Harmed and dangerous: how do we stop violence against NHS workers?

SPECIAL REPORT: More and more people in public-facing jobs are being confronted by violence and abuse at work, and the NHS is at the sharp end. Existing policies are failing — we need a more co-ordinated and energetic approach to tackle the root causes and protect the staff who care for others.

Barbara McCready, a specialist physiotherapist at the North Cumbria Integrated Care trust (NCIC), has experienced aggression and abuse from patients and relatives — often arising from long waiting times and “frustration and concern about the care of people’s loved ones,” she says. “I understand why emotions can be high in these circumstances but aggression or violence doesn’t resolve things.”

It’s important to remain calm, McCready (pictured above) says, and to try to respond “with kindness and compassion” even when facing abuse. “When things go wrong or communication breaks down it feels very difficult for us too,” she adds. “We’re human, and we’re in these roles as we’re very passionate about caring for others and really do want to help.”

McCready took part in the trust’s ‘HUMAN’ campaign, which aims to reduce violence, threats and verbal aggression by trying to build a rapport with people who may be angry or worried. Instead of stern ‘zero tolerance’ messages and prosecution threats, the trust’s posters feature striking, close-up photos of real staff members under the headline ‘We Are All Human’, supplemented with simple messages like ‘I’m a Dad too’ or ‘I’m a carer too’.

“We wanted to make a calmer environment,” explains Kath Hughes, NCIC’s head of communications, who helps run the campaign. “We knew zero tolerance messages weren’t effective. They just add to a pressurised environment and people rebel against it. We thought seeing ‘I’m a Mum too’ might make some people — not all — think about how they respond to those who are trying to care for them.”

It’s hard to gauge the true extent of the problem, since the NHS stopped collecting national statistics on violence and abuse in England when NHS Protect was wound up in 2016. In the latest NHS Staff Survey, 26% of staff reported experiencing “harassment, bullying and abuse” from patients or the public, slightly down on previous years. Good news? Well, not really. The survey only measures the number of staff experiencing abuse, not the number of incidents or their severity. Figures published by individual trusts, often as part of their own anti-abuse campaigns, point firmly in the opposite direction.

A typical large trust now has over 1,000 incidents of violence and abuse a year. Figures compiled by ITN found over 41,000 physical assaults on NHS staff in 2023 — a 21% increase since 2019. One trust, Nottingham University Hospitals reported over 1,800 incidents of “aggression, violence and harassment” during 2022-23, and over 1,100 during the first six months of 2023-24 — the highest on record. All but one of the organisations I spoke to — including several who would only comment off the record — said the problem has got significantly worse since the pandemic.

When work can be scary

Ambulance staff have long borne the brunt of this. Adam Hopper, violence prevention and reduction lead for the Association of Ambulance Chief Executives (AACE) has collected statistics on violence and abuse against paramedics for the last eight years. He found a staggering 17,000 incidents reported in 2023-24, more than double the 2016 level. While some of this can be attributed to more frequent reporting, there’s “a clear upward trend” since the pandemic, he says.

“Going to work, you can expect to get threatened and abused quite often, unfortunately,” Hopper warns. Paramedics are taught to spot the warning signs: swearing, clenched fists, people standing in a certain way. “It can be scary,” he says. “The hairs go up on the back of the your arm, you get that feeling and start looking for your exits. You think, if this goes wrong, how do I get out?"

South West Ambulance Service paramedic Lauren Setchell was sexually assaulted by a patient while on duty: “It really hurt me. Any sense of safety I had disappeared."

The AACE’s Work Without Fear campaign has highlighted some of the shocking abuse paramedics face, and the “real, deeply personal impact it can have” — often leading to absences from work and sometimes to paramedics losing their careers, says Hopper.

USDAWLauren Setchell, a South West Ambulance Service paramedic, was sexually assaulted by a patient she had gone to help. “Most people would be shocked to know that after the sexual assault, I had to clean the back of the ambulance where he’d urinated on it,” she says. “It really hurt me. Any sense of safety I had disappeared.” It was “a huge relief”, she adds, when local police reversed their original decision not to proceed against the attacker and charged him with sexual assault.

