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Let’s fix the DVA-shaped hole in the training for medics once and for all

Medina Johnson is the Chief Executive of IRISi, and Gene Feder is a Professor of Primary Care at Bristol University Medical School. They provided this blog for us as part of our 16 Days campaign around the Health response to domestic abuse.

Not a seasonal carol but all together now:

There’s a hole in our training dear tutors, dear tutors,

There’s a hole in our training, dear tutors, a hole.

With what shall we fix it trainee medics, trainee medics?

With what shall we fix it, trainee medics, with what?

(and here’s the bit that doesn’t scan!)

With training, a simple care pathway and direct referral to a specialist advocate,

With training, a simple care pathway and direct referral to a specialist advocate,

With that!

Ever get the feeling we’ve been here before?

For years our medical school curricula have chosen to exclude training on DVA (domestic violence and abuse) and for years health care professionals have been missing thousands of patients with experience of DVA.  This is not a statement of blame but one of fact. None of us, whatever the discussion or wherever we work, want to begin a conversation with someone if, through our lack of skills, training, experience and onward support, we can’t deal with where it will lead us and may leave our conversation partner feeling worse than they did before the conversation had started. This is a dilemma we hear regularly from health care professionals who have a suspicion, a clinical inkling, that they are seeing patients who they are concerned are experiencing current DVA or the effects of historic DVA, don’t know how to ask them about this, don’t know what to do with what they are told and don’t know what to offer next.

Our first call to action is to invite all medical, dental, nursing, midwifery, physiotherapy and occupational therapy courses to review their curricula and ensure that teaching on DVA is integrated into epidemiology, history taking, diagnosis and treatment of patients. In a recent study of UK medical schools, of the 25 that responded, 21 had some teaching of DVA in the curriculum, but 11 had two hours or less in the five year course.

Our second call to action is to commissioners within Clinical Commissioning Groups, Public Health teams, Health Boards, Local Authorities, Police and Crime Commissions and wider. Why wouldn’t you want to fund a local programme of training, where clinicians are taught to ask, respond, refer and record, coupled with a clear referral pathway?

Standalone DVA training for health staff, which does not have a robust evidence base, doesn’t work. The IRIS model does. We know that sounds a bit simplistic, but the whole reason we developed the IRIS model is because training on its own generally doesn't shift what clinicians do. The reason IRIS is successful is because training is tightly integrated with a referral pathway and ongoing support to practices. Each locally commissioned programme is delivered by a strong partnership between a local clinical lead and a specialist advocate educator usually based in specialist, third sector VAWG organisation.

In the seven years since IRIS became a commissionable model, over 800 general practices in England and Wales have become IRIS DV Aware Practices and over 8,000 women have been referred to their local IRIS AE.  We estimate that over a further 29,000 women will have had a discussion about DVA with their primary health care clinician, will have received signposting information and will know that there is support available if they need it and when the time is right for them.

The IRIS model has now extended to sexual health services and we are working on projects exploring this approach in pharmacy and dentistry.

For more information, please email us: info@irisi.org or see www.irisi.org

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A day in the life of a hospital Idsva service

As part of the 16 Days of Action against Gender-based Violence, we’re looking at the Health response to domestic abuse. Communications Officer Ruth went to spend a day with a hospital-based Idsva (Independent domestic and sexual violence advisor) service to find out more about how being located in the hospital helps them to support their clients. 

I head to the hospital’s busy main reception and the receptionist pages Punita who comes to meet me. Punita is a Senior Idsva (Independent domestic and sexual violence advisor), and one of two who work at the Bristol Royal Infirmary (there is a Bank Idva to cover any outstanding shifts). She leads me to the A&E department, and to the Idsva service’s cosy little office which is a stone’s throw from both A&E and the staff room.

The walls are covered with thank you cards from clients and family photos. There’s also a ‘Wall of Shame’, where Punita sticks up the names and prison sentence of perpetrators who have been successfully prosecuted. “One of our greatest outcomes was a prolific offender pleading guilty to Section 18 GBH and being sentenced to 8 years imprisonment – a really fantastic outcome”. 

The BRI Idsva team provide a daily service and receive between 300-350 referrals a year. Punita explains that Mondays can be busy as some patients may have been prevented from seeking medical attention over the weekend. “One lady with a fractured jaw in 3 places had to wait until Monday morning to come to A&E once the perpetrator had left for work – she told me she was in agony over the weekend but her partner would not let her out of the house”.   

