VIOLENCE: Increasing numbers of patients vent their feelings in violent attacks on NHS staff. Action is being taken to tackle the problem but, as Ann McGauran reports, success seems a long way off

In one of his most populist election speeches, prime minister Tony Blair promised zero tolerance of 'yob culture' in a second term.

Magistrates and judges would be given new sentencing guidelines, he said.

And health secretary Alan Milburn told this month's human resources in the NHS conference that persistently abusive and violent patients might be denied treatment.

But while initiatives have been pouring forth since New Labour was elected first time around, the number of reported incidents has continued to soar.

The cross-government 'zero-tolerance zone' campaign is now 20 months old and magistrates were issued with new sentencing guidelines last September.

In 1998-99, there were 65,000 violent incidents involving NHS staff. In 1999, the government was seeking a 20 per cent cut in reported attacks by 2001, with a 30 per cent drop by 2003.

Trusts are supposed to have agreed baselines for target reductions with their regional offices. But none of those contacted knew what their baselines were. This confusion suggests that accurate and comparable statistics may take time to emerge.

Chris Taylor is head of the Health and Safety Executive's health services unit. He says the Department of Health recently told him of a 2004 deadline for the 30 per cent target, but he has not had anything in writing.

According to Mr Taylor, the original target dates assumed the baselines would be set earlier than they were.

The Department of Health was unable to tell HSJ how many trusts had agreed baseline figures, because regions were in the process of collecting the returns.

Meanwhile, the trusts HSJ spoke to were reporting steep year-on-year rises in reports of physical assault and verbal abuse.

Most trusts say that, as awareness of the zerotolerance zone campaign has grown, there has been a rise in the number of staff deciding to officially record attacks.

This makes it hard to establish what proportion of the increases is genuinely the result of an actual rise in the number of incidents.

Chief executive of University Hospitals Birmingham trust Mark Britnell says his organisation has a 'really good reporting system' that logs about 1,000 incidents a year.

He notes that as awareness has increased the numbers have risen. Three years ago, the trust logged 400 incidents in a year.

He is critical of government attempts to emphasise targets.

'I think targets are pretty meaningless. Each trust should be made to demonstrate to staff that it is tackling abuse. A list of good-practice points would be more useful.'

And what of the mysterious issue of baselines for the targets? 'The baselines are very tenuous, indeed, ' he says.

'It is much more important that trusts can be seen to be taking care of staff.' His trust has given careful consideration to how staff security can be built into its new private finance initiative hospital (see panel, top right).

In other trusts, too, reports on assault have increased.

In March 2000, the then junior health minister Gisela Stuart chose Sandwell Healthcare trust as the venue to launch the second phase of the zero-tolerance zone campaign.

So what has happened there since her high-profile visit? In the year ending March 2000, there were 36 reported incidents of physical violence.

At the end of March this year, the figure had grown to 54.

The trend for reports of verbal abuse was even worse, with the numbers trebling from 40 to 120.

Colin Holden is the trust's human resources director.

'We have seen an increase, but we suspect this is because We have had a zero-tolerance campaign for some years, ' he says.

'My gut feeling is that quite a lot of the increased reporting was due to us telling people they do not have to put up with that sort of thing, and promising to support them when it happens.'

If Sandwell is anything to go by, it seems that even strong support from local magistrates will not necessarily bring down the number of reported incidents.

The chair of the local bench issued guidance to say that if a member of the health service suffered violence it should be considered an aggravating factor.

John Sinclair is adviser on the management of aggression at Grampian University Hospital trust in Aberdeen.

He reports a shocking 1,892 incidents of verbal and physical abuse in 2000, compared with 720 the previous year.

The trust is large, with 8,000 staff; the almost threefold increase indicates the deep-rooted nature of the problem.

'The main thing is getting a proper baseline. I do not see incidents levelling out for a number of years, ' he says.

'There is a historic lack of reporting.'

Traditionally, staff have simply shrugged their shoulders and considered attacks as part of their job.

Mr Sinclair expects the numbers to double again next year and believes about 40-60 per cent of staff still do not report incidents.

A key problem in deterrence, he says, is that 'unfortunately, many staff do not want to go down the line of prosecution'. Some, for example, may not want to go to court because they are suffering post-traumatic stress disorders.

Making it possible for trusts to take out cases against offenders, rather than relying on individual staff to bring actions to the criminal courts, would make a big difference, Mr Sinclair says.

