Protecting healthcare workers

The NHS Security Management
Service (NHS SMS) is responsible for all policy and operational guidance concerning security management throughout the NHS in England. It promotes the right of all NHS staff to feel safe in their working environment, despite often being at greater risk of violence and verbal abuse than many other professionals. Figures released last November showed that during 2008-09 there were 54,758 reported assaults against NHS staff working in all care sectors. A key part of the NHS SMS’s work is ensuring that appropriate action is taken against offenders. In this capacity, it made a number of suggestions in response to the public consultation on the draft sixth edition of the Code for Crown Prosecutors.

Code for crown prosecutors
The Code gives guidance on the general principles to be applied when making decisions about prosecutions. Crown Prosecutors’ responsibilities include determining the charge in all but minor cases and reviewing cases submitted by the police for prosecution. When deciding whether charges should be brought, prosecutors consider whether there is sufficient evidence for a realistic prospect of conviction and, if so, whether the public interest requires a prosecution.
    
Offences committed against those ‘working in the public sector or providing a service to the public’ are classed as public interest factors in favour of prosecution. Taking into account the responses from the consultation in October 2009, some of these factors have been amended in the new sixth (2010) edition. For example, previous editions gave examples of public sector workers and service providers – citing a police officer, a prison officer and a nurse. The NHS SMS suggested that these factors should be clarified or expanded to ensure that offences against anyone providing NHS services are taken more seriously.
    
The new Code, issued in February 2010, incorporates various clarifications, as well as changes in law and practice. There are clearer explanations of the public interest factors both for and against prosecution and of how the public interest stage of the Full Code Test is applied. Specifically, the ‘nurse’ example has been expanded to include members of the emergency services and health or social welfare professionals. This places the emphasis on the nature of the service provided, rather than on particular occupations, prompting prosecutors in England to consider a wider definition of NHS staff and view offences against them more seriously. The NHS SMS hopes this will lead to more prosecutions for offences committed against NHS staff, resulting in more convictions.
    
The 2010 Code will also increase the work of the NHS SMS’s Legal Protection Unit, which works closely with the police and Crown Prosecution Service to increase the number of prosecutions brought against those who assault NHS staff.
    
It does, however, also acknowledge the balance that must be struck between the factors in favour of prosecution – including the need to safeguard the public – with the public interest in diverting a defendant with a significant mental illness from the criminal justice system. This is particularly significant in the context of the NHS SMS’s figures for assaults against staff: the highest number, by a substantial margin, is within the mental health sector: 196 assaults per 1,000 staff. A prosecution is usually considered less likely if the suspect is, or was at the time of the offence, suffering from mental or physical ill health, unless the offence is serious or there is a real possibility that it may be repeated. Those most at risk from offences committed by people with mental ill-health are those who provide care services to them. The revised Code therefore gives equal regard to safeguarding staff providing care services to such individuals.
    
A key theme in the consultation document was consistency in approach and decision-making. Therefore, the NHS SMS also recommended that reference to Home Office guidance dealing with mentally disordered offenders should be reinstated within the new Code. This guidance not only details existing powers, but also encourages inter-agency cooperation to make the most of resources and deal with mentally disordered offenders appropriately and consistently.

Help from the NHS SMS
The NHS SMS’s priority is tackling incidents of violence against staff that are reported to Local Security Management Specialists (LSMSs). In 90 per cent of trusts, these staff are trained and accredited by the NHS SMS to ensure that the highest standards are applied locally. It is important for all NHS staff to identify their LSMS and, if subject to any incident of violence, to report it to the police and LSMS.
    
On 1 April 2010, the requirement to report physical assaults to the NHS SMS was extended to capture data on all security incidents. The Security Incident Reporting System (SIRS) is a new security management tool for the NHS, introduced to coincide with this change in reporting requirements. SIRS will provide a more accurate picture of the nature and scale of security incidents across the NHS in England and enable trends to be identified. This will inform policy development, further contributing to staff safety. By regularly receiving and collating data from trusts, SIRS allows local findings to inform prevention and deterrence work nationally. At a local level, it enables trusts to monitor security incidents, spot trends and compare their performance against the national picture.
    
Working pre-emptively, the NHS SMS has developed guidance for staff treating patients with a history of violence and in need of long-term care. This includes a nine-point plan for nurses to use in care planning to identify potentially violent patients. It advises them to check patient records and engage with the family to establish the patient’s history.
    
In primary care, there is also support in the form of the violent patient scheme (VPS). This enables practices to report violent patients to the police and could result in the removal of patients from doctors’ lists. GPs should engage with their primary care trust about their local VPS, which may be used when an act of physical violence, verbal abuse or intimidating behaviour is committed against any member of the practice, other patients or anyone who has reasonable fear for their safety or that of others.     

Reporting patients in this way could result in their removal from the practice’s list, usually for 12 months. These patients may then be treated under the VPS by the primary care trust.

Conflict resolution training
Clearly, it is essential that there are mechanisms in place for dealing with security incidents. However, it is equally important that the underlying culture is addressed. In response to this need, the NHS SMS launched a national syllabus for conflict resolution training for all frontline NHS staff in April 2004. This gives staff the skills to recognise and defuse potentially violent situations. Similar programmes specifically tailored for mental health settings and ambulance staff run in parallel.

Specific consideration is also given to lone workers in the NHS. Due to the nature of their work, lone workers need additional organisational support, management, training and instruction to deal with the increased risks to their security and safety, as well as being enabled and empowered to take a greater degree of responsibility for these concerns. To this end, the NHS SMS launched its Not Alone guidance in conjunction with the Department of Health providing 30,000 subsidised lone worker alarm systems to these vulnerable staff.
    
Whether it is by giving lone workers a means of summoning assistance, GPs the option to remove violent patients or prosecutors the tools to treat abuse of all NHS staff more seriously, the work of the NHS SMS is giving everyone in the health service – staff and patients – a better chance of the safety and security to which they are entitled.