Steve Raven was attacked by a drunk patient while on duty with the West Midlands Ambulance Service. “I thought I was going to die. He broke my jaw, caused facial nerve damage and affected me mentally as well,” he recalls. “It’s sad… I was there to help him, but he ended up putting me in hospital.” He has mixed feelings about the two-year prison sentence handed to his attacker — “a young man has damaged his life, ruined his own prospects,” he says — but the incident left him needing anxiety medication and regular counselling. “Every day, to go to work, is always a tough thing to do, but I still want to do my job,” he says.

‘There’s more aggression out there’

The apparent trend towards more public violence isn’t confined to the NHS. A recent survey by USDAW, the shop workers’ union, found that assaults on retail staff doubled last year, with one in five reporting that they’d been physically assaulted by a customer. The Unite union recently reported a “tsunami of abuse” against Britain’s bus drivers, with 82% reporting abuse and 79% saying the problem was getting worse. Job centre staff and railway workers have also reported sharp increases in abuse and violence in recent years.

med“There’s more aggression out there, we’re becoming a less civil society,” warns Alan Lofthouse, UNISON’s deputy head of health, and this, combined with frustration about NHS services, creates a “perfect storm” where violence and abuse are more likely to happen.

“Staff are at breaking point over here, so they’re less likely to see the signals of aggression as they escalate. Meanwhile, over there you've got angry relatives who are frustrated for their loved ones,” he explains. Another factor is “patients in the wrong areas” — dementia patients on general wards, for example. “You need specialist training to deal with patients with specialised conditions. Without that, things can easily escalate,” he says.

He’s sceptical about the impact of security measures such as body cams and new laws mandating tougher sentences for people who assault emergency workers. “They were brought in as a deterrent, but violence has gone up since,” he says. “Politicians say, ‘We have a zero tolerance approach, a law to prosecute offenders, and a camera to capture the assault.’ But what’s being done to prevent the assault in the first place?”

Dr Rob Hendry, medical director of the Medical Protection Society, which now offers a telephone counselling service to doctors experiencing violence at work, agrees that staff shortages and long waiting times are “key triggers” for abuse. They account for the vast majority of incidents reported in a recent MPS survey, he says, but “the constant flow of negative stories in the press about the NHS may also be fuelling the public’s anxiety… and making people feel they have to fight for their relatives to get treatment.”

Hendry believes that unless zero-tolerance policies are visible and “properly enforced right across the NHS” — and taken seriously by the police — staff may be discouraged from reporting incidents. “There’s a worrying notion that that violence and intimidation are now somehow part of the job, with some healthcare staff becoming desensitised to it,” he warns.

Understanding ‘social’ and ‘anti-social’ violence

“People who are very emotionally charged are not going to act calmly or rationally. It’s often a good person having a bad day, but they have this need to vent which can escalate into physical violence,” says Dene Josham, former Royal Marine and celebrity bodyguard, and now lead instructor at Streetwise Defence. Josham (pictured right) and co-founder Julie Waite have worked with NHS trusts, universities, community groups and private businesses, training thousands of people in personal safety and violence prevention.

 

Streetwise do not teach punching, kicking or martial arts, but use the ‘trauma-informed’ approach to violence prevention now widely favoured in the NHS. “The aim is to understand the human psychology behind violence, the motivations, so people can take preventative measures,” says Josham.

 

Identifying the type of violence can give you “a roadmap” for dealing with it, Waite explains. ‘Social violence’ — patients or relatives frustrated by treatment delays, for example — can usually be escalated (or de-escalated) “verbally by the steps you take”, she says. “Interactions with staff can escalate up to a breaking point. But the actions staff members take can make a difference.” ‘Anti-social violence’, by contrast, is usually motivated by criminality or hatred. “It can’t be de-escalated and you need to move straight to getting support,” she adds.

 

Streetwise recently worked with Stagecoach bus drivers and conductors facing abuse from passengers angry at rising fares and cuts to services. Rising public violence is a problem “across the board”, says Josham. “Everyone’s under pressure and the systems aren’t in place to deal with it. A lot of organisations don’t appreciate the the damage violence can do — the trauma and the knock-on effect,” he says. “They say we can’t afford that. But we need to protect our people.”

