Preface and summary

84,273 incidents of violence or abusive behaviour by patients within the NHS were reported during the year 2000/2001. Many more remained unreported. To these must be added even more incidents of disorder and incivility. Loutish patients insist upon dropping litter in hospitals, having the TV on at full blast regardless of what other patients may want -one patient even discharging himself against doctor’s advice because he could not have the television on sufficiently loudly - and talking noisily on mobile phones in busy wards or taking calls during consultations. They use emergency ambulances as a taxi service – one man calling for the ambulance 150 times in one year with impunity and all but have sex with their visiting partners in multi-person wards. Doctors, nurses, and patients who object to such behaviour are subject to further verbal abuse, or worse.

Theodore Dalrymple, an experienced hospital doctor, shows in this report that such incidents are a new phenomenon and that it is the toleration of ‘minor’ incidents of incivility which leads to the increase in violence towards doctors and nurses. Twenty years ago doctors and nurses only had to deal with occasional minor abuse by drunken patients in Accident and Emergency; today hospitals have trained security guards and even police stations on site. If this trend continues soon ‘a knowledge of karate will be as important to a doctor as a knowledge of pharmacology’. While the ‘great majority [of patients] are, as they always have been, perfectly reasonable’, a troublesome minority is growing. Most hospital patients are middle-aged or elderly; the disruptive minority is young. The behaviour of this minority of patients makes hospitals unpleasant places for both those who work in them and, perhaps more importantly, for the vulnerable and often elderly sick. ‘Muggers do not have to be … a very large proportion of the population to have a profound and adverse effect upon the atmosphere of a neighbourhood and upon the quality of life of everyone who lives in it.’ The same is true of incivility in hospitals.

There is a continuum of uncivil behaviour from patients who casually disregard conventions by wearing baseball caps in hospital beds or chewing gum while being talked to at one end to those who are physically violent towards doctors and nurses at the other. Theodore Dalrymple argues that if hospitals are once again to become tolerable places minor infractions must be challenged along with more serious threatening behaviour. Not challenging minor discourtesies leads to a culture in hospitals in which anything appears to go and patients are not made aware of how their behaviour can make the lives of others a misery. Too often, however, even criminal behaviour by patients is not prosecuted. ‘If serious [incidents] go unpunished trivial ones are encouraged precisely because they are so trivial compared with the unpunished serious ones.’

This same lesson applies not only to hospitals, but also to uncivil and disorderly behaviour in schools and social security offices. Teachers and social security staff, just like doctors and nurses, report a dramatic increase in both uncivil behaviour and violence. Such reports, from the people who actually have to deal with loutish behaviour on a daily basis, perhaps give one a truer picture of the situation in hospitals, schools, and social security offices than official figures can. They do not suffer from underreporting and take account of behaviour which, while making life extremely unpleasant, does not fit into neat categories or is not actually illegal. Only by tackling ‘minor’ infractions will an environment be created which deters more serious violent behaviour.

While the views expressed in this Report are the author’s own, and not those of the Social Affairs Unit, its Trustees, Advisers, or Director, I can warmly commend them for raising an important issue.