Nine ways to set up your practice to combat domestic violence
Professor Gene Feder and Dr Alex Sohal talk through the systems every practice should have in place
There is much that practices can do to help prevent domestic violence and improve the health outcomes of women suffering it – including some measures now required by law. Here are nine key steps GPs can take.
1 Know your local and national domestic violence services
Understanding the scope of provision and how best to refer women helps to develop a simple pathway for your patients to access these services, most of which are provided by third-sector agencies. Such services can help assess risk to women and their children, provide advocacy and broker access to housing, criminal justice and social care support.
The local council may also have a domestic violence co-ordinator who can provide advice and information. The contact details for local and national domestic violence services and how best to access them should be documented in the practice handbook and be available to all locum doctors and other temporary staff.
At a minimum, each member of the primary healthcare team should be aware of the freephone 24-hour national domestic violence helpline run in partnership between Women's Aid and Refuge (0808 2000 247).
2 Develop an effective working partnership by engaging with local services
Ideally, the practice should identify a contact person at a local domestic violence service who can directly liaise with clinicians and provide care for your patients, including full risk assessments and safety planning. A named health professional should be identified to act as the practice's domestic violence lead who will liaise with local agencies and have specific training in the issues surrounding domestic violence.
The Identification and Referral to Improve Safety (IRIS) trial tested a practice-based domestic violence training and support programme along with a care pathway.1 An advocate educator from a local specialist service trained the practice teams and took referrals directly. One year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded just 12 referrals.
3 Encourage spontaneous disclosure of domestic violence by letting your patients know your practice is accessible
Spontaneous disclosure is only likely to occur if a woman feels that she can trust the doctor and practice. Having information about domestic violence with telephone numbers for national helplines and for local services in your practice – for example, leaflets in the waiting room – can help a woman to feel she can trust a practice.
4 Directly ask at-risk women if they are experiencing domestic violence
GPs should have a low threshold for asking about domestic violence when women present with conditions associated with current or historical violence. These include mental health problems such as depression, medically unexplained symptoms such as tiredness, gynaecological conditions such as chronic pelvic pain and chronic conditions such as irritable bowel syndrome.
A useful initial question may be: ‘How are things at home?', followed by a more specific question like: ‘Many women with this symptom may be suffering abuse from a partner or adult they live with – is that happening to you?'
Four validated HARK questions – standing for humiliation, afraid, rape and kick – can be used to identify the different dimensions of domestic violence – physical, sexual and emotional abuse, and fear of a partner (see box on the following page). This information should be in the practice protocol. Encouraging clinicians to ask about domestic violence can be achieved by training and by using the HARK questions as an electronic prompt triggered by certain Read codes consisting of conditions associated with domestic violence, something that the IRIS trial did.
Women should only be asked about domestic violence when it is safe to do so – in other words, when they are not accompanied by anyone who can understand what is being discussed. This may include young children who may report back to a controlling partner or a relative who is translating for the woman.
5 Designate a ‘safe room' in the practice
If a woman discloses any type of abuse GPs should ask: ‘Are you safe to go home?' Other useful questions are: ‘Are either you or your children in danger?', ‘Has violence become more frequent or severe recently?' and ‘Are there weapons in the home?' If the answer to any of these questions suggests risk of immediate harm, then urgently contact either a domestic violence service or – if it is not possible to speak to an advocate immediately – the police. The practice needs a designated safe room where a woman can wait while the appropriate service is being contacted. This needs to be a private space where the woman can speak without fear of the perpetrator having access or of being overheard. However, for the vast majority of cases seen in primary care, domestic violence is closer to a chronic condition and the situation will not be urgent that day.
6 Ensure staff know how to safeguard children exposed to domestic violence
Children are present in the household in approximately 60% of domestic violence cases and also have a high risk of direct abuse. So in each case of domestic violence, the GP needs to enquire whether children are present in the household and assess the level of risk for any child. A child is at greater risk if under seven years old, the mother is pregnant, or if the mother or child has special needs.
Safeguarding procedures need to be initiated when there are concerns about the welfare of children or vulnerable adults. A judgment about whether the exposure of children to domestic violence requires an intervention is complex and should be discussed with the named doctor.
If consent is not given, confidentiality may be broken when safeguarding vulnerable individuals. Dilemmas about breaking confidentiality can also be discussed with colleagues, including the safeguarding clinical lead in your practice.
The safety of a child is your first concern, and if a child comes to harm you may need to justify why other agencies were not informed. Referrals to social and healthcare services for concerns about child abuse need to be made in writing within 48 hours of deciding to refer (Laming report 2003, recommendation 21). Good practice in relation to safeguarding children also includes your practice registering babies with the birth notification form sent from the maternity unit using the newborn's NHS number as opposed to waiting for parents to register the birth. In children of school age, at registration your practice should record the child's current school (Laming report 2003, recommendation 86).
7 Record and keep domestic violence information confidential
There should be a consensus within your practice on how to record domestic violence using agreed Read codes and a discussion on how best to ensure that this information is kept confidential in consultations where the perpetrator or other third parties are present.
A shared understanding within the practice team on the benefits and potential dangers associated with recording whether a woman has historically or is currently experiencing domestic violence is required.
One danger of recording domestic violence as part of a patient's record is that it may be displayed on the computer screen within the medical record. Clinicians need to ensure that this information is not visible to third parties within consultations.
8 Have regular practice meetings involving the whole team
Gathering the knowledge of the whole team at regular meetings will increase the identification of domestic violence. Health visitors and other community-based professionals may often be more aware of domestic violence occurring within vulnerable families.
9 Provide face-to-face training on domestic violence for the whole practice
Specific evidence-based domestic violence training and support programmes for primary care are available that can be commissioned for the whole practice team (see www.irisdomesticviolence.org.uk), and these can cover a range of issues including practical experience on how to ask sensitively about current or past abuse, and how to provide an empathetic and safe first response to a disclosure of domestic violence.
Whole-practice training on safeguarding children, including the link to domestic violence, is recommended at least every three years for all NHS staff.
Professor Gene Feder is professor of primary healthcare at the University of Bristol and a GP in Bristol, and Dr Alex Sohal is a GP in Whitechapel, London. They are the RCGP clinical champions for domestic violence
1 Feder G, Agnew Davies R, Baird K et al. Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial. Lancet 2011 online, 13 October
2 RCGP. Responding to the DVA in general practice and contact numbers. http://tinyurl.com/7f25tus
3 RCGP. Violence against women and children course. http://tinyurl.com/6r55wmj
One point is given for every yes answer
• Humiliation: Within the last year, have you been humiliated or emotionally abused in other ways by your partner or your ex-partner?
• Afraid: Within the last year, have you been afraid of your partner or ex-partner?
• Rape: Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner?
• Kick: Within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?