ALL THE LINKS YOU EVER NEED FOR CSA & AFTER

At this festive time of year rates of domestic violence and abuse (DVA) rise sharply, so we make no apology for devoting our December Blog to this Hot Topic. Surprisingly many GPs admit to receiving no training on DVA. And yet it is common, has a significant impact on the physical and mental health of victims and their children, and it often goes undetected in primary care.

In recent years there have been reports published by the DoH, and the RCGP has made DVA a clinical priority. Research strongly suggests that improvements are needed in the way DVA is addressed in the health service. There is increasing evidence that interventions are effective in improving the lives of women and, importantly, those who experience DVA want us to ask about it and many see us as an important first contact and source of support.Our hope is that after reading this blog you will have a better understanding of how to approach this largely hidden problem. Have you detected any cases in the last year? Do you regularly ask? If the answer to these questions is no, then we urge you to make this a priority area on your PDP for the forthcoming year.

There are now several excellent resources to improve practice in this area, some of which are listed below. None should replace attendance at DVA training, but the RCGP and DoH have produced an e-learning tool, free to non-members, and a great place to start (worth 2 CPD credits). Last year on the Hot Topics course we covered IRIS, the first UK based RCT into primary care training in DVA, and the same group have produced training materials for UK general practice, also referenced below. As with so much in general practice, multidisciplinary working and communication are key – why not find out what local training is available and involve the whole practice?

Definition of DVA

“Any incidence of threatening behaviour, violence or abuse (psychological, physical, sexual or emotional) between adults who are or have been intimate partners or family members, regardless of gender or sexuality. An adult is defined as any person aged 18 years or over. Family members are defined as mother, father, son, daughter, brother, sister and grandparents, whether directly related, in laws or stepfamily” (Department of Health 2009). DVA also includes female genital mutilation, forced marriage and ‘honour based’ violence, which are covered in the RCGP e-learning module referenced below.

So, how big is the problem?

· One in four: In the UK 1 in 4 women will experience abusive or violent behaviour from a partner at some time in their lives.

o Men are also of course affected, but women are more likely to experience sexual coercion, and are more likely to experience severe forms of physical assault. 2 women are murdered each week in the UK at the hands of a current or previous partner.

o Women are also significantly more likely to live with fear and suffer health consequences as a result of DVA…

· Health consequences include both acute and chronic problems

§ Mental health is most often affected, with conditions such as depression, anxiety, PTSD, suicidal ideation and substance misuse.

§ Chronic health problems such as gynaecological disorders, chronic pain, neurological symptoms, GI disorders.

o There are also significant health consequences for any children involved.

· Financial cost

o Effects of DVA are estimated to cost the NHS £1.7 billion per year (2008 cost).

What can we do as health professionals?

· To help people to access specialist support and advice in a safe and confidential manner.

o So, we have to detect DVA more often and refer (or advising self-referral) to a local service.

o There are important issues at a practice level regarding a safe, standardised and secure system for documentation (e.g. use of ‘hidden notes’ or agreed Read Codes to document DVA). If unsure, discuss with your practice lead for DVA, Child Protection and/or PM about the current practice policy. A practice meeting may be necessary. (The RCGP e-learning module ‘resources’ section in lesson 5:“Improving your Practice” has a list of Read Codes and further useful information on this).

o Having posters and easily available credit card-sized information in waiting rooms and/or toilets is a quick and easy measure to take and suggests that we recognise the problem of DVA and are willing to discuss it.

· Be alert to aspects of histories or symptoms that could suggest DVA and follow up with specific questions

o Those most at risk are women with mental health problems, recurrent attenders with minor complaints, and pregnant women (1/3 of DVA starts during pregnancy).

How to ask?

· Be safe – do not ask about DVA in the presence of another family member including children other than infants, as this can increase risk for the individual.

o Example questions –

§ Start with general questions eg. “Are there any problems at home?”

