Zero Tolerance may very well be the reason for increased assaults on NHS Staff.

Disclaimer: To make it clear, the following article expresses no intent with respect to assaulting NHS Staff. The article is specifically written to advance an argument and stimulate debate about something which has long been an impediment to proper healthcare and treating the patient as a person, not an illness. The very fact that this disclaimer is required (because the writer knows that a certain NHS board may found upon it in an effort to brand them as beligerent is proof positive of the matters opined in this article).

The NHS has a zero-tolerance policy on abuse, put in place by politicians because they believe that it will reduce such abuse. However, the reality is, and I would assert based on personal experience, that it has the opposite effect.

Enter any A&E in the country and you will find in almost every cubicle, posters like this:

NHS zero tolerance | HeideKlein_OrangenKopf | Flickr

The primary question of this article is, what is the demarcation point that something becomes abuse? Is it assault, or screaming at the person, or can it be considered to be the moment the staff members sensibilities are upset? I ask this question because it is a real issue.

NHS Policy is the adoption of a zero-tolerance approach to any form of abuse by a patient or other person on their premises. NHS Fife policy defines “abuse” as “Any incident in which a member of staff or person working on behalf of NHS Fife is verbally abused, threatened or physically assaulted by a patient or member of the public in circumstances relating to his or her employment” but there is no definition of the level at which something becomes abuse.

Conversely, ask any psychiatrist about their field, and they will tell you that in order for them to be able to do their job, the patient needs to be honest. It is a fundamental precept in psychology that suppressed anger can be an underlying cause of anxiety and depression. Anger that is not appropriately expressed can disrupt relationships, affect thinking and behaviour patterns, and create a variety of physical problems. Chronic (long-term) anger has been linked to health issues such as high blood pressure, heart problems, headaches, skin disorders, and digestive problems. But what happens in a circumstance, whereby a patients experience, particularly over a protracted period has been one of wanton disregard through error, omission, complacency or indifference, resulting in justifiable anger at the situation? What then.

To give an example, a patient has been ignored because of incorrect opinions in previous admissions, he sits in A&E during his 18th attendance at the hospital due to rapid deterioration of clinical status, on one occasion monitored and confirmed by a suitably trained physician, so concerned at those observations that she, herself has called an ambulance. The patient has been stuck in a loop of stabilisation and discharge because of wrongful opinions on his symptoms being psychosomatic in nature (later disproven unequivocally). Doctors have founded upon those opinions so as not to investigate, diagnose, treat, and mitigate symptoms, yet no doctor has extended to him his inalienable right to know about those opinions, to seek to have them confirmed or disproven and for the patient to seek treatment for them if confirmed. The patient has developed an acute awareness of something lurking in the background, an almost dismissive attitude towards his health concerns but is unaware of the false opinions floating around him because nobody told him. He is in medical limbo.

The doctors in A&E insist he should be completely open about his feelings, but it’s clear to him that they are not being entirely honest. He’d like to be honest, but every time he raises his gaze to the wall, there’s a picture of a police officer pointing at him with the words “ZERO TOLERANCE” in capital letters next to it.

In each admission to A&E, he is consistently faced with a reminder of the NHS’s zero-tolerance approach to expressed anger towards staff.

I don’t have to guess about how this patient feels, because this patient is me. For three years, I languished in pain and in distress, and in fear at the hands of NHS Fife between 2007 and 2010. In 2021 I have found that there were opinions being floated around (by doctors with no speciality in psychiatry I might add) that my collapses, which had seen me fall through a plate glass table, a kiddies playpen and an open door to a dishwasher. 18 hospital visits in three years, only one admission for investigation and not knowing what the hell was going on. I was stuck in limbo, and unless you’ve ever experienced that for yourself you will never know for yourself.

The one thing that sticks in my head to this day is the dismissive attitude in the hospital, and reasonably I could feel myself over that three year period getting angrier and angrier. You’ll never know the level of self-control it takes to control that sort of anger, nor how much you are actually capable of injuring, the pain of your illness, the anguish of disregard and the anger of having zero ability to actually do anything about it because the indifference you are experiencing means you’re not being properly investigated.

The other thing that sticks in my head is that damn poster. I remember acutely asking myself on my first admission how any person could get so angry that they would lose control and punch a doctor or nurse. It just didn’t make sense to me, three years on, that same poster, re-attached to the wall numerous times with sellotape and curling at the edges, while I have never had the intention to act on such anger, I could certainly get inside the mind of a person who lacked the level of self-control I had.

The question? How can I express justifiable anger at the same doctors disregarding me again and again? The answer is simple – I couldn’t because the second I did, that Zero Tolerance approach would kick in.

I remember an incident where I collapsed in A&E in Dunfermline on a Saturday night, and rather than rendering assistance, the charge nurse on duty stood over the top of me and yelled at me to get up. And so, for 10 minutes I lay with my nose pressed against the solid concrete floor, unable to move. A family member returned to find me there and challenged the nurse – it transpired that because they hadn’t put me on the board, they’d mixed me up with the drunk guy in the next cubicle. No apology was offered after they scraped me off the deck, and what’s more, it was recorded in my notes as a collapse incident with absolutely no record of leaving me on the floor.

So disillusioned with NHS Fife, I actually stopped going to the hospital when a collapse occurred. On one occasion, I was in an extremely bad way. I knew (but obviously not the reason why) that I would be disregarded if I went to the hospital, but I knew this couldn’t continue. So I phoned a taxi and when it arrived 5 mins later, I crawled out to it. I was in a daze. I don’t remember much for the next minutes during that journey, except the driver asking if he’d be better heading to the hospital, to which I said no. I remember exiting the taxi and the sensation of the floor moving, of grabbing onto a railing and stumbling into the building. I remember something about speaking to the reception and seeing her running around the desk in a panic before I keeled over. I rely upon the words of the GP who run out to see me about what happens next because in all honesty, I don’t remember entirely.

