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What to do When Behaviour Becomes Unacceptable in your GP Practice

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In the majority of cases, complainants can be placated, calmed, and even turned into fans by following a complaints procedure that includes listening, empathy, and apology without acceptance of blame. But occasionally a patient, family member, or visitor, becomes abusive – either physically or verbally. After our recent post titled “Handling Complaints in the GP Practice the Easy Way”, we’ve been asked to summarise the recommended strategy to deal with unacceptable behaviour.

Defining unacceptable behaviour

In general, unacceptable behaviour is any behaviour that would be deemed abusive. The NHS document “Unacceptable Behaviour – Guidance on warning letters and other written communications” defines unacceptable behaviour as:

“unreasonable and unreasonably persistent complainants who, because of the frequency or nature of their contacts with an authority, hinder the authority’s consideration of their, or other people’s, complaints.”

Unreasonable behaviour can be categorised as either non-physical (mostly verbal) or physical assaults. Non-physical assaults include:

- Offensive language

- Racial or sexist remarks

- Offensive gestures

- Threats

- Stalking

- Etc.

Physical assaults include:

- Punching

- Kicking

- Striking with a weapon

- Spitting

- Etc.

However, unreasonable behaviour may also include behaviour of an anti-social nature, such as climbing on buildings, playing loud music, graffiti, drug use, urinating in public… the list is almost endless.

If you believe you or a member of staff, or the practice, is the subject of unreasonable behaviour and you’ve exhausted your complaints handling procedure, your next action is likely to be giving the guilty party a warning letter.

How to write warning letters

Before you write a letter, you should ensure that you have sufficient evidence to do so. So it is important to document events leading up to the letter. Records should include witness accounts, and might also include:

Incident report

Previous incident reports relating to the same offender

Details of external incidents

Always make sure that staff are aware of best practice when recording telephone calls (a written record must also be made of abusive calls). Envelopes and packages of abusive mailings should be kept, and emails or other electronic messages must be printed out. It might be that stricter action may be deemed necessary (such as taking the case to the Police), but where a warning letter needs to be written it should include:

- Name and role of the person sending the letter

- Description of the unreasonable behaviour

- Details of previous steps taken to address the behaviour

- Detail of why the behaviour is deemed to be unreasonable

- Actions to be taken if the behaviour is repeated

- Advising of those who have been copied in, and if NHS records have been marked

- Give details of date of review

- Give details of how the warning may be challenged and the complaints process


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5 Tips on warning letters

Here are a few tips when sending a warning letter:

- If possible, send the letter from someone unconnected with the incident. This diverts attention from those who provide treatment and also serves to highlight seriousness

- There is no need to go into detail about the incident (the person receiving the letter is central to the event)

- Say what the impact has been on provision of services; often the offender doesn’t realise until it is put in writing

- Always warn the person of further consequences – don’t be afraid to seek advice from NHS Protect about this

- If you think that others need to be told, you are probably right – this includes other individuals and external agencies (but don’t forget to detail in the letter)

Make handling unacceptable behaviour practice policy

It’s unrealistic to fully detail how to handle unreasonable behaviour and warning letters in a single blog post. However, as a matter of course all members of staff should be aware of the guidelines and situations that would warrant such written communication.

As part of your GP practice training regime, and perhaps also your induction package, you might consider making available the NHS document “Unacceptable Behaviour– Guidance on warning letters and other written communications” and running a ten minute Q&A session on it in a team meeting. Raising knowledge and awareness will help to raise standards and safety in the practice, and keep all members of staff safe from unreasonable behaviour.

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