The Special Allocation Scheme, also termed Violent Patient Scheme, was first introduced as a Directed Enhanced Service (DES) in 2004 to provide general primary care medical services in a secure environment to patients with a history of violent behaviour.
Patients are allocated following a process of immediate removal from a GP practice list, resulting from an incident involving the GP practice – usually on the practice premises – that has been reported to the police.
The scheme is set out in the PMS Directed Enhanced Services Directions,1 but different areas have introduced various versions of the scheme so the contractual arrangements and payments set out below will be specific to your area. You should be able to obtain a copy of your specification from your local LMC or offices of NHS England.
In our area, it is necessary to read and implement the specification and sign the contract. In some areas the service is commissioned, so practices are expected to write a tender document setting out how they intend to meet the specification.
Our practice, which for the purposes of the DES covers about 450,000 patients, is usually caring for between 30 and 50 patients under the scheme at any one time.
NHS England informs the practice when a new patient is being allocated, enabling it to register the patient on the clinical system and add the code that identifies them for the purposes of the DES, usually 91D (Violent Patient Scheme).
The code is required to enable quarterly searches of consultations with allocated patients. These quarterly consultation figures trigger the payments.
Currently NHS England pays a retainer of around £2,500 per year to the practice and £93.06 for each consultation with scheme patients. The consultation payment is the same for appointments, telephone consultations and home visits. EMIS has the capacity to search numbers of consultations for defined groups of patients; other systems will probably provide similar searches – ask for assistance from your IT team.
Removal from the previous list often occurs before the allocation, so functions such as EMIS’s GP2GP does not work. This is unfortunate, as detailed clinical information can be invaluable. NHS England is aware of this issue and looking at a possible technical solution to have records stored in a national hosted repository.
An alternative is to contact the previous practice and request a summary; also request the previous practice prints out all computer records when sending paper records to Primary Care Support England.
Before the patient has their first contact by phone or face to face, a risk assessment is essential. It must be done by someone familiar with such assessments. Under-assessment puts staff at risk and over-assessment inappropriately raises staff anxieties and leads to overuse of resources. There are no specific general practice tools but a risk matrix helps to stratify the risk.2
Factors to take into account are: the event that led to removal, history of previous violence, significant mental illness (psychosis), anxiety and agitation and history of odd behaviour. You are looking for what might happen; for example violence toward a member of the team and the likelihood of it happening.
Then you will consider what steps you can take to reduce the impact. Risk assessments should be repeated after the first face-to-face consultation. For the great majority, risks lessen when the attendance and consultations are handled carefully.
Specifications vary, but having an alarm system is the main security consideration (along with some training and the risk assessments). A very small minority – around 1% – of patients may need to be managed in conjunction with NHS England under high-level security, for example with visits accompanied by police or other security personnel.
Security should, wherever possible, be discreet but effective, rather than overt. Some practices ask patients to sign behaviour contracts, although we have not found this useful. Patients likely to follow them don’t need them, and vice-versa.
Similarly, the use of security guards is contentious; their presence can potentially inflame situations. Some practices use security guards in plain clothes. If a significant event does occur, the practice must call the police as any practice would.
The working environment needs to be safe. Alarms are essential in consulting rooms and it is advisable to have two types: a silent alarm such as the ‘Big Red Button’ on EMIS that calls staff without the patient knowing, and a noisy alarm to inform everyone.
Plans need to be in place to ensure responses are adequate. The clinician should always sit closer to the door than the patient and ensure there are no potential weapons to hand for the patient to use – such as pens, paperweights or hot coffee.
Home visits are very rarely required. When they are, the risks must be re-assessed. Some visits can be done as any other. If there is moderate risk it may be better to take a colleague. For high-risk patients, the police are able to accompany the clinician. Be aware that it may take a few hours to set up a visit with the police.
It is essential that staff are effectively trained in de-escalation (a set of behavioural approaches that can help to defuse hostile situations), although specific requirements for this seem to vary around the country. Many local areas have such training available as part of customer care.
That said, our best training came from a large retired police officer, with martial arts expertise, who asked the audience what they should do if someone came at them with a knife. As we puzzled over sophisticated, intelligent answers, he halted the discussion and simply said ‘run’. It was a lesson in keeping it simple.
Care of these patients is the same as for any other patient. However, it is worth noting that the prevalence of mental health problems is substantially higher than in the general population with predominance of personality disorders and adult ADHD. You may want to discuss this with your local mental health trust to see if there are opportunities for a mental health worker to be allocated to your practice.
Extra staffing may be required for the administration of the DES service delivery. We always require a minimum of two administrative staff to be available in the building. The administration is probably no more than four hours per quarter but dealing with extra needy patients and some of the training and support systems does take up time. A rough estimate of about 8 hours per week is reasonably accurate for a DES allocation of about 30-50 patients. In addition, there is some extra clinical time as the patients are generally more complex than average.
Staff support should be part of the daily routine. After an incident, support or debriefing is often needed. If a staff member is being picked on, implement a ban on the patient having any contact with employee for a month.
Hold regular staff meetings to discuss problem patients and their impact on the practice. In addition, most, but not all, patients respond to sitting down with the Practice Manager and senior GP partner to discuss unacceptable behaviour in the context of the practice giving, and the patient receiving, good health care.
At the end of each quarter, searches need to be completed to identify the number of patients registered under the DES in that quarter and the number of face-to-face and telephone appointments that have involved those patients. If your local service is commissioned, there may be other requirements and you may be able to claim for specific items including training and equipment.
At the end of month 12, if there have been no incidents requiring a call to the police, the patient can return to a practice in their locality. The patient can be deducted, and the DES code removed.
In our experience, only a handful of the hundreds of patients we have managed in the past 12 years of the DES have presented significant problems. For those few, we have worked with NHS England and other agencies to ensure the patients have good care and the practice is unaffected.
The payments do meet the cost of running the service, including both the administration and the management, and probably leave a small amount that can be used to help sustain the practice.
The benefit of the service in our practice has been to develop a workforce who are more mindful of the emotional needs of patients and more adept at understand patient behaviours. Locally we are acknowledged as a friendly practice with a very good team spirit. A proportion of the reputation comes from our willingness and ability to take on challenging patients.
One drawback is that there have been times when staff have realised we are becoming burnt out by demanding patients. However, we have learnt how to do a ‘reset’. We sit together, talk about what has been happening, what the problems are and what needs to change. Implementation of the solutions brings us back together and, curiously, seems to calm the patients as well as us.
Dr Simon Abrams is a GP partner in Liverpool
1. UK Government. National Health Service, England. The Primary Medical Services (Directed Enhanced Services) Directions 2019. Part 9: Violent Patient Scheme
2. iAuditor website. Risk assessment.
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