§ Move on to more direct questioning eg. “Are you afraid of your partner or anyone else?Has someone hurt you now or in the past?”

§ HARK is a series of questions that can remind you of the various types of abuse to ask about – standing for:

· Does your partner humiliate you

· Are you ever afraid of your partner?

· Has your partner raped you?

· Has your partner ever kicked (or physically harmed you?)

o Another way to bring up the topic is to make a connection between the patient’s symptoms or presentation and possible abuse eg. “Sometimes people with this symptom(s) have experienced some form of abuse in the past or at present – might that be happening to you?”

How to respond to disclosure of DVA?

· Acknowledge the admission of abuse and thank the patient for trusting you with the information. Give reassurance. eg. “You do not deserve to be hit or hurt”. “You are not alone. Help is available”

· Give reassurance about confidentiality…

o Other than when a child or vulnerable person is at risk, when you should discuss with your DVA or child protection practice lead about disclosure. Make every attempt to empower/gain consent from the patient first.

· Consider child protection issues

o Guidelines suggest that a safeguarding referral should be made in all cases where a child less than 12 months of age is in the household (including any unborn children). Check local policy with your Child Protection lead. DVA clearly crosses over with Safeguarding Children issues, for which local training should also be available.

· Offer to provide details of local agencies, including a discrete credit card sized information card which can be kept in a purse or wallet. Tell her that help is available.

· Assess immediate safety – always assess risk of immediate harm.

o e.g. “are you safe to go home?”

o If at immediate risk, contact the police or local DV service and ideally have a safe and private area where the patient can wait until they arrive.

· Document any injuries clearly, and take photographs if you have the facility to do so, or arrange for a police surgeon to do so.

2 points to remember:

· Not asking can signal that you are not a potential resource for the patient.

o Many ‘survivors’ interviewed about their experience of GP and other health professionals’ approach to them suggest that health professionals often did not ask, even in the face of clear evidence suggestive of likely DVA.

· Refrain from telling patients what they should do

o Do not force a disclosure. There is a benefit in asking even if abuse is not acknowledged. We must remember that for many women, it can take years to have the capability to move on from an abusive partner. Showing that we are supportive and willing to discuss DVA is a positive thing in itself.

NB Practice Points: Domestic Violence and Abuse

· Consider making this a part of your PDP

· Do you have a practice lead for DVA? If not, why not become it?! Arrange a PHCT meeting to discuss

· Liaise with local agencies and your Child Protection lead. Get posters up and have information ‘credit cards’ to hand out

· Have antennae alert – and start asking! You will make a difference

· Support, but do not tell people what you think they should do

We hope you have found this useful. Please feel free to share your expertise and experience in the comments section. Thanks for reading!

Zoe and Simon

References & GP Resources

1. RCGP e-learning module ‘Violence against women and children’ http://elearning.rcgp.org.uk/. (Developed with funding from the DoH and free to non-members). An excellent resource including a comprehensive set of resources. The module (without additional impact) is worth 2hours of CPD.

2. Taket, A. Responding to domestic violence in primary care. (BMJ 2012;344:e757)

3. Liebschutz, J.M., Rothman, E.F. Intimate-Partner Violence – What Physicians Can Do. (N Engl J Med2012:367;22)

4. IRIS website. (A GP-based domestic violence and abuse training support and referral programme.)

http://www.irisdomesticviolence.org.uk/

5. Richard Smith. Writing in the Guardian in 2010. http://www.guardian.co.uk/commentisfree/2010/mar/16/nhs-domestic-violence-women

6. Department of Health 2010. Report on the health aspects of violence against women and children from the domestic violence subgroup.

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_113728

Resources for patients

http://www.nhs.uk/Livewell/abuse/Pages/domestic-violence-help.aspx

http://www.womensaid.org.uk/

http://refuge.org.uk/get-help-now/

http://www.bbc.co.uk/health/support/domestic_violence_usefulcontacts_index.shtml