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Violence against Health Workers

Volume 547: debated on Tuesday 3 July 2012

Motion made, and Question proposed, That this House do now adjourn.—(James Duddridge.)

Our national health service employs more than 1.7 million people. Of those, just under half are clinically qualified, including 120,000 hospital doctors, 40,000 general practitioners, 400,000 nurses and 25,000 ambulance staff, as well as an army of other health care workers. Only the Wal-Mart supermarket chain, Indian Railways and the Chinese People’s Liberation Army directly employ more people.

On average, our health service deals with 1 million patients every 36 hours. That is about 500 people a minute or eight people a second. As those figures suggest, the size and volume of the NHS means that literally millions of interactions between patients and staff occur every single day. In the vast majority of cases, these interactions are positive and result in successful outcomes for patients and staff alike, which is why, simply put, the NHS is one of the best health care models on the planet. But sadly, things sometimes go wrong for patients and badly wrong for staff. The superb staff who provide such sterling service to the public can find themselves the victims of violence while working on our behalf to provide those very services. The purpose of this debate is to highlight this wrong and seek support from the Government for righting it.

The NHS management service’s latest statistics reveal more than 150 reported physical assaults on health care staff per day—and that is before verbal assault is taken into consideration. According to the latest 2010-11 NHS survey, 7% of NHS staff had been victims of assault in the previous 12 months. The Royal College of Nursing’s research reveals further troubling statistics, with almost 11% of those surveyed having been assaulted at work in the previous two years and more than 60% of all respondents having suffered verbal abuse at work. Indeed, one respondent commented that

“verbal abuse seems to just be accepted as part of our work”.

That is totally indefensible.

In Northern Lincolnshire and Goole hospital trust, which serves the Scunthorpe area, there were 13.1 assaults per 1,000 members of staff in 2009-10. Although that figure is below the national yearly average of 16.8 per 1,000, it is still far too high. One assault against any person simply trying to do their job in any profession, never mind people who routinely save lives every day, is completely unacceptable.

Two weeks ago, I joined a local ambulance crew for five hours of their 12-hour shift, and I was hugely impressed by the professionalism of the paramedic team and the staff at Scunthorpe general’s accident and emergency department. Patients were treated with great skill, care and dignity, which is exactly as it should be, but I was shocked to learn that the fantastic paramedic I was with had gone to a house call about a year ago and was seriously assaulted by the man he had gone to help. He was chased around the house by the man, who violently and persistently assaulted him. The assault was so bad that it resulted in his being off work for six months.

I received today this e-mail from a staff nurse at Scunthorpe general hospital:

“I understand that you are taking part in an adjournment debate tonight on the above subject. I was assaulted by a patient in January this year. With colleagues I went to clean up a patient that…had attacked a nurse earlier in the day and no one felt able to approach him since. I was subjected to a violent attack which meant I was on sick leave for three months. I have had intensive physiotherapy and still attend physio regularly. I suffered a needlestick injury while trying to sedate the patient and will be tested for blood borne viruses in the next few weeks. During the time I was off work and, for some time since, I have been in constant pain, I had limited use of my right arm and restricted movement of my neck. I could not hold a pen to write or brush my teeth. Everyday tasks took hours and I became depressed and withdrawn. Even now I am unable to perform all my duties as a nurse. Yet, mine was not a serious injury. I have made considerable improvement but will always have some level of pain and restriction of movement.”

She goes on to thank us for raising this issue in Parliament.

I congratulate the hon. Gentleman on bringing this issue to the Chamber, and I wish to associate myself with his comments. In Northern Ireland, including in my constituency and in particular the Ulster hospital, there have been several attacks on accident and emergency personnel and ambulances. It is not specific to Scunthorpe but happens across the UK. Would better co-ordination between the hospital authorities, ambulance and emergency personnel and the police be a way of addressing some of these issues?

