Zero Tolerance Policy

Zero tolerance and managing unreasonable behaviour and communications policy

1. Purpose

A good patient–clinician relationship, based on mutual respect and trust, is fundamental to safe and effective care. Our staff aim to be polite, helpful, and sensitive to patients’ needs and circumstances. We ask patients, their relatives and representatives to treat staff and other patients with the same respect.

This policy sets out:

• the standards of behaviour expected
• what we consider unacceptable (zero tolerance) behaviour
• what we consider unreasonable behaviour and unreasonable levels of contact, including misuse of online services (including Accurx)
• the actions the practice may take, using a staged, proportionate approach

This policy is designed to protect patient safety, staff wellbeing, and fair access for all patients. It is not intended to prevent patients from raising concerns, requesting care, or making a complaint.

2. Scope

This policy applies to behaviour directed at, or impacting:

• practice staff, clinicians, contractors and trainees
• other patients and visitors
• the practice premises and property
• communications with the practice by any route, including face-to-face, telephone, letters, email, online forms, Accurx messages, and social media

3. Equality, vulnerabilities and reasonable adjustments 

We recognise that communication or behaviour can be affected by disability, mental ill health, learning disability, neurodiversity, cognitive impairment, trauma, language barriers, hearing/visual impairment, or safeguarding and domestic abuse contexts.

We will consider whether a reasonable adjustment or a communication plan would help (for example, a preferred channel, a planned review appointment, interpretation support). 

This does not mean we will accept abuse, threats, harassment or violence.

4. Definitions

Unacceptable behaviour (zero tolerance)

Behaviour that involves abuse, harassment, intimidation, discrimination, threats, violence, or serious disruption.

Unreasonable behaviour or unreasonable levels of contact

Behaviour that, by its nature or frequency, places a disproportionate burden on staff time or resources, prevents the Practice from managing clinical risk safely, or disadvantages other patients, even if no abuse is used.

5. Standards of behaviour expected

We expect patients and those acting on their behalf to:

• communicate politely and respectfully
• provide accurate information to help us assess needs safely
• allow reasonable time for a response in line with clinical urgency and capacity
• follow triage outcomes and appointment processes, raising concerns via the appropriate route if dissatisfied

6. Unacceptable behaviour (zero tolerance)

The following behaviours will not be tolerated and may result in immediate action, including contacting the police where appropriate, and/or removal from the Practice list in line with NHS regulations:

• shouting, swearing directed at staff, or aggressive conduct
• personal insults, humiliation, or discriminatory language (including racist, xenophobic, homophobic, transphobic, misogynistic or ableist abuse)
• threats of harm, threats to damage property, or intimidation
• harassment, stalking, coercion, or unwanted sexual comments/advances
• physical violence or assault (including pushing, spitting, throwing objects)
• deliberate damage, theft or vandalism
• malicious allegations made in bad faith with the intent to intimidate staff
• repeated behaviour that causes distress or disruption after prior warning and support

Unacceptable behaviour does not need to be face-to-face and includes written, telephone, online, Accurx and social media communications.

7. Unreasonable demands and unreasonable levels of contact

A demand or pattern of contact may be considered unreasonable when it places an excessive burden on staff time or resources, prevents safe triage, or disadvantages other patients.

Examples include (not exhaustive):

• repeatedly requesting a response within an unrealistic timescale
• contacting multiple members of staff about the same issue after being advised of the correct route
• repeatedly asking the same question after a clear response has been provided
• submitting further requests while an existing request about the same issue is already being reviewed
• excessive follow-ups that require disproportionate time to review, respond to, and file
• repeatedly refusing clinically appropriate triage outcomes and insisting on alternatives without clinical grounds

8. Appointments, triage and clinician preference

• all appointment requests are clinically triaged.
• appointments are allocated to the most appropriate clinician and within the timeframe determined by clinical need.
• we will try to accommodate preferences where possible, but this cannot be guaranteed.
• if a patient declines an offered clinician, we will offer the next appropriate option, which may be at a later date, unless a clinician determines that same-day care is clinically required.

9. Treatment requests and prescribing

Clinicians follow national and local evidence-based guidelines. Patients cannot require specific medication, referrals, investigations or treatments where there is no clinical indication. We will explain decisions and discuss alternatives where appropriate.

