hold corporate responsibility are not audited for appropriate HSW liability, workers are more worried about losing their jobs(being perceived as ‘troublemakers’) than actually reporting an incident, the service users who are being targeted are left unprotected, the system prefers to ‘blame and shame’ rather than investigate and support,(its’ easier for the managers, and -if you did’nt know about it you can’t be held responsible for inaction). This issue remains unchanged,I wonder why???

  6. ‘Capacity is nothing to do with prosecution’? Difficult to know where to start with that response really, suffice to say that I have never known a single case in an inpatient setting where the Police/CPS have pursued a case against a patient where they were deemed to not have capacity/ability to form mens rea. Although perhaps your comment is merely distinguishing that mens rea is the trump card? In which case I would agree, but the above point still stands that the two professions often lack clarity around this issue. Indeed normal practice is for the police to ask the responsible clinician for a capacity assessment and decisions are made on the outcome of this. The points in relation to the two ‘languages’ used and the lack of natural justice that health staff sometimes feel after being the victim of an assault, coupled with the issue that for some patients the lack of reality confrontation can be therapeutically counter productive are, I feel, important issues for consideration.

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