26th September 2019
Donna Allender is the Pathfinder Domestic Abuse Project Lead Officer for the Somerset Clinical Commissioning Group (CCG). Having previously led the development of the Health IDVA service within an acute hospital she is keen to capitalise on the expertise of the Pathfinder consortium in scoping a sustainable domestic abuse model across targeted health services with the Somerset CCG area.
In Somerset an estimated 13,200 women have been impacted by domestic abuse within the last year, 2139 of these are accessing support via our community-led domestic abuse service, 58% of which are police led referrals.
With only 1 in 5 survivors of abuse reporting to the police, there are an estimated 11,062 women potentially requiring early intervention and prevention. Thus it is vital that health play a proactive role in identifying and responding to patients exposed to domestic violence and abuse.
Whilst this report identifies the risk to women within our communities it in no way excludes the impact on children or the estimated 7,700 males that have been exposed to domestic abuse within the last year.
The estimated annual cost of domestic abuse to services within Somerset is £33.5 million (not including the human and emotional cost). £15 million of this is related to healthcare.
In the spirit of sharing best practice, I detail some of the activities that Somerset has progressed within our Acute Hospitals. It is by no means exhaustive and requires continual assessment and revision. With an annual average of 100,000+ patients passing through the Emergency Departments of our Acute Hospitals, embedding the NICE Quality Standard 2016, in a way that is effective and efficient is an evolving process.
First and foremost it was important to understand the challenges within the clinical setting; environmental time pressures, medical priority, patient interface, safeguarding knowledge and skills. It was noted that whilst there was a breadth of experience in delivering a measured, empathic first response to patient care and that all teams were fully aware of their statutory safeguarding responsibilities. Opening up the topic of domestic abuse, responding effectively to disclosure, assessing risk and referring to appropriate services was an area that many practitioners still felt very uncomfortable about.
We also identified that whilst robust safeguarding policies and procedures existed, domestic abuse was a feature rather than a detailed protocol for response. Domestic abuse was included in mandatory safeguarding training. However, again as a feature rather than a targeted programme designed to progress clinical enquiry, risk assessment and referral to specialist support.
The value of building relationships with the clinical team cannot be underestimated. Demonstrating a willingness to understand the day to day challenges and devising workable solutions that support medical teams to deliver interventions in a timely and appropriate way, not only enables the Trust to more specifically embed the NICE quality standard - driving measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – but also supports the clinician in feeling confident when delivering meaningful patient engagement.
One of our overarching aims was to embed an Emergency Department response that communicated to our patients that we recognise the impact of violence and abuse on health and wellbeing. That they are not alone and that we can offer appropriate routes to help and support.
Single Person Triage
At registration, all patients are informed that we conduct single person triage and that those accompanying them will be asked to remain in the waiting room until the triage outcome has been determined. Of course, we operate this within reason. If patients have additional support needs that require a carer to be present then this is accommodated.
At the point of triage, all patients 16 years and above, male and female are routinely asked about domestic abuse. However, this is largely designed to inform the patient that we are listening, available and confident in our response to violence and abuse at home.
Given that a high percentage of domestic abuse survivors presenting within health are often in a pre-contemplative stage, i.e. either not identifying that their experience is classified as domestic abuse or simply not be ready to engage in support. We must open up the question beyond the traditional ‘Are you at risk of domestic abuse?’
The way we ask the question is dependent upon the presenting situation, for example; our guidance for triage is:
“Given the widespread nature of violence and abuse, we routinely screen for risks at home”, “Is there anyone at home that has threatened to hurt you or someone that you care about?”
Whereas our guidance for maternity may be framed in the following way:
“Women exposed to abuse at home are particularly vulnerable to pre and post-natal stress”, “Is there anyone at home that makes you feel unsafe? Anyone who’s behaviour concerns you”?
More generic lines of enquiry may be:
“Not everyone recognises that they are in an abusive relationship”, Does anyone consistently put you down or belittle you? Threaten or intimidate you?
“How are you coping at home? Is there anything that you are worried about? Anyone that makes you feel unsafe or that you are frightened of?”
Our enquiry does not stop at triage. When the patient moves into other areas of the Emergency Department for further assessment, clinicians have access to a clinical code that is embedded into their clinical recording pathway. If concerns have been identified at triage or the presenting complaint has a number of safeguarding indicators that denote domestically abusive activity, the clinician can use the code and a series of simple questions appear within the clinical notes.
- When was the last escalated incident, what happened?
- Is this the first injury that the patient has sustained? How does it compare to previous injuries?
- Does the abuser intimidate or threaten the patient?
- Would the patient describe their abuser as controlling or psychologically abusive?
- Are the abuser's behaviours getting worse, are the incidents of conflict happening more frequently?
- Identify the location of the alleged abuser, and if the patient is frightened of them?
- What is it that the patient is frightened of?
The questions are designed to offer a framework of assessment that is conversational, whilst prompting disclosure that informs us about the severity and frequency of the abusive activity surrounding the patient.
If the patient consents to engage with the domestic abuse specialist, the clinician can generate an automatic referral to the safeguarding team via the electronic clinical record.
Supporting clinical enquiry is our Emergency Department First Response Procedure. A simple yet detailed protocol on how to respond to disclosure, assess risk and refer to specialist Health IDVA support.
Advice ranges from reassuring the patient that their disclosure will not be shared with the abuser, encouraging engagement with the hospital IDVA service, to specific risk assessment and safety planning measures. Links to this pathway are available.
Level 3 Safeguarding Training for Domestic Violence and Abuse
A key element in driving best practice response is of course training; the content of the training is designed to meet the NICE Quality Standard, universal level 1 & 2 targeted training for domestic violence and abuse and Level 3 Adult Safeguarding Competencies (which is an intercollegiate document).
This is a full day of mandatory training for the Emergency Department that aims to embed best practice by enhancing knowledge, skills and confidence when delivering safe actions and interventions to patients at risk of violence and abuse. It includes interpersonal violence and the role of the Emergency Department, establishing professional curiosity, domestic violence and abuse (Honour Based Violence, Sexual Violence, Older Patients at Risk, Complex Need), clinical enquiry, risk assessment and referral pathways.
Having an IDVA working directly with the ED team has been invaluable. A comprehensive training programme delivered by the IDVA empowered staff to carry out routine enquiry and manage patient disclosures sensitively. As the project has evolved the IDVA was able to share powerful accounts of successful interventions that the staff had been involved with and the positive impact the support of the IDVA had then made to the patients. Having this special advocate embedded as part of the team and making safeguarding around domestic violence part of our everyday culture cannot be underestimated.
- Nurse Consultant Emergency Medicine
The Health IDVA role has continually developed within the Trust, providing a clear process for evidence-informed practice within the organisation. The IDVA has shared valuable skills and knowledge with the safeguarding team, ensuring that the service is not only sustainable but that survivors of domestic violence and abuse may access a responsive and supportive service even in the absence of the IDVA. This service is now indispensable, ever-evolving, and as a trust, we are very excited about where this development is taking us.
- Associate Director Quality Governance and Safeguarding