Repeatedly demanding a specific outcome after a clinical decision has been explained may be managed under this policy.

10. Missed appointments (DNA)

We understand circumstances change. Patients are expected to cancel appointments as soon as possible if they cannot attend.

Repeated DNAs may trigger:

• contact to understand barriers and consider reasonable adjustments
• warning letters where DNAs are avoidable and persistent
• review by the management team where DNAs form part of a wider pattern that compromises safe care or fair access

DNAs alone do not automatically result in removal. Decisions will be proportionate and consider vulnerability and clinical risk.

11. Online requests and Accurx messages

We recognise patients may have more than one concern. However, to keep you safe and ensure requests are handled fairly:

• do not submit multiple online requests about the same issue while a request is already being reviewed
• do not send repeated Accurx messages requesting updates on an active request unless asked to provide additional information
• if you have new, clinically significant information, state clearly what has changed

How we manage duplicates

• duplicate submissions about the same issue may be merged into one clinical triage request
• we will provide a single consolidated response where appropriate

Response times and urgent issues

• online requests and Accurx messages are not continuously monitored
• we aim to review messages within core working hours and respond according to clinical urgency
• if you believe there is an immediate risk of serious harm, call 999
• if you believe your issue is urgent and cannot wait, telephone the Practice for same-day triage

Misuse of online services

Misuse includes repeated duplicate submissions, sending high volumes of messages that prevent safe triage, or using abusive/threatening language in online communications. This may be managed under the escalation process below.

12. Use of the term “safeguarding” 

We take safeguarding seriously. If a patient uses the term “safeguarding” (or raises a concern about a child or adult at risk), we will ensure the information is reviewed promptly and acted on appropriately.

To help us respond safely, we may ask for:

• who is at risk
• what has happened and when
• why you believe the risk is immediate
• where the person is now and who else is involved

If there is immediate danger or a serious immediate risk, call 999.

13. Actions the Practice may take (staged approach)

We will act proportionately, focusing on de-escalation first where appropriate, while maintaining staff safety.

Stage 0: Immediate safety actions (may occur at any stage

• end a call or consultation if a person is abusive or threatening
• ask a person to leave the premises
• involve senior staff immediately
• contact the police where appropriate

Stage 1: Early intervention and initial warning

• verbal or written message explaining the concern and the expected standard of behaviour/communication
• clear explanation of what needs to change
• offer of a communication plan or reasonable adjustment where appropriate
• record in the clinical record and/or practice incident log/zero tolerance tracker (as appropriate)

Stage 2: Formal written warning and communication agreement

• written warning describing the behaviour and impact
• agreed communication plan (for example: single point of contact, set routes, one request per issue, planned review appointment, response timeframes)
• confirmation that continued behaviour may lead to further action, including consideration of removal

Stage 3: Final warning and restrictions (where proportionate)

• final written warning
• restrictions on communication routes may be applied where necessary to protect staff time and safety (for example: correspondence only via a named point of contact, or scheduled calls), while ensuring access to necessary clinical care

Stage 4: Consideration of removal from the practice list (last resort)

Removal is exceptional and considered only when trust has irretrievably broken down or where staff/patient safety is at risk.

Removal will be carried out in line with NHS regulations and PCSE processes, typically as an eight-day removal request. Immediate removal is reserved for serious incidents of violence or threatened violence reported to the police.

14. Complaints and concerns 

This policy does not remove a patient’s right to raise concerns or to complain.

• Patients may use the practice complaints procedure.
• If a patient prefers not to complain to the practice, they may complain to the commissioner of NHS services (in line with NHS complaints arrangements).

15. Removal of other household members

In rare circumstances, the practice may need to consider whether it can safely continue to provide services to other household members (for example, where home visiting or attendance at the Practice would create an ongoing safety risk due to the behaviour of a removed individual).

Any decision will be:

• based on risk and practicality of safe service delivery
• proportionate and evidence-based
• made on an individual basis and in line with NHS regulations and PCSE processes

Last Review: October 2023
Reviewed and Updated: January 2026
Next Review: January 2027