He calls on key staff in Scottish trusts to co-operate in drawing up a report for the Scottish equivalent of the Crown Prosecution Service on why hospitals should be able to take cases forward.

Mr Sinclair also wants the Scottish Executive to have regular liaison with the personnel responsible for anti-violence strategies in trusts.

Unison head of health in Scotland Jim Devine says that enabling trusts to take cases to the criminal courts would be a powerful development. He has pledged Unison in Scotland's support for any such move.

Jon Richards is an assistant national officer for Unison, responsible for health and safety for NHS members. He believes the idea of trusts being able to press criminal charges is certainly worth consideration.

'We would like to see it investigated and if it were a viable option, we would welcome it.'

The 20 per cent reduction in violence by 2001 was always extremely ambitious, he adds.

He is more optimistic about the 2003 target, but would be happy with a significant fall in reported incidents.

A winter 2000-01 Health Service Report survey of 45 trusts was more pessimistic, with only a third expecting to achieve the 2003 deadline.

In the trusts surveyed, the overall level of reports of workplace violence had risen by more than a fifth (22 per cent).

The former Newcastle City Health trust was one of those singled out as an example of good practice by then health minister John Denham when the zero-tolerance zone campaign was launched in October 1999.

It merged its mental health services at the beginning of April with Northumberland Mental Health trust to create the Newcastle, North Tyneside and Northumberland Mental Health trust.

The Northumberland part of the trust recorded 251 incidents of physical assault and verbal abuse for the year ending March 2000, rising to 404 in the same period this year.

North East Ambulance Service trust had its training programme for operational staff praised by Mr Denham.

Training development manager Peter Cuthbertson says zero tolerance is a platform to build on to minimise risks to staff.

'Can the scourge of violence ever be removed? I think we can reduce it in time, but never eradicate it, ' he says.

'There will always be people tanked up on drink and high on drugs.

'If society as a whole can't actually tackle aggression, then the NHS is not going to be able to solve it, and it will always be there, ' he adds.

Safe bet: security in a new PFI hospital

Ian Harrison is trust security adviser for University Hospitals Birmingham trust. He says the private finance initiative development to replace the existing Queen Elizabeth Hospital and Selly Oak Hospital will 'totally revise what We have done in the past'.

The number of entrances will be reduced 'to two, if not one', there will be 'a big, welcoming security presence', CCTV throughout the site, and a heavier concentration of cameras in sensitive areas. He does not support the use of CCTV on individual wards, however.

Mr Harrison is also looking at a smart-card system for access control on all sensitive wards, theatres and laboratory areas and one major control room where all CCTV and technical alarms would be monitored. He adds: 'I would want to design everything myself to make sure we have what we need.'

Multiple initiatives, moving deadlines, tenuous targets

June 1997 The new Labour government issues guidance on security in accident and emergency departments.

September 1997 The Department of Health publishes further advice on how to deal with violence and aggression.

Autumn 1998 Launching Working Together: securing a quality workforce for the NHS, the then health minister Alan Milburn tell trusts they must have systems to record violence against staff in place by April 2000 and publish strategies to achieve reductions in the number of incidents.

The then health secretary Frank Dobson launches joint NHS and Royal College of Nursing guidelines entitled Safer Working and the 'Stamp Out Violence' campaign. He says that A&E departments are being refitted to make them safer, including CCTV. He promises£30m for further modernisation in 1999.

Health minister Alan Milburn announces that the NHS will be expected to cut incidents of violence against staff by 20 per cent by 2001 and 30 per cent by 2003.

October 1999 Launch of the cross-government zero tolerance zone campaign. At least 110,000 copies of guidance documents and posters are requested by managers and staff.

September 2000 New national sentencing guidelines issued to all magistrates' courts. Aggravating factors to be taken into account when sentencing include whether the offence occurred in hospital or medical premises, and whether the victim was serving the public.

October 2000 Further NHS zero-tolerance zone campaign guidelines issued to support staff in ambulance and mental health trusts, in the community and in primary care.

March 2001 The zero-tolerance zone campaign website claims that almost all trusts have published policies for cutting the incidence of violence and have provided evidence that a wide range of measures are being introduced to tackle workplace violence.

June 2001 HSJ understands that the Department of Health has moved the 30 per cent reduction target to April 2004.