Published: 03/06/2004, Volume II4, No. 5908 Page 10 11

A centrally imposed anti-violence strategy to protect NHS staff marks a departure from the zero-tolerance campaign which left trusts some freedom to choose how to tackle the growing problem.But will it get better results?

Alison Moore reports

Five years after launching its 'zero tolerance' campaign to tackle violence against NHS staff, the government is changing tack.

Instead of gently encouraging trusts to tackle abuse, it has opted for a stronger centrally imposed approach targeting the most serious assaults, generally those involving physical violence. And where the police or Crown Prosecution Service cannot or will not proceed, a team of legal experts employed by the NHS will take cases to court.

There has been much support for this hard-nosed approach, led by the Counter-Fraud and Security Management Service special health authority. But will it reduce the tide of violence against staff, given that reported incidents have risen from 65,000 in 1998-99 to 116,000 in 2001-02?

The answer seems to be: it will be impossible to tell. The statistics included physical and non-physical assaults, with different organisations defining assaults in different ways. A new national reporting system installed in December will count only physical assault, and indications so far suggest only a few thousand cases will be reported each year.

The CFSMS insists its strategy is not about massaging figures downwards, but about ensuring consistency across the NHS, and ensuring that violence is not just reported, but tackled.

The special health authority was set up last year with a remit to lead NHS work on violence. Unlike other initiatives, it will be mandatory - trusts and other health service bodies are already being told what they have to do.

CFSMS chief executive Jim Gee says: 'It is a consistent, comprehensive and professional approach across the NHS. Health service organisations need to make sure they abide by it. Whether someone works for the NHS in Doncaster or Devon, they deserve the same level of protection against violence. That is central to the employers' role.'

The CFSMS's approach includes:

conflict-resolution training lasting a day for all frontline staff - a massive task as it will involve taking 750,000 people out of the workplace for training;

publishing a handbook which offers examples of good practice in preventing, detecting and dealing with violence;

taking a tougher line on offenders, pursuing them through the criminal and civil courts;

setting up a network of local security management specialists who have to produce an annual report - sent to the CFSMS - and report any weaknesses in securityrelated systems.

Mr Gee denies this approach is being followed because of past failures. 'What we are doing is putting in place a much stronger local structure in each NHS organisation, ' he says. 'We are trying to provide national support and coordination, but our emphasis is on building strong local structures.'

Unusually, one of the mechanisms being used to ensure compliance is secretary of state's directions - direct orders from the top, where compliance is mandatory.

This has already caused some disquiet in the service.

West Hull primary care trust chief executive and NHS Alliance spokesman Graham Rich says: 'It is a departure from the norm. Something needs to be done, but local resolution is the way to do it.

'I found it completely counter to the national policy of devolution and local determination. It is not the best way to energise and motivate organisations to take responsibility for it.'

The news that he needed to nominate an executive director to take responsibility for violence came 'out of the blue', he says.

Although foundation trusts will normally be exempt from the directions, they will be forced to comply through clauses in their contracts with PCTs.

This has raised some eyebrows, but University College London Hospitals trust chief executive Robert Naylor is not unduly worried when this mechanism is used on an issue where there is so much general agreement.

'It is more a question of how extensively this route will be used, ' he says. 'I think that if the secretary of state started to put a whole lot of statutory responsibilities in. . . then foundation trusts and the regulator would have something to say.'

The CFSMS is also setting up its own legal protection unit, headed by a barrister, to pursue more cases through the courts. This could involve both taking forward criminal cases which the police or CPS are unable or unwilling to take to court, and looking at alternatives, such as anti-social behaviour orders, which have already been used by some NHS trusts.

And the service is considering introducing a national anti-social behaviour order against one person who has caused problems at several different hospitals, although it will not reveal which areas are involved.

Mr Gee insists that this should not be seen as a criticism of the police and is working with the Association of Chief Police Officers to draw up a memorandum of understanding about who does what.

Offenders could also be taken through the civil courts, to get compensation for damage caused to property or to staff, or to obtain injunctions.

Repeat offenders are of particular interest. 'We have found that where someone comes in and assaults a member of staff in one NHS organisation it does not mean that they would limit themselves to that organisation, 'he says.

The CFSMS is looking at how known offenders could be 'flagged up' in the new electronic health records which should eventually be available to all health workers involved in their care.

Despite the government's tough talking under the zero-tolerance campaign, court action against offenders has been extremely rare.

The last available figures suggest there were 50 prosecutions in the eight months to March 2003.

This may have been because of a reluctance among health service organisations to go through the courts, but in many cases the police or CPS could not take action because of lack of resources or difficulties in obtaining evidence.

This created a feeling that the attackers were simply getting away with it and that reporting incidents was futile, says senior employment adviser with the Royal College of Nursing Sheelagh Brewer.

'On paper the CFSMS's strategy looks like it should make a difference. . . it needs to be aimed at those trusts which have not done very much, ' she says.

But he is equally keen to see good preventative measures put in place, not only the training to help staff defuse some difficult situations, but more NHS buildings designed to reduce aggression and protect staff.

'If you are really interested in reducing assaults, you need to look at why they take place, ' he says.

But some of these policies will involve extra costs for NHS bodies. Conflict resolution training, for example, can be carried out either by CFSMS staff, internal trust trainers or 'outside' specialists - but the costs must be borne by the organisation commissioning the training.

So will this change in strategy mean there will be fewer assaults on NHS staff? Because of the changes in reporting methods, it will be very hard to tell.

NHS bodies will initially only have to report assaults involving physical violence to the CFSMS, and have their own internal reporting procedures for nonviolent offences.

Mr Gee does not rule out national figures being compiled for both physical and non-physical incidents, but in the short-term the concentration is on incidents involving violence.

He says the new definitions adopted by the CFSMS and now being used by all NHS organisations when reporting are more closely linked to legal definitions of offences. To continue with different NHS bodies using different definitions as they had previously would be 'daft' .

The new system has been in use since December and by the beginning of May around 800 cases had been reported through it. Even allowing for slow uptake, this suggests only a few thousand cases will be reported each year.

Mr Gee is swift to point out that the new figures are not directly comparable with the past ones, but says the CFSMS is keen to concentrate on the most serious cases.

'It is the old question of how do you eat an elephant? A little at a time. We wanted to deal with the most serious assaults first, ' he says.

Nor is it just about figures: there could be significant benefits for the NHS if staff simply feel more secure and less threatened in their work. The 2003 NHS staff survey showed violence as a concern for many staff, and fear of violence - as much as the actuality - may affect recruitment and retention.

Fifteen per cent of staff had suffered from physical violence over the last 12 months (mainly from patients and their relatives, but a handful from managers and work colleagues).

Hinckley and Bosworth PCT chief executive Colin Blackler says getting the message across to staff that something is being done is very important: 'People will see through it if it is just lip service.'

So improvements may be hard to detect from the figures alone, but there are few in the NHS who will criticise the added clout the CFSMS brings to the battle against those who demoralise and injure the service's staff.

What will trusts and PCTs be obliged to do?

Nominate an executive director or similar to take responsibility for security.

Follow a specified plan when an incident involving physical violence occurs, including involving the responsible director and calling the police.

Report all incidents involving physical assault to the CFSMS.

All staff must be offered conflict resolution training over the next four years, as will new staff when they join.