Aggression and violent behaviour in general practice: population based survey in the north of England

Three studies, the last one eight years ago, have suggested that general practitioners in the United Kingdom are frequently subjected to verbal abuse, with an estimated annual frequency of such incidents of between 25% and 59%.^1–3 In one of these studies 5% of general practitioners reported having been threatened with a weapon in the preceding year³; annual rates of physical injury ranged from 1% to 11%.^1–3 These three studies, and subsequent discussion, raised concern that aggression towards general practitioners was becoming more common. To estimate accurately the current frequency of such incidents we undertook a survey of general practitioners working in a health authority in the north of England.

Subjects, methods, and results

During May to September 1997 we sent a brief questionnaire to all 419 general practice principals in the area administered by Leeds Health Authority. Principals were asked to recall their experiences of aggression directed at themselves at work over the previous year in four categories: verbal abuse, specific threats, physical action without injury, and serious incidents (including threats with a weapon or attacks leading to physical injury). We obtained the Jarman index⁴ for each electoral ward. This showed the percentage of patients attracting deprivation payments on that practice's list. The score was used to classify practices as high or low deprivation according to whether the percentage was above or below the median for the sample.

Completed questionnaires were returned by 380 (91%) principals (244 men, 136 women). The table shows the numbers of respondents who experienced any of the four categories of aggression and the incidence of aggression by deprivation. A higher proportion of women than men reported experiencing verbal abuse, but a higher proportion of men than women reported physical contact abuse or a serious incident. A higher proportion of doctors in the high deprivation practices reported aggression than doctors in the low deprivation practices.

One doctor was involved in an incident that resulted in minor physical injury, and in five incidents doctors were threatened with a weapon. Two of these incidents involved patients described as psychotic at the time of the attack; a further three involved a patient with an alcohol or substance misuse problem.

Comment

In our cross sectional study, over half of the 380 respondents reported experiencing verbal abuse in the preceding year at work, but only five reported being threatened with a weapon and only one reported physical injury. General practitioners serving deprived populations were more likely to report verbal abuse and more serious incidents, and our results show that the risk of more serious episodes in deprived areas might be disproportionately high.

Caution is needed in interpreting the results because of possible bias from retrospective reporting and from the lack of a definition of verbal violence in the questionnaire. None the less, the rate of verbal abuse in our study was similar to that reported in the largest previous study carried out by Hobbs in 1991²; Hobbs's study, however, reported an annual rate of physical injury of 3.8% compared with 0.3% (1/380) in our survey.

Several factors might explain the lower rates of serious incidents in our study. High rates of serious incidents observed in previous studies may have been overestimates if those who had experienced the serious incidents were more likely to be among the proportion who returned questionnaires (in Hobbs's main study, this proportion was only 40%²). Previous investigators might have surveyed general practitioners covering areas where violent behaviour towards doctors is more common. Finally, a genuine reduction might have occurred.

Future studies should examine the psychological effect of frequent verbal abuse on primary care workers. In addition, a prospective inquiry should be set up to identify and describe serious incidents in more detail.

Table.

Reported aggression at work towards 380 general practitioners covering the population of Leeds Health Authority during 1997

Respondents	Verbal abuse			Specific threats			Physical action			Serious incidents
	No of respondents	% of respondents (95% CI†)		No of respondents	% of respondents (95% CI)		No of respondents	% of respondents (95% CI)		No of respondents	% of respondents (95% CI)
All	205	54 (49 to 59)		108	28 (24 to 33)		24	6 (4 to 9)		6	1.6 (0.7 to 3.4)
Sex:
Male (n=244)	121	50 (43 to 56)		63	26 (21 to 32)		17	7 (4 to 11)		5	2.0 (0.8 to 4.7)
Female (n=136)	84	62 (53 to 70)		45	33 (26 to 41)		7	5 (3 to 10)		1	0.7 (0.1 to 4.1)
Relative risk (male v female)		1.3 (1.0 to 1.5)*			1.3 (0.9 to 1.8)			0.7 (0.3 to 1.7)			0.4 (0.04 to 3.04)
Deprivation:
High deprivation practices (n=181)	119	66 (59 to 72)		71	39 (32 to 47)		18	10 (6 to 15)		5	2.8 (1.2 to 6.3)
Low deprivation practices (n=199)	86	43 (37 to 50)		37	19 (14 to 25)		6	3 (1 to 6)		1	0.5 (0.09 to 2.8)
Relative risk (more deprived/less deprived)		1.5 (1.3 to 1.8)**			2.1 (1.5 to 3.0)**			3.3 (1.3 to 8.1)*			5.5 (0.7 to 46.6)

^*P<0.05, ^**P<0.001 (calculated by using χ² test or Fisher's exact test). 

^†Calculated by using the technique described by Wilson.⁵