Punita and her team are NHS staff, which means they have full access to all hospital records. This allows them to look at patient attendance, not just in A&E but Trust-wide, read through patient notes and check for patterns of attendance or any injuries that might be signs of domestic abuse. In this way they can be proactive as opposed to just reactive; they don’t have to wait for referrals to come to them before they take action.  

Looking at the cases in the system is a stark reminder that the signs of domestic abuse aren’t just physical; Punita estimates that around 80% of the patients they support disclose mental health problems and may further present in A&E with self-harm or overdose. Part of her work has been to establish structured referral pathways from the Psychiatry Liaison unit in the hospital – including adding a domestic abuse screening question to the Mental Health Matrix (a screening form completed by staff) to prompt a referral to the Idsva team as necessary. 

Having access to hospital systems means they can ‘flag’ high risk patients, prompting members of staff to take action - it could say ‘please contact Idsva’, flag that the patient’s partner should be kept away (stipulating current bail conditions or terms of a Restraining Order), or raise any other safeguarding concerns. Punita will also be notified if that patient re-attends in A&E or as an outpatient, so she has the option to follow-up with patients when they are in hospital again or can research for updates, i.e. if patients that are injured need further treatment.  

“Health is a vital piece of the Marac puzzle”, Punita says, “Even if the patient doesn’t want to get support from us at this time, we can use the information we have to refer high risk patients to Marac and monitor hospital attendances in the future”. “Repeated screening of high risk patients and the offer of Idsva referral during each A&E attendance is best practice – as a Trust we are sending out the message that domestic abuse is wrong, that hospital is a safe place to disclose and that advisors are on site daily to provide support”.  

Hospital Idvas also provide a vital link between the Marac process and clinical staff. “Oh, they’re amazing” says Helen; a nurse in A&E. Helen describes a case where a woman came into A&E in the early hours of the morning, with a fractured wrist. The patient said she slipped and fell, but when Helen looked at her patient record there was a flag from Punita on the system. Seeing this flag prompted Helen to separate the patient from her partner, without raising suspicion, in order to safely ask a few more questions, dig deeper and eventually a referral to the Idsva service was made. Punita tells me that this patient is extremely high risk and had been discussed at Marac every month for the last five months. Helen explains that without them here in the hospital, she wouldn’t always have the confidence to ask – and wouldn’t have anywhere to refer patients to.  

Carey, a physiotherapist, agrees that the Idsva team play a vital role in empowering staff: “Having them here, and the training they provide, gives us the confidence to know when it’s ok to let someone go home and when we need to refer them on. And they’re very visible to staff – I’m always popping into their office to ask questions”. 

Punita and I take a walk around A&E, which she does every day. She shows me the cubicles where patients are seen by clinical staff – Punita has made sure that these cubicles have posters on the walls, highlighting the signs of abuse and mouse mats at every work station, in case a new member of staff needs guidance on how to “Ask the question” and refer on. “We have a high turnover of junior doctors, so the mouse mats play a key role in getting this information out”.  

There are many creative ways that the Idsvas and clinical staff work together to support patients who are experiencing domestic abuse. Patients often come into hospital with their partners, so staff find ways of making sure that the patient can be seen alone in a space where they feel safe to disclose. It’s only by being so deeply embedded in the hospital that the Idsvas can make these links with other departments, and find ways to reach victims of domestic abuse in a safe way.  

Back in the staff room I talk to Punita and her colleague about how working in A&E compares to other settings. “It’s totally different, you’re working with clinicians who are trained to see people in terms of their injuries and immediate health needs, whereas we’re trained to see them as a different entity in terms of measuring their current risk and implementing safety plans to keep them and their family safe. So it’s like two worlds merging and learning to work in cohesion”. “Also we’re not trained in terms of the exposure to extreme physical injuries so that’s an adjustment at first”.   

Towards the end of the day Punita takes a call from a member of staff about a patient who she knows to be at high risk. She has come into the Gynaecology department for a minor concern, but Punita would like to see her, so they agree that the Consultant will set up a follow-up appointment which Punita will attend. 

