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The noble Lord said: We move now from the issues we were discussing a moment ago to the issue, raised in the Bill, of preventing assaults in hospital premises. Our amendment simply seeks to extend the protection given by Clause 170 to,
- “any premises in which medical, surgical or paramedical treatment is provided under arrangements made under the National Health Service Act 2006”.
The question we are putting to the Minister is: why stop at hospital premises?
It is helpful to consider a survey carried out last year by the British Medical Association. Six hundred doctors responded to the survey on their experiences of violence in the workplace; doctors, not staff in hospitals. One-third had experienced some form of violence, including threats and verbal abuse. One in 10 had been physically attacked—including being stabbed, kicked, punched, bitten and spat at—of whom one in three had received minor injuries and one in 20 were seriously injured.
Another problem came to light—that violence towards doctors in their own surgeries is under-reported. Doctors do not like to report such violence to the authorities, particularly if it comes from a person accompanying a patient on their premises. The most frequently stated reasons for this violence were dissatisfaction with the service, including frustration with waiting times, and refusal to prescribe medication. Those are the two key issues: people waiting too long and not getting the medication they wanted. That had doubled as a cause of violence since the BMA’s previous survey in 2003.
Other findings from last year’s survey show that half of the doctors said that violence in the workplace is a problem; more than half had witnessed violence against other staff, such as nurses and receptionists; female doctors are more likely to experience violence in the workplace than males; junior doctors are more likely to experience violence, followed by GPs; and only one in 10 doctors has access to a secure facility in which to treat violent patients.
Like the BMA, we believe that it is simply unacceptable to permit any form of aggression towards healthcare workers. We support the basic concept behind Clause 170 but fail to see any rationale for limiting it as it has been. I note that the noble Baroness, Lady Finlay, has also tabled amendments to Clause 170. I wait to hear from her, but I can say to her now that we agree with her amendments. I beg to move.
Baroness Finlay of Llandaff: I welcome the extension of Clause 170. I regret that I was unable to state that at Second Reading, particularly as so many people had criticisms of the Bill; a positive comment might have been welcome. The clause seeks to make it a criminal offence to commit a nuisance or disturbance on hospital grounds, and there can be little doubt, if any, that we must protect healthcare workers from this type of behaviour.
However, I have tabled Amendments Nos. 164 to 166 because, as drafted, the Bill does not offer that type of protection to all those who provide NHS services. The elegant amendment in the name of the noble Lord, Lord Thomas of Gresford, unfortunately
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Amendment No. 166, which is included in this group, seeks to protect NHS workers in the community who provide care in patients’ homes. My amendment would make it an offence to cause physical or mental harm to that group of NHS workers. I have worked in healthcare for 30 years and seen aggression in the hospice setting and violence in the community. I was very lucky, but others have been seriously maimed and some killed. I myself was threatened with a knife when on a home visit some years ago and have been on home visits where the family members of the patient were extremely unpleasant. I know how vulnerable healthcare workers feel when visiting in the community, even though lone-worker policies are in place to track their movements and provide some sort of protection. I remind the House that ambulance workers are often the first to arrive at a patient’s home in an emergency, such as when someone is injured in a drunken affray. And it is not just ambulances; healthcare workers’ own vehicles are often effectively an office on wheels for those who are out in the community full-time. They deserve the same protection as anyone in a vehicle on NHS premises, who are covered in the Bill.
Official NHS statistics show that, in 2006-07, 55,709 physical assaults against NHS staff were reported—and the phrase “officially reported” is important because we have no way of knowing how many incidents go completely unreported. That is more than 150 a day, over 1,000 a week.
Improvements are being made. The number of physical assaults against NHS staff seems to be falling. The Government have made that a priority and a benefit is beginning to come through, but the numbers are still far too high and the type of assault far too damaging. Some might say that the offences are already in general legislation, but this is a classic situation where legislation can be tightened, which then gives out a message to society. We must have zero tolerance of the assault of healthcare workers, just as we have in place a specific offence of assaulting a police officer in the course of his or her duty.
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Lord Clinton-Davis: I am rather innocent in this issue, but I do not see where the amendments fit in. In what way is it envisaged that they will improve the present law?
Baroness Finlay of Llandaff: They are important in terms of sending a very strong message to healthcare workers, to those who are responsible as their managers and to the population as a whole that there will be a specific offence and that any assault on a healthcare worker who is going about the course of their duty, wherever they are located, will not be tolerated.
Every medical professional knows that confused, aggressive and even violent patients might be extremely ill; I am not advocating criminalising sick people. However, it is not acceptable for the family or friends of patients to feel that they can create an uncontrolled—often alcohol-fuelled—disturbance and not be admonished. The most robust protection possible must be available to deal with individuals who deliberately seek to cause disturbance and prevent others doing their job to help patients.
Baroness Butler-Sloss: I very much support all of these amendments. As a judge I have tried a number of cases involving vulnerable adults and children who were being cared for outside NHS premises, and in several of these cases the family and friends had behaved appallingly. I remember one case in which a man who had had a dreadful accident was being treated on private premises. He was in a coma and his wife was attending every day. His family decided that this would not do. Their behaviour towards this private clinic—paid for by the NHS, but not an NHS building—was such that the clinic came in desperation to the High Court for an injunction providing that the family could visit for only two hours every other day. This was not an unusual circumstance. I welcome the Government’s proposal in Clause 170 but, having appreciated the importance of this protection, they should carry it one or several stages further.