I thank the hon. Gentleman for his comments. He reminds us that, sadly, the problem affects people across the nations of the United Kingdom. I will come to the issue he raises later, but I want now to quote the final comments of the nurse who wrote to me:

“You can have no idea what it means to have this problem recognised and debated. I do not expect to be compensated in monetary terms for the pain I have suffered or the possibility that I may not be able to work to retirement age but I do want to see measures put in place to effectively protect staff who are expected to deal with difficult and violent patients.”

The costs of such assaults are multi-fold. There is the cost to the NHS of care for the victim, the cost to the NHS of the health worker’s absence from work and the possible loss of an employee if recovery is not complete. Added to that is the potentially devastating impact on the health worker’s own health and well-being, with further strain on family, friends and the wider community. I would like to pay tribute to all the fantastic people working in the NHS, including the people and organisations working hard to prevent such violence from taking place against health workers. Northern Lincolnshire and Goole Hospitals NHS Trust has launched an e-petition to heighten public awareness of the issue. The fact that the trust has recognised it in this way is to be applauded, but there is much more to be done. That is why the trust’s partnership approach, working with Unison and others to find ways of practically addressing the issue, is to be welcomed.

NHS Employers—part of the partnership for occupational safety and health in health care—is also actively involved in raising the issue of violence and aggression against staff, and is looking at how it can be managed, working hard to help create healthy and productive workplaces. Work is also under way—led by NHS Protect, with input from the Royal College of Nursing and others—to look at preventing and managing physical assaults on staff which result from a patient’s underlying medical condition, such as dementia. Many physical assaults result from a patient’s underlying clinical condition, but rather than ignoring this, steps can be taken to reduce the risks. Work to take these positive initiatives forward needs to be systematically supported and funded if it is to bring real change and reduce the risk to health workers from such patients.

All these initiatives are positive and to be welcomed. However, I want to highlight a number of concerns raised with me by the Royal College of Nursing, Unison and others. I am keen for the Minister—who I know is committed to ensuring that the Government do their best in this area—to say in his response what practical steps the Government are taking to address those concerns. The Government have funded work by the Design Council with a limited number of A and E units to reduce violence through design solutions. That is to be welcomed. How will the work be evaluated, and how will any improvements to the safety of staff and patients in such units be shared and implemented more widely? With the end of Secretary of State directions, which required NHS trusts to have measures in place to protect staff, how will it be possible to ensure that all provider services meet standards similar to those currently set under Secretary of State directions? They include access to a local security management specialist, training on conflict resolution, central reporting of physical assaults and a requirement to follow policies and guidance—for example, lone working guidance—published by NHS Protect.

Lone working nurses and health care workers absolutely need protection. They often form an invisible work force. Many health workers already work alone with limited, if any, back-up or support. The quite proper policy direction of providing more services in the community means that more health workers are likely to find themselves in potentially vulnerable situations as sole workers. How will Government ensure that there are systems in place to minimise risk and protect the work force?

Full consideration needs to be given to the possible impact of changes in health care delivery combined with efficiency savings on the likelihood of risk of violence against staff. In particular, a risk assessment of the impact of closing units, lengthening A and E waiting times and staff shortages needs to be undertaken and the effects mitigated. That needs to be recognised. In this climate of cost-cutting and austerity, how can we be certain that such measures will be put in place to reduce the risks to staff? Staff who report incidents need more support from their employers and the police. They need feedback after they have reported incidents, and they need to know what action is being taken to prevent any reoccurrence. Lack of feedback and support can lead to under-reporting of incidents and reduced morale.

I welcome the fact that pressure from Unison has resulted in a change to the code for Crown prosecutors to increase the number of prosecutions for assaults on public servants. The closer working relationship between NHS local security management specialists and trade union safety representatives has been a positive development. NHS Protect has also agreed protocols with the police and the Crown Prosecution Service. Under the memorandum of understanding with the Association of Chief Police Officers, the police are committed to progressing all cases of violence and abuse against NHS staff as a priority. The Crown Prosecution Service has also made a commitment to

“work with the police to ensure that these cases are treated with the seriousness that they deserve and encourage a robust charging policy”.