The service is doing an amazing job of reaching and supporting patients experiencing domestic abuse. From talking to Punita, it’s clear that none of this been achieved overnight. She has been in the hospital for six years, and it’s her sheer tenacity that has enabled the service to become so well embedded.  

“You’ve got to make yourself visible in every way you can and just keep pushing to put domestic abuse on everyone’s radar”. She tells me about an Idva working in another hospital, who has no office space and has to sit outside in her car and wait for referrals to come in. “You need to have an equal footing to all other specialisms working in the hospital – domestic abuse isn’t a ‘take it or leave it’ subject – you need the office space, you need the access to hospital systems and you need everyone on board from Trust Leads to Safeguarding teams to nurses and doctors, otherwise you’re not going to reach those vulnerable patients desperate for support – Vital opportunities will be missed”. 

 

Please would you consider making a donation of £25, or a regular gift of £10 a month, or whatever you can afford to help us call for specialist domestic abuse teams in every hospital in the country? You can donate online here or by texting STOP16 followed by the amount you want to give to 70070. Thank you.

'Early intervention is going to save lives' - domestic abuse support in hospitals

Mandie Burston was the Royal College of Nursing's Nurse of the Year in 2015, and is a passionate advocate for domestic abuse awareness in Health settings.

With no bias or boundary domestic abuse continues to infiltrate every sector of life, where no one is immune. It can begin at any time in life, it is rarely a one off event, and it is devastating and destructive to those directly and indirectly affected.

As many prepare for the upcoming festive period, all those involved in domestic abuse take 16 days of activism, raising awareness with public promotions, social media updates, conferences, TV and radio campaigns, with the single aspiration: that that the person suffering hears the messages of hope, and reaches out on to the road of recovery.

On the 28th November, Her Royal Highness the Duchess of Cornwall visited a programme embedded into University Hospital of North Midlands Accident & Emergency department, showcasing an award-winning project which helps those who are attending A&E and affected by abuse. ARCH, a local charity, with over 30 years’ experience have improved education & awareness for staff, who in turn, now recognise & respond promptly, initiating early interventions.  

Domestic abuse is often hidden by shame, guilt, and confusion. It is known as the most unreported crime and continues to affect 1:3 women, 1:6 men, 1:5 children. Those affected can be silenced through fear, crippled by depression and mental health complexities; they may have addictions which began as coping strategies or forced behaviour by a perpetrator. The only commonality of those abused is a failure by professionals to recognise and respond early.

In Health, we see those affected by depression, addiction, with bumps and bruises, unexplained injuries, vague symptoms, but do we ask why? Do we enquire about the safety of the person; do we ask if they are being abused? Do we fully understand the dynamics of a perpetrator-victim relationship and conduct ourselves accordingly ensuring the safety of those affected?

Early intervention is going to save lives. Sadly time and time again the headlines tell of a tragic story of a lost life, despite countless attendances to an A&E department, despite several GP appointments, despite various professional agencies' involvement, no one asked the question 'Are you safe?' On average a women dies at the hands of her perpetrator every 2.5 days. This does not include the deaths of those associated to addiction and health associated disease process.

Simple solutions are often the best solutions and with current NHS resources being stretched to the limit, by fostering a partnership with an Idva service, the human, emotional and financial cost of abuse can be met head on.

The role of an Idva is a light at the end of a very dark frightening tunnel to someone who is living with abuse. An Idva understands, advises on safety, will never say “just leave”.  An Idva becomes a helping hand in the hell of abuse. Those who work as Idvas do so silently, discretely, with empathy and understanding, with knowledge and compassion. With time and resources, Idvas can turn lives around into something worth living, in a world without fear.

For more information and resources, visit our 16 Days homepage

'I want to let them know they're not on their own' – training tomorrow's GPs on domestic abuse

Recent research found that the current level of domestic abuse training given to future GPs is inadequate. As part of the 16 Days of Action against gender based violence, we’re calling for domestic abuse training to be provided to all medical professionals. SafeLives Communications Officer Ruth spoke to Briony – a trainer at SafeLives who recently spent two days training medical students at King’s College London.

Hi Briony, can you tell me a bit about how this training at King’s came about, and what sort of topics you covered?

The training was part of a much wider area of their syllabus which is quite new – around improving access to healthcare for vulnerable patients.