• For more information, visit: streetwisedefence.com.

Hard work

The Social Partnership Forum (SPF), the national negotiating body for NHS unions and employers, advocates a ‘trauma-informed public health approach’ to reducing violence and abuse against staff. Lofthouse, who chairs the SPF violence prevention and reduction group, explains: “That basically means understanding the causes and drivers of violence. And they are there. The guy with the tattoos who’s violent in A&E — that might be traced back to an unloving childhood and a history of alcohol and drug dependency. We need to fix some of the issues in the NHS and broader society but, in the moment, we shouldn’t accept that it’s part of the job.”

It also means investing time and money to make sure vulnerable staff are equipped to resolve conflicts and de-escalate tense situations. “If trusts invest, make roles clear, give staff a say, work with health and safety reps, this stuff starts to make a difference,” says Lofthouse. “But that’s the difficult to do, boring stuff. It’s much more appealing to just slap cameras on people and throw them into dangerous situations.”

Bita Ebrahim was abused by a patient while cleaning floors at West Cumberland Hospital. “I had to request assistance from the ward staff to calm the patient down. As much as I understood the patient, I felt embarrassed.”

The Violence Prevention and Reduction Standard (VPRS), agreed by NHS unions and employers in 2021, sets out what organisations should be doing tackle the problem, including training, monitoring, encouraging the reporting of incidents and consulting with unions on new measures and technology. Someone at board level should be accountable for meeting the standard, with commissioners expected to make twice-yearly compliance checks as part of contract reviews.

There’s little sign that the VPRS has made much impact so far. Adam Hopper says the framework “relies on self-assessment with an emphasis on continuous improvement”, and isn’t as “rigorous” as the NHS Protect regime. It’s also voluntary — employers are only expected to make “all reasonable efforts” to comply. A recent UNISON survey found only 19% were fully compliant, while 40% didn’t even know about it. The union wants the VPRS to be mandatory and baked into contracts between commissioners and providers.

Hopper praises the “hard work” of the ambulance service in generating an “effective reporting culture”. This isn’t just about compiling statistics: perpetrators of abuse and are now flagged, so paramedics know in advance they may be dealing with a dangerous individual. “The last thing we want is somebody going into a situation completely unaware of how bad somebody can be. You need as much intelligence as possible,” he explains.

Money has also been put into training, Hopper says, teaching paramedics about conflict resolution and de-escalation, and how to break away from an attacker, as well as dynamic risk assessment — “understanding what’s going on around you”, he explains. “If we were looking after ourselves as well as the patient, that first punch might not hit us. I think, generally, we don't understand how much we put ourselves at risk.”

But training standards are inconsistent, he says, with some trusts offering no training and others leaving it to e-learning. And unlike the police, who do annual refresher courses, paramedics are offered them only every three years.

Efforts to reduce violence and abuse have been hampered by a lack of co-ordination and policy direction for years. The NHS can’t stop this on its own, but it can do much more to put its own house in order and work better with other parts of government to tackle the root causes. That requires political will and a sense of urgency from NHS leaders that seems to be missing. It may be significant that during the recent re-organisation of NHS England, the violence reduction team was cut from 12 posts to 2.5.

“There’s some really good practice and innovation but it’s largely driven by individuals, a few good trusts and one or two ICBs,” Lofthouse concludes. “It's patchy at best. There's a lack of strategic direction from the government and NHS England.”

Read more about this

• Violence Prevention and Reduction Standard & guidance notes, NHS Social Partnership Forum (2020): mip.social/vprs
• You Gov survey on violence against NHS staff: mip.social/yougov
• Work Without Fear campaign, Association of Ambulance Chief Executives: mip.social/wwf
• Trauma informed practice guide, Department of Health and Social Care: mip.social/TIP

Photos: Courtesy of North Cumbria Integrated Care NHS Trust, Association of Ambulance Chief Executives and Streetwise Defence.