It is crucial that that should lead to a more consistent approach by police forces to following up the perpetrators of either physical or verbal abuse. RCN research suggests that police follow-ups are sometimes inconsistent around the country. Some forces follow up complaints robustly and work closely with local hospitals, but others appear reluctant to get involved in procedures, especially when the incident involves a patient with an underlying mental health condition. Such incidents in particular need more close examination, as a significant number of physical assaults on health workers are by patients with underlying mental health problems. How can the Government ensure that the memorandum of understanding between ACPO, the CPS and NHS Protect will be consistently and effectively implemented?

The reporting and investigation of assaults also need to be properly addressed. According to the RCN survey, although only about 11% had suffered physical abuse at work, 74% of the incidents they recalled were never reported to the police. Staff need to be confident that they will be supported by their employers and the police. They need to be given the confidence always to report assaults. There needs to be a culture of trust that, when reported, such assaults will be taken seriously and fully investigated, with proper support given to the victims. Proper feedback and support in the reporting process will help to keep up morale in the NHS work force and reassure staff that they should not expect to be put in danger while carrying out their duties on behalf of all of us.

In this age of austerity, budgets are being squeezed, and organisations that protect workers are being asked to do important jobs with a lot less funding. For example, the Health and Safety Executive, which plays an important role in keeping people safe at work, has had its work force reduced by a third in the last 10 years, with the number of inspections that it carries out falling from 75,000 to 23,000 a year. That could lead to the real danger of worker safety being jeopardised, which makes it even more important for NHS employers to take completely seriously the need to protect their work force and minimise the risk of attack from patients. Health and safety is not red tape; health and safety saves lives.

Worryingly, the cuts in NHS and local authority budgets and in the Health and Safety Executive are in danger of combining with the confusion caused by the NHS reforms to cause local security management specialists to become increasingly reliant on safety representatives to help them to identify those work areas in which NHS staff will be most at risk. Many local security management specialists used to work with primary care trusts. With the abolition of PCTs, there is a possible danger of confusion and uncertainty about their role in the workplaces that they cover. How will the Government ensure that the risk inherent in the changes does not lead to more health care workers finding themselves in situations in which their personal safety is put at risk?

Every single person should be able to go to work without the fear of physical harm. I strongly back Unison’s calls for a zero-tolerance approach to safeguarding NHS staff. Everyone needs to work together with a clear and persistent focus to make sure that all staff can carry out their work free from the fear and the threat of physical or verbal assault. When individuals are found guilty of attacks on health care workers, that should inform the sentencing and be treated with the utmost seriousness.

As Julian Corlett, Unison branch secretary for Scunthorpe general hospital, wrote to me:

“Violence directed at health workers is never acceptable and is not part of the contract of employment. We must dispel the myth that violence in the NHS is inevitable, or unpredictable and therefore uncontrollable. It therefore remains our key objective to see a significant and sustained reduction in the number of violent incidents directed at NHS staffs across the country, with more prosecutions and severe sanctions for those perpetrating such violence. There has to be the presumption that those committing these offences are more likely to face prosecution than not if we are to see sustained reductions in the figures anytime soon.”

Julian speaks from experience with great passion and clarity; his words will echo round this Chamber and in the world outside it. We should be vigilant and proactive in ensuring the safety of those who work within the NHS. In the words of the children’s laureate, Michael Rosen, on the 60th anniversary of the NHS, we must do all we can to protect the

“hands that touch us first...and the hands that touch us last”.

