I have a patient whose partner always accompanies them to GP appointments. I suspect the partner is controlling and abusive. How can I support and refer the patient for help, without putting them in danger?
Medicolegal adviser: Don’t assume someone else will address it
This is a situation GPs may face only rarely in their career, but taking a few moments to consider a sensible approach could be life-saving.
Domestic abuse can be physical, sexual or emotional and can include forced marriage and ‘honour crimes’. An abuser can be a partner, ex-partner or a family member. According to the 2017 Crime Survey for England and Wales, an estimated 1.9 million adults aged between 16 to 59 years experienced domestic abuse in the previous year (1.2 million women, 713,000 men).1
If you suspect domestic abuse, it is important not to assume that someone else is addressing the issue. You should try to provide an opportunity for the patient to disclose what is happening. In this case, you would need to create an opportunity to be alone with the patient.
It is not your role to encourage a person experiencing abuse to leave their partner or report the issue to the police, but rather to provide information that allows the patient to decide an appropriate course of action. If the patient does not disclose abuse but you still suspect it, accept their account but offer other opportunities to talk.
If appropriate – for example, if a disclosure is made but the patient does not want any action at that time – you should consider whether you can provide information discreetly. This may include details for the local domestic violence agency and independent domestic violence adviser.
In rare cases, you may need to act immediately and breach confidentiality in the public interest, to safeguard the patient or others.2 This may involve sharing appropriate information with a partner organisation, subject to protocols and local safeguarding guidance.3
Dr Gabrielle Pendlebury is a medicolegal adviser at Medical Protection
GP safeguarding lead: Create ways to pass on information discreetly
Seeing the couple together gives you the chance to witness relevant aspects of their relationship – such as the power balance, non-verbal cues and verbal communication where the partner may speak for the patient.
However, for safe enquiry about domestic abuse and to offer support, it’s important to see the patient on their own, with an independent translator if language is a barrier.4 Do not let a family member translate in such cases.
Identify and raise opportunities to see the patient alone – for example, for an examination, cervical smear, antenatal care, NHS Health Check, well-man or well-woman consultation. If the partner is resistant to this, that’s a red flag. It is crucial not to be intimidated yourself and to be firm that it is usual practice to see individuals on their own. If the partner insists on remaining in the room, an examination behind a curtain may give the only opportunity to offer help.
Develop practice mechanisms to inform patients of available support for domestic abuse, such as posters in toilets and waiting rooms and information on electronic advice screens. Clinicians or reception staff can provide information leaflets along with a urine test bottle, or via red stickers left in the toilets, which patients can put on the bottle if they would like help. Stickers and lip balm with the National Domestic Violence Helpline number disguised as a barcode are also available to give out.5,6
Share your concerns with colleagues and consider how you will document this on the patient’s medical record, including redactions from their online record.7
Dr Neera Dholakia is a lead GP for safeguarding in West London
Salaried GP: Do not risk becoming emotionally involved
It will be difficult to tackle the problem if you never see the patient on their own. A possible starting point would be to phone the patient to try to catch them alone; you could say you are calling to discuss a ‘health check’.
If this fails, invite the patient for a medication review or blood pressure check. If they come in accompanied by their partner, you can ask the partner to leave for a ‘personal’ examination.
If the partner still does not leave and the patient consents to them staying, it may be hard to broach the subject directly. Other options include giving the patient a pile of leaflets with one for a helpline or refuge tucked in among them, or asking them for a urine sample after ensuring there are leaflets and posters in the bathroom.
If there are children involved, contact the health visitor or school nurse. If you have serious concerns about them, contact your local safeguarding team.
As a GP you are in a privileged position to get to know your patients and some lateral thinking may be needed to approach this issue. No two situations will be the same.
However, if an adult is not classed as ‘vulnerable’, they are generally deemed competent to make their own decisions. Do not risk becoming emotionally involved yourself. Do what you can, but be prepared to step away and simply be ‘available’ if they come to you for help.
Dr Justine Hall is a salaried GP in Guildford, Surrey
1 Office for National Statistics. Domestic abuse in England and Wales: year ending March 2017
3 NHS England. Adult safeguarding pocket guide.
4 NICE Quality standard (QS116) – Domestic violence and abuse. February 2016.
5 Safe Lives.
7 RCGP. Patient online guidance.