Baroness Howe of Idlicote: I, too, congratulate the Government on this clause; this is clearly an important issue. But I also support the amendments, particularly those of my noble friend Lady Finlay. We are increasingly encouraging the use of non-hospital premises for the treatment of different groups of patients, not least the elderly. Palliative care, which we are also increasingly encouraging, will require many visits by medical staff and others to a patient’s home. I support the amendments for those reasons alone. It is natural that all these areas should be included in the Bill and I hope the Minister will take note and add them.
Baroness Hanham: I welcome this clause on disturbances on hospital premises. I know full well that A&E departments can be a nightmare at night, as they can be at any other time as well; that there are occasions when not patients but their relatives cause
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This part of the Bill is specific about how disturbances on hospital premises are to be managed, and that is why I have some slight difficulties with the amendments. Although there would have to be a specific offence of causing a disturbance on hospital premises—it will have to be a new offence; I hear what the noble Baroness says—there will also have to be a way of addressing the offence in reality. Security staff in hospitals will presumably be given extra authority to deal with difficult patients—to restrain and hold them until the police arrive. So they will have a power to hold if not a power to arrest. I am struggling to see how you can do that on premises of that scale and with that security.
I have no difficulty with the proposal that any member of NHS staff looking after patients should not be subject to violence. I am simply concerned with how to bring that to reality, and how to bring police to the premises to deal with the matter.
Baroness Finlay of Llandaff: Does the noble Baroness agree that the police have an extremely good record on responding to calls at places such as hospices and that they will attend at a disturbance although there may not be a security person on the premises? They will try to provide a rapid response. However, it is important that a clear message is sent to the public that if they come into such premises and cause a nuisance or affray, they will be prosecuted rather than simply asked politely to stop.
Baroness Hanham: I accept that the police are extremely good at responding to any incident on NHS premises. A friend of mine was stabbed in his surgery by a patient who could have been described as vulnerable, who would not have been prosecuted but dealt with elsewhere. I do not argue the merits of the amendments, but I remain nervous about some of their aspects.
Lord Bassam of Brighton: I shall make a considered and lengthy response to this set of amendments—for which I apologise in advance—not least because we are sympathetic to the issues which lie behind them. I particularly thank noble Lords who have recognised and congratulated the Government on bringing forward the provisions from Clause 170 onwards which more generally address the issue. I am grateful for the support we have received. We are conscious that we are struggling with an issue that poses a particular difficulty—an issue which the noble Baroness, Lady Hanham, touched on. I shall work through our observations on this group of amendments in that context.
This is not an easy issue to resolve. We had some of this debate before when we discussed amendments to the corporate manslaughter legislation—legislation which is somewhat parallel—which addressed the offence of obstructing a police officer in the course of his or her duty. It was a very useful debate and on that occasion we extended the law to offer further protection
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I turn first to Amendments Nos. 163 and 164. The application of the offence of causing nuisance or disturbance to hospital settings only is a targeted response to a specific problem. Some 78 per cent of respondents to the 2006 Department of Health consultation on tackling nuisance and disturbance behaviour on NHS healthcare premises supported the introduction of an offence to deal with this behaviour, and most respondents felt that the acute hospital setting is where such behaviour is most prevalent. I think that that is probably right.
It is important, however, to understand that the practical benefit to NHS staff is in Clause 171—to which noble Lords referred—where they are provided with a power to remove a person suspected of committing this offence. Although the offence is the basis for this power, on its own it does not have the intended impact, which is to enable NHS staff to deal with an incident of nuisance or disturbance behaviour immediately.
Simply extending these provisions, which are specifically designed for hospitals, to the wider NHS is both unjustifiable and would make them unfit for purpose as it would assume the problem exists in the same way in other healthcare settings as it does in hospitals, and that the correct method to deal with nuisance or disturbance behaviour in these settings is to remove the person from the premises. I do not consider that the problem is identical in other healthcare settings or that the solution to deal with the problem in other healthcare settings should be the same.
As I believe the noble Lord, Lord Thomas of Gresford, said, evidence presented by the BMA in January this year highlighted the problem of violent behaviour against doctors outside the hospital setting; namely, in GP surgeries. For the purpose of this study, violent behaviour is defined as physical assault as well as verbal aggression or abuse and threats or harassment. The latter could be classed as nuisance or disturbance behaviour under these provisions. However, 94 per cent of GPs state that violent behaviour is committed mostly by patients rather than family, relatives, friends or companions at whom these provisions are aimed. That is usually the case in an A&E hospital setting where families, relatives or friends are likely to cause the problem and the aggression. In the GP surgery, the situation is rather different. I think that the noble Lord, Lord Thomas of Gresford, referred to likely causes of the problem in the GP surgery, for example issues to do with medication or a disagreement over treatment. So, the causes of the problem are very different in that setting.