I begin by congratulating the hon. Member for Scunthorpe (Nic Dakin) on securing this debate on violence against health care staff. It is an issue that every Member of this House can agree is totally and utterly unacceptable in every instance. I would like to praise the reasoned and measured way in which the hon. Gentleman made his points. I also share with him the disgust about what has happened to some of his constituents who work—day in, day out—on behalf of patients in his constituency. Sadly, this problem is not restricted solely to his constituency, as it applies to all constituencies where, regrettably, acts of violence are directed against NHS staff. I can assure him that this Government have zero tolerance of that sort of treatment —physical or verbal—against people who work in our NHS on behalf of patients.

Violence against health care workers can never be tolerated. Nobody should expect to suffer violence at work. This is especially the case for those who are committed to caring for others. Clearly, the human cost alone makes it unacceptable; although the physical effects may be transient, the deeper emotional scars can often last a lifetime. Beyond the effect on the individual, too, there are other factors: the disruption to services caused by the incident and its aftermath; the impact on staff welfare, sickness absence, recruitment and retention and the cost of additional security, all of which divert resources, human and financial, away from providing health care.

In short, the cost to the NHS of violence is huge and it affects us all. I am determined that we should do all we can to prevent violence against health care staff and to take the toughest possible action when violence does occur to ensure that those responsible are held accountable for their actions. From the outset, the Government have been committed to taking action to tackle the problem of violence. We have encouraged NHS organisations to work more closely with their local police forces to clamp down on anyone who is aggressive or abusive to staff—and while we may have made progress, there is still a long way to go.

In 2010-11, the latest year for which figures are available, there were almost 58,000 reported physical assaults on members of NHS staff. Hon. Members are able to consult the reported figures for each health body, as these are placed in the Library each year. In the majority of those assaults—some 40,000—the patient’s medical condition was a factor. This means the culpability of the assailant may have been in question or that a legal sanction may not have been appropriate. However, that still leaves some 18,000 cases in which the assailant’s medical condition was not a factor. While this number is smaller than for the previous year, it is nowhere near small enough: 18,000 is 18,000 too many. We are committed to taking whatever further action is required. The hon. Gentleman expressed concern about sanctions and convictions. I can tell him that sanctions against offenders, ranging from cautions to fines to imprisonment, have increased—there was a 24% increase in 2010-11—but the number is still not high enough.

We are taking action in a number of ways. Some are new, while others have succeeded in the past and we have therefore continued to support them. Of course, the main priority is to prevent violence by protecting staff and managing high-risk situations before they escalate. NHS Protect, which the hon. Gentleman mentioned, is the body that leads the work to tackle crime throughout the health service. It has identified violence against staff as one of its key priorities for 2012-13, and has developed a work programme aimed primarily at preventing assaults.

There are trained security management specialists at more than 90% of NHS trusts in England. They are responsible for investigating security breaches, along with the police, and for implementing new systems to protect NHS staff more effectively. NHS Protect supports NHS organisations by providing advice, assistance and best-practice guidance.

The Criminal Justice and Immigration Act 2008 introduced powers to deal with antisocial behaviour on NHS hospital premises, which enable an authorised person to remove those who are suspected of creating a nuisance or disturbance. A three-year training programme funded by the Department of Health and managed by NHS Protect, which will end in April 2012, has enabled more than 600 staff at over 80 hospitals to be trained in the implementation of the Act. They have been empowered to respond to disruption such as foul language and verbal abuse, intimidating gestures, excessive noise in waiting areas or wards, and the obstruction of thoroughfares. Feedback from staff trained by NHS Protect in the use of the Act’s provisions indicates that the powers are working well in practice on the front line, helping to provide a safer environment for NHS patients, staff and visitors.

The hon. Gentleman raised the important issue of design, particularly but not solely in accident and emergency departments. In November last year, I was pleased to be able to speak at the launch of a project organised jointly by the Department of Health and the Design Council involving the use of design to reduce violence in A and E departments. Leading experts developed and tested potential solutions and identified areas for action. We are currently in the implementation phase of that project. Early indications are positive, but in order for the impact of the solutions to be fully evaluated, a detailed framework has been generated by the design team to record both quantitative and qualitative data. Those data will generate the evidence base that will formally endorse the concepts, proving their efficiency and their impact on the costs of violence and aggression in A and E departments. The evaluation has not yet finished, but we hope to communicate the results later in the year.