They were second year medical students so most of them were quite a bit younger than the learners I usually train, and all of them are working towards being GPs. Most of it was around the basics: definitions, getting them to think about their ideas around what domestic abuse is, then looking at the Home Office definition, which structures a lot of the responses in the UK. We talked about that question of ‘why doesn’t she just leave?’ exploring the reasons why a person who is experiencing domestic abuse can’t – or shouldn’t have to – leave. We also looked at how abusive relationships develop, and the fact that they start in the way most relationships start. We looked at how a person might develop control over another person and how they sustain that, the different tactics they might use. So really trying to move the focus away from physical violence, towards the different forms of emotional and psychological abuse they might see in their practice.

We then talked about the health impacts of domestic abuse; so the long term effects in terms of physical health, but also in terms of mental health, and the various ways that these might present in patients they see. So we talked about the dynamics of domestic abuse, and how that might impact on what a person tells us, or how they choose to engage at different points depending on what’s going on.

What were you hoping for them to get out of the training?

The main message I wanted them to go away with was ‘you ask about all these other things that have an impact on people’s health, and we know from global research that domestic abuse has a significant effect on health. So why would you not ask about that?’ They need to be comfortable talking about this.

I also wanted to let them know that they’re not on their own – there are places for them to refer to. We know that the mental health impact on GPs can be really high, so as well as helping GPs to give the best response to patients who are experiencing domestic abuse, it’s about reducing the impact on them too. Letting them know that if they come across this, they can feel empowered to take action and refer it on – but they don’t have to deal with it by themselves.

What do you think the difference is between training GPs before they are qualified, compared to later on?

At this point in their training they haven’t seen many patients, so they’re still deciding what their own style of consulting is going to look like – so to train them now, and make this part of their practice, is so much easier than talking to established GPs who are already carrying so much with them.

There’s definitely a role for continued professional development (CPD), and medical practitioners – like many other professionals – do have to have that. It is important because resources change, pathways change, best practice is updated.

But I think it’s such a great opportunity to be able to train them early on, because as students they haven’t got the load of carrying cases and patients, targets, all the things we know that health professionals are dealing with. So to get them at this point where they still have the luxury of some time to think and reflect on ‘what sort of GP do I want to be?’ is really valuable. And, they’re still learning, so they see the training as something for them to take on board and assimilate – rather than something they have to do in order to tick a box. Getting GPs together in a practice for two hours to do training can be incredibly difficult – and it can feel like it’s putting pressure on an already strained service.

The other good thing about making it a part of their training is that it professionalises this issue. It makes domestic abuse awareness another part of their job, rather than a sort of add-on.

Did any interesting discussions come up in the training room? Did they have any preconceptions about domestic abuse?

It’s interesting, I think I actually had some preconceptions, because of the experience I’ve had training established medical professionals. I went in expecting these medical students to have the same ingrained ideas about what domestic abuse looks like… but actually, they’re 19 years old and they got it. I asked them what domestic abuse means and they talked about it not just being physical abuse, how it can be emotional and financial… clearly they’d already absorbed a lot of those messages which I think is a good sign of how things are changing in society. They had some of the same concerns as their older colleagues around ‘what can I do?’, so we gave them some very clear pathways.

Why do you think it’s so important for health professionals to have training on domestic abuse?

Well in research, patients who were survivors said that they were more likely to tell a medical professional – particularly their GP – than the police or someone else. So, on that basis it’s essential that health professionals have this knowledge. This was only a couple of hours of training, but I think it’s enough to plant the seed and get people thinking about domestic abuse as a health issue. It’s not a ‘women’s issue’, it’s not a voluntary sector issue – and it’s not just a criminal justice issue either: four out of five victims never tell the police.

If we know that people are using the health service because of the impact of the abuse they’re experiencing, and we know that people feel more comfortable disclosing abuse to health professionals than anyone else, then it doesn’t make sense for us to not be training them. We’ve got all these expert professionals – Idvas, young people’s workers, outreach workers – who are all doing an amazing job, but we’re not training a key group of people who could be referring to them.

 

Please would you consider making a donation of £25, or a regular gift of £10 a month, or whatever you can afford to help us call for specialist domestic abuse teams in every hospital in the country? You can donate online here or by texting STOP16 followed by the amount you want to give to 70070. Thank you.

