The threat of violence towards GPs has led South Essex health organisations to set up a special allocation scheme. Carolyn Larsen and colleagues explain GPs have had the right since 1999 to remove a patient immediately from their list for actual or threatened violence or aggression.

1South Essex has experienced an increasing rate of patient removals. There was an 11 per cent increase in immediate patient removals between 1999-2000 and 2000-01, with nearly 50 patients removed for violence/ aggression in 2000-01.

South Essex health authority, with South Essex local medical committee, primary care organisations and community health councils have therefore developed a special allocation scheme.

In keeping with the principles of health service circular 2000/01, patients with a violent history continue to receive primary care from volunteer GPs in a secure environment.

There is also an emphasis on addressing any underlying causes of aggressive behaviour and an opportunity to help the patient to understand how the NHS works and their individual responsibilities for their healthcare.

The ultimate aim is for patients who have been immediately removed to return to mainstream general practice with an understanding of appropriate acceptable behaviour.

We agreed with the local medical committee that we needed to recruit volunteer GPs to provide care for these patients. Six have now been recruited. It was also agreed that each GP would register no more than 12 known violent patients at any one time.

Each GP receives an annual retainer fee of£6,000 and an additional annual capitation fee of£750 for each registered patient. In return for this fee, the volunteer GPs are required to:

provide a full clinical assessment, including psychological and social needs, for each patient;

work with other primary care practitioners, social services and other agencies, including mental health services, to try to identify and treat any clinical and underlying causes of disruptive behaviour, so as to prevent further deterioration;

provide information on the availability of general medical services work with the patient to develop understanding of the NHS health and social care system, and encourage appropriate use of services in the future.

Management support for the scheme is provided by a commercial deputising service. This acts as the first point of contact for patients, liaising with their named GP to organise appointments and provide advice, arranging any appropriate follow-up and referrals on behalf of the scheme GPs.

Primary care is provided by the patient's named GP at two centres in South Essex: a primary care centre operated by the local commercial deputising service and the mental health unit at a local hospital.

Surgery sessions are offered on five afternoons a week. Patients needing urgent medical advice, or treatment outside normal surgery hours, are offered advice or treatment by a doctor employed by the commercial deputising service. Uniformed security personnel are present during surgery opening times to minimise the likelihood of further violence and aggression.

This scheme was established on 1 October 2000 and an ongoing review of its progress is being carried out by a multidisciplinary steering group.

Initial review of the scheme has highlighted the following factors:

fifty-seven patients are involved;

most are men and aged 20-40;

most contacts have been for repeat prescriptions and ongoing treatment;

there have been no further incidents of actual or threatened violence to scheme GPs or staff at either of the secure venues to date;

regular meetings between the scheme GPs, facilitated by the HA, are important to address problems at an early stage and develop common policies, particularly in relation to repeat prescribing;

further training support needs to be provided, not just to the scheme GPs but to all other GPs and practice staff across South Essex to improve their skills in managing potentially confrontational situations. An initial training programme provided for scheme GPs and their practice staff with input from local police has been helpful.

Each patient will be reviewed annually by their scheme GP, with a view to returning to mainstream general medical services.We are developing a patient information leaflet, which we hope will reinforce the messages provided by the scheme GPs.

While the scheme is still in its infancy, we hope it will help us identify the underlying causes of patients' violent behaviour, reducing the number of immediate removals.We also plan to do further work with local CHCs to assess users' views to assist in our evaluation of the scheme.


1HSC 2000/01. Tackling violence towards GPs and their staff. The NHS (Choice of Medical Practitioner) Amendment Regulations 1999. January 2000.