The Government intend to change the legal framework in respect of antisocial behaviour. One of those changes is designed specifically to tackle antisocial behaviour affecting the NHS. As Members may have noted from the Home Office White Paper that was issued in May this year, we propose that NHS Protect be named as a relevant authority to apply for crime prevention injunctions. That is intended to enable a quicker response to the problem of antisocial behaviour, and to avoid the need for the police or local authorities to apply for injunctions on behalf of an NHS body.

While much of the work will focus on assaults for which the person committing the act can be held responsible, we will not ignore cases in which a person’s medical condition is a factor in violence, especially as such cases represent the majority of reported physical assaults against NHS staff. NHS Protect is working with a clinically led expert group to develop guidance on the prevention and management of violence in circumstances in which the medical condition of a patient puts staff at greater risk of assault.

When necessary, we need to challenge the idea that the existence of a particular medical condition is a bar to prosecution. Whenever an assault occurs, an assessment of the assailant's culpability must be made. When assailants cannot be considered legally culpable for their actions, prosecutions cannot be appropriate, but when assessments reveal that people were in control of their actions and knew what they were doing, there should be a presumption that sanctions will be sought. Indeed, there is some clinical opinion that such action can assist in making a person understand the impact of their behaviour, and so affect it in a way that discourages repeated incidents. For action to be taken against offenders, we first need staff to report when they have been subject to violence, either verbal or physical. That staff have confidence in the action that will be taken is paramount in encouraging them to do so, and the role of the local security management specialists is key to that.

All the initiatives I have mentioned are designed to prevent violence from occurring. We must, however, remain prepared for the times this prevention activity is not as effective as we would like it to be. When violence does occur, we need to ensure that those responsible are held to account.

To pick up on the valid point the hon. Gentleman made about joint collaboration, NHS Protect has signed a three-way agreement with the Association of Chief Police Officers and the Crown Prosecution Service, with the stated intention of curbing violence and antisocial behaviour in the NHS. This agreement recognises that the police and the CPS are bound by guidance and codes of practice on communications with victims and witnesses, and that employers have a duty to support in every way they can staff who have been victims. This joint-working agreement supports the Government’s commitment to act. NHS Protect will this year be working to translate this national agreement into local protocols for more effective collaboration between the police, the CPS and health bodies in seeking appropriate sanctions for acts of violence. NHS Protect is currently identifying best practice in the management of physical assaults in mental health settings, with a view to issuing specific guidance for that sector. This will include working with the police to take forward prosecutions where it is appropriate to do so.

The hon. Gentleman also raised the important issue of how to protect the lone worker. To better protect lone workers, NHS Protect led the delivery of a lone worker alarm service for the NHS. Over 40,000 staff, and more than half of NHS trusts across England, now use this service, which enables a lone worker to signal covertly for help from the emergency services if they find themselves in a dangerous situation. The service also provides a system control centre, which enables listening to, and recording of, incidents in case evidence is later needed as part of a prosecution.

I wholeheartedly share the hon. Gentleman’s concern about violence against health care staff. We should always do everything we can to prevent it, and when we cannot prevent it, we should seek the strongest sanctions against those responsible.

I hope that the hon. Gentleman and the House are reassured by my account of the work we are undertaking, and by the Government’s and my own personal commitment to tackling this completely unacceptable problem.

I thank the hon. Gentleman. He rightly holds this subject very close to his heart. The Government share his concern, and we are determined to do all we can to minimise the cowardly, dastardly and disgusting attacks on people who do so much to help the frail, the vulnerable and the sick in this country.

Question put and agreed to.

House adjourned.