Kathryn Hinchliff on the impact of Service Managers training and Leading Lights accreditation

Kathryn Hinchliff is Leading Lights Programme Lead at SafeLives. Here she talks to Senior Communications Officer, Natalie Mantle about our Service Managers training and Leading Lights accreditation, and the opportunities they can open.

 

Hi Kathryn, can you tell us a bit about your role/your background?

Kathryn Hinchcliff

I have worked in the domestic abuse sector for 14 years now, with half of that time at SafeLives on the Leading Lights team. Before I came to SafeLives I worked as an Idva/Outreach service manager in Rotherham and have also worked in Norfolk managing a county wide Idva service. I started out in this sector as a data-monitoring worker in Norfolk, collecting and analysing information from the police, health services, housing and DA services to inform practice across Norfolk. I think this slightly geeky background has stood me in good stead for my role as Leading Lights Programme Lead. I also worked for a short time in a refuge and this experience has really helped me as we have developed leading lights to meet the needs of all specialist domestic abuse services and not just Idva.

Can you tell me about the Service Managers training course and why it’s so important?

We developed the service manager’s training for three reasons. Firstly, we found that service managers were often working in isolation. We felt this group would really benefit from some peer support, and a nationally recognised qualification to back up the important work that they do. Managers were also struggling to fully embed standards across the organisation, and finally, frontline staff attending our accredited courses were leaning new approaches and sharing resources, but were finding it hard to implement in their teams as their managers did not always understand the approach.

The course covers effective support and supervision for staff, case management best practice, the importance of good governance and improving the multi-agency response. It also looks at how services can be commissioning ready and better evidence the impact they have. Feedback from the course repeatedly emphasises the benefits of the tools and resources provided, the impact on practice and the opportunities for peer support.

What opportunities can Service Managers training open up?

The course is an essential first step to achieving Leading Lights but many managers and senior staff choose to do the training for their own professional development – to learn from their peers and review their practice.

The service manager’s training is now a nationally recognised level 4 award and the only course of its kind in the UK.  Many learners have fedback how helpful it has been for their own personal development. The course encourages and teaches reflective practice and really helps managers to critique their services and identify opportunities to improve. One of the assignments involves auditing files using the SafeLives recommended audit tool – learners have fed back during the training that this has been eye opening for them and has helped them to identify potentially concerning gaps in practice as well as helping them see the really good practice and celebrate that with their teams. One learner reflected that the course really increased their confidence in their management style and was instrumental in giving them the confidence to apply for and get a promotion. 

If anyone is thinking about taking the Service Managers course but isn’t sure, what words of wisdom would you offer them?

One of the reasons I love training on the service manager’s course is because it is so rare that service managers give themselves time for professional development and have the time to properly reflect on their practice. It is fantastic to see the changes they have implemented from block 1 to block 2 and then see how embedded these are once they are assessed for leading lights. The course is intensive and managers can struggle to see how they will fit in the assignments and for some it may be a long time since they did any formal learning. So I would say if this is something that is stopping you then please do get in touch as we can support learners in many ways to complete the course and get back into learning. Over 300 service managers have now been trained – if they can do it so can you.

Leading Lights is coming up for its 10th birthday and we now have more than 50 accredited services. How do you think it’s changed over the years? What difference do you think accreditation makes to services?

Leading Lights has developed a lot over the 10 years with a big review taking place 4 years ago to ensure the accreditation is suitable for all specialist domestic abuse services and not just Idva. We now have a flexible model that has been developed in consultation with community based services. Our 50th service to be accredited was Bedfordshire Families First - Horizon project who run group work programmes for victims of domestic abuse. They are the first such programme to receive the accreditation and it was great to see the excellent practice they have put in place to ensure their clients are supported safely. Accreditation is a great way for services to celebrate their success with the teams, it provides a quality mark that is recognised by commissioners and most importantly it improves practice at every level of an organisation so that victims of domestic abuse are getting a better, safer service.

"The course was transformative – it was the first time I had attended a management training that was geared specifically towards this sector, and as a result I took so much more away from it than any previous course I have completed. The training cemented my existing knowledge and, at the same time, introduced me to areas of strategic management and governance that hadn’t previously been as ‘on my radar’ as they could have been."

Zoe Jackson, Aurora New Dawn

 

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