Head of the National Audit Office, Sir John Bourn, reported to Parliament today that good progress has been made to improve the protection from violence given to NHS staff. However he said that more needs to be done particularly on risk assessment, staff training, follow up after an incident has been reported, and the establishment of effective partnerships between the NHS and other public agencies such as the police.
In the last 2 years the level of reported incidents of violence and aggression against NHS staff working in acute, mental health and ambulance Trusts has increased by 13 per cent. Around 95,500 incidents were reported in 2001-02 and only a fifth of Trusts met the Department’s national improvement target of a 20% reduction by April 2002.
Better awareness of the need for reporting and more widespread use of common definitions of what constitutes violence and aggression have contributed to this reported increase. But many Trusts consider that increased hospital activity and higher patient expectations particularly in relation to waiting times, have also contributed to an increase in the actual levels of violence.
There is little or no data on the financial impact of violence and aggression but, based on their estimates of the cost of work-related accidents, the National Audit Office estimate that the direct cost is likely to be at least £69 million a year. This excludes staff replacement costs and the human costs, such as stress, low morale, lost productivity and high staff turnover, which are known to be substantial.
Nurses and other NHS staff who have direct interaction with the public (including the ambulance service, accident and emergency departments and acute mental health units) face the highest risk of violence and aggression. For example, nurses are up to four times as likely as other employees to experience an incident and the average number of reported incidents in mental health and learning disability Trusts is almost twice the average for all Trusts despite evidence that staff in mental health units are much less likely to report incidents. Generally there remains a high level of underreporting, particularly by doctors, and we estimate that almost two in five incidents go unreported.
The Department of Health, through its zero tolerance zone campaign, has been successful in raising awareness of the need for staff to report and in informing the public that violence against staff working in the NHS will not be tolerated. The NAO’s survey found that while all NHS Trusts have embraced the values set out in the NHS zero tolerance zone campaign, different definitions are used and there are wide variations in reporting standards and in the support provided to staff. These factors make it impossible to say conclusively how far the increase in reported violence reflects an actual increase in incidents, or measure how individual Trusts are performing.
Violence and aggression against NHS staff results from a complex combination of personal and situational reasons including anxiety, medical or psychological conditions, drugs or alcohol and it is difficult to predict what could trigger an incident. The NAO found that many Trusts have generally responded positively with better use of risk assessments, staff training, and improvements to the physical environment to make it both more patient-friendly and at the same time more secure for staff.
However the NAO identified the need for further work in key areas. While Trusts had improved their reporting procedures over recent years, two in five incidents still go un-reported and more needs to be done to ensure that staff understand how and why they should report incidents and to demonstrate the value of reporting by ensuring that appropriate action is taken and feedback provided to staff. A survey by the Royal College of Nursing suggested that in four out of five cases no action arises from an incident being reported, and it is clear from the NAO’s work that some Trusts do not provide adequate support to staff wishing to pursue civil actions.
The NHS needs to do more to establish partnerships with the local police, the Crown Prosecution Service, social services and the media to ensure that there is a clear understanding of different organisations’ roles leading to a clear and consistent approach to dealing with violent individuals and incidents in NHS settings.
Effective staff training is crucial in tackling violence and aggression. The NAO found that the approach across Trusts is improving but that doctors, ancillary and support staff are still not receiving sufficient training. They also highlighted uncertainties about the quality of courses in the absence of a system of accrediting course providers and a need for annual training needs analysis for all clinical and support staff.
While Trusts have implemented various security measures aimed at combating violence and aggression, such as CCTV and panic alarm systems, there is limited scientific evidence of the effectiveness of these measures. When introducing new measures Trusts need to identify clearly the risks they intended to address and evaluate their impact.