Yes, despite the fact that a general practitioners observations were of rapid physical medical decline, of low oxygen rates, low blood pressure and serious physical symptoms so worrying she called 999, I was taken to hospital, given some oxygen and discharged. And as I became compos mentis in the hospital and I could feel the anger underneath the surface as the doctor said (like he had so many times before) that he was sending me home? There in front of me was that bloody poster?

I specifically requested in consort with that doctor to self-refer myself for psychiatric evaluation to either prove or disprove once and for all, what she had discovered. The doctors at NHS Fife had allowed me to walk around for 3 years with possible mental health issues that could have possibly been a serious threat to my life, but yet, not one had bothered to tell me, or indeed allow me to seek to confirm or disprove the theory and seek treatment if it were found to be the case.

Ultimately it was proven I had no mental health issues, however, the psychiatrist noted my serious frustration at the way I was not being treated.

In recent weeks, I have found out that after a number of consecutive failures, what I was led to believe was the underlying health issue was never actually confirmed due to the laziness of the board. But something more sinister has reared its head. It appears that the reason that it was never confirmed or disproven was because of transpositional error. And people should take note of this.

As a result of my medical issues not being properly investigated and treated/mitigated I ballooned in weight. I requested that consideration to metabolic issues be considered (and it never was), and new evidence opined in 2021 with relation to legal matters with NHS Fife has identified that I’ve likely had a disorder since I was a child with a metabolic component, meaning the medications being stuffed down my throat for a decade in absence of medical assistance have likely been having a negative effect – oh! and since being withdrawn from those medications my weight started dropping rapidly – I won’t go into that, but it is pertinent, because in the same letter written by the doctor above she says this:

Now, this is important, because despite being ignored for 3 years due to false opinions on mental health, followed by a finding of no mental health, the board didn’t do much in the way of investigation. It was opined I might have M.E, and a request was made for investigation. I was led to believe it had been confirmed, and also led to believe assistance was not forthcoming, because, by the admission of one of NHS Fife’s own employees, M.E services in Scotland are virtually non-existent. In 2021, I now know that was never confirmed, the reason? It was being opined that my underlying medical issues were because I had Type II diabetes and sleep apnoea.

Do you see how that works? I developed weight, type II diabetes and sleep apnea because of NHS Fife’s negligence in dealing with an underlying medical issue, only for it then to be founded upon as possibly being the cause of the underlying medical issue. Why? Because that narrative deflects liability for the board. And so, I sit 13 years after the initial onset of symptoms, back at the start of my illness, adrift and not knowing the underlying cause, and along with it, the emotions of that time come flooding back with the ultimate question at the root of all my fear – will my next collapse be my last?

Of course, now that we’re talking about legal liability, a new sinister application of the zero-tolerance policy has appeared – the use of it by NHS Fife’s senior management to try and shut down dissent. The zero-tolerance policy, you see, has zero provisions for justifiable anger, it has zero provisions which protect the patient from abuse of the policy, and so literally any small expression of annoyance can be founded upon – and it is, particularly when the board faces repercussions for shoddy behaviour.

It is a badly written policy because it has the effect of not allowing patients to communicate true feelings to clinicians out of fear of their words being twisted, or recorded wrongly resulting in detriment to any investigations into their underlying medical condition. It creates a situation where justifiable anger is forcibly repressed out of fear of reprisal, and it is used by more unscrupulous members of the NHS Fife senior management as a blunt instrument to ignore reasonable concerns of patients, to fail to answer legitimate questions and to silence the patient – which can only lead to one inevitable outcome – more anger which the patient, in turn, is forced to repress.

This mentality of the local health board does not only extend to its patients. I am aware of at least 19 patients and 5 members of staff at the board where the “zero tolerance” policy has been used to deflect the board’s liability and to bully staff into silence. One very public example is that of Dr. Sheena Pinion who was constructively dismissed by the board for standing up for patient welfare. She made a protected disclosure after an HIV infected surgeon continued to conduct surgery after being told to stop. The board created the circumstances to brand her in such a way as being beligerent, the zero-tolerance policy then used to constructively dismiss her.

The zero-tolerance policy doesn’t work, indeed I would argue that the fact it is consistently abused by the likes of NHS senior management actually creates a situation where patients become even angrier. From disregard to blatant hostility, the policy used as a blunt instrument to try and silence under threat, any person who deviates from the official line. The policy requires serious revisiting, not just by the health secretary, in line with the NHS boards in Scotland but including patients rights advocates and patients themselves. The policy, in a lot of cases, actually makes patients angrier because of wrongful implementation – which increases the prevalence and opportunity of a patient imploding as cracks in their armour begin to show. You’re already vulnerable in a case of health issues, but to add the pressure of being unable to assert yourself and express how vulnerable you are and how angry you are, will only lead to one thing – catastrophe.

So I guess the question from all of this is, where’s the distinction between reasonable and unreasonably anger, because anger in wanton disregard is justifiable (so long as you’re not violent) in my opinion – but wheres the pathway to be able to express it, without ending up as a criminal smudge on the medical directors wall, all because they want to deflect liability?

Suppression of anger is unhealthy, but yet this is exactly a consequence of this policy. A patient is forced not to vent in fear of consequencies of doing so (and trust me if you even raise your voice slightly in protest, the first thing they do is point at the poster), and it builds up and up until suddenly, Bang! they explode. Unfortunately, they are then labelled a criminal, and it is founded upon to continue to disregard them. Cause begets effect, and then effect is founded upon to negate cause.

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