As I say, this is different from the hospital setting which, by its nature in being open to the general public 24 hours a day and spread over a large area, has nuisance or disturbance behaviour committed by non-patients on a regular basis. Of course, none of this is acceptable and that is why we seek to legislate in a particular way. This supports the view that the
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We believe that further research needs to be undertaken on nuisance or disturbance behaviour in other healthcare settings, and how this can best be dealt with, before a solution that is fit for purpose can be devised. Without further investigation and consultation on the nature and extent of the problem having taken place, it would not be appropriate to attempt to deal with the problem by extending a solution that has been designed specifically for hospital settings to other healthcare settings, when the settings and the problem itself are different in nature.
As far as the power to remove in Clause 171 is concerned, most hospitals have full-time security staff and CCTV coverage to protect staff from those causing a nuisance or disturbance and to deter potential offenders. Under these proposals, trained security staff could assist in exercising the power to remove a person from hospital premises should they commit the offence. Not all GP practices, dental surgeries, nursing homes or hospices have such security services available to them. Therefore, enabling the offence to be committed on such premises would prove problematic as there would be no guarantee that a correctly trained person would be available to remove an offender from the premises, using reasonable force if necessary. Applying these proposals to the wider NHS would therefore ironically put the safety of such NHS staff at risk.
Applying the offence to ambulances or vehicles used by NHS staff in connection with work to attend a patient’s home would be impractical due to the mobile nature of such vehicles and the potential for offenders to be removed from the vehicle to a place that leaves them vulnerable; for example, at the side of a road. Furthermore, fully trained security staff would not necessarily be available to remove offenders from the ambulance or NHS staff vehicles, by force if necessary, so exercising the power would again put ambulance staff and other NHS staff at risk.
The Government recognise the risk to NHS staff working outside hospital settings and believe that all healthcare staff deserve to work in an environment that is safe and secure. The NHS Security Management Service has introduced conflict resolution training for all front-line staff and has trained over 250,000 staff to date. Local security management specialists have been placed in every healthcare body to oversee security issues and to take forward reports of nuisance or disturbance behaviour and more serious offences such as assault.
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Guidance has also been issued by the NHS Security Management Service on the better protection of members of staff who work alone—as raised by the noble Baroness, Lady Finlay of Llandaff—and a long-term communications programme is under way to encourage
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Amendment No. 165 seeks to supplement Amendments Nos. 163 and 164 by extending the definition of “NHS staff member” to include staff working in NHS settings outside hospital premises. I have already dealt with the reasons why it would be inappropriate to extend the application of this offence and the power of removal to NHS premises other than hospital premises. Amendment No. 165 is unnecessary, as the current definition of “NHS staff member” in Clause 170(4)(c) already covers persons other than those employed directly by the hospital in which an offence might be committed.
Indeed, the current definition covers persons who are employed by a relevant English NHS body or are otherwise working for it, whether as or on behalf of a contractor, as a volunteer, or otherwise. The relevant English NHS body can be an NHS trust, including a mental health trust, primary care trust or an NHS foundation trust. This broad definition means that a range of NHS staff could have a nuisance or disturbance caused to them which may constitute an offence under Clause 170(1), whether they are employed directly by the hospital, by a primary care NHS organisation, or even as a contractor or volunteer. There is broad coverage. If the NHS staff member in question is on NHS hospital premises in connection with his or her work, he or she will be protected by these provisions. For example, an offence could be committed against a GP if they were visiting the hospital to see a patient or on business-related matters. This is because they are employed or contracted to work for a relevant English NHS body—a primary care trust—and are thus an “NHS staff member” for the purpose of these provisions.
Amendment No. 166 creates a new offence of causing “physical or mental harm” to an NHS healthcare worker who attends a patient in their own home. We do not consider the introduction of such an offence necessary or appropriate. Such an offence is unnecessary, as the causing of physical harm to the NHS healthcare worker would already constitute assault or another criminal offence against the person under current legislation. If a healthcare worker was caused physical harm in a patient’s home, the appropriate course of action would be to call the police to deal with the situation using their powers under existing legislation.
It is unclear what is meant in Amendment No. 166 by the causing of “mental harm” to an NHS worker and how one could measure or prove that mental harm was being caused as an incident occurred so as to enable the police to respond to an incident, or to consider that an offence had been committed. On that basis, I do not consider that the introduction of an offence of causing “mental harm” to an NHS healthcare worker who attends a patient’s home would be appropriate. However, we recognise that there is a risk to NHS staff members who work in the community, in particular those who attend the homes of patients to provide treatment, care and advice.
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In 2005, the NHS Security Management Service issued guidance to lone workers entitled Not Alone: A Guide for the Better Protection of Lone Workers in the NHS. This offers practical advice to such staff on protecting themselves against potentially hostile and/or violent situations when attending a patient’s home in connection with their work. As I have already mentioned, conflict resolution training is available to all front-line staff.
Finally, a long-term communications programme is now under way to encourage better reporting of abuse and violent behaviour against NHS staff in a community setting. This will help to identify the nature and scale of the problem for lone workers, and help us to work towards a suitable and effective long-term solution.
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