20th September 2019
Dr Tara Jones is a designated GP across the county of Surrey. Here she is being interviewed at a Pathfinder event by Monika Lesniewska, a consultant at SafeLives, about her and her general practice’s response to domestic abuse.
TJ: In Surrey, the majority of our county hasn’t got IRIS, but I work in the area where we do have IRIS[i].
ML: So, what are some of the differences you see between the practices that do have IRIS and ones that do not?
TJ: For us, we just had a big domestic abuse deliberation day in Surrey in the last couple of months and one of the statistics that came out of that was that 85% of GP referrals into specialist services came from the Surrey CCG area which is the one that has IRIS. This doesn’t surprise me in the least. I think the one thing to be conscious of is that GPs have done a lot of signposting in the past, but it hasn’t gone down as a formal referral. So, they may have given a card or a leaflet but that isn’t captured. So, what’s different with IRIS is that it is capturing those formal referrals, which means you can evidence that GPs are doing that. That said, even where we haven’t got IRIS, I think there's that message of 'be prepared to ask the question and know what to do'. For me as a GP, and talking to other GPs, we’re used to not knowing everything but what we do say is ‘I can’t solve that, that’s not my area of clinical expertise but I know where you refer you onto’. So, awareness of what your local services, how to access them, what they can provide- we’re lucky in Surrey but I know that in some of our neighbouring areas the DA services are only available to work with high-risk cases. So, something to consider when referring patients is what sort of services are offered to them. So, you don’t get a formal referral pathway but it’s taking that same approach if I'm asking the question 'what can I then offer?'.
ML: So do you think that strengthening multi-agency work with the specialist services could be beneficial for practices?
TJ: We’ve done quite a lot of work within our safeguarding training of DA awareness and that’s been supported by our specialist services and that’s made a real difference. Bringing quite senior member of teams into our training. They can talk about their service because they’re best placed to tell us what services they offer. I think that’s been really, really helpful. Although some of our areas don’t have IRIS, it’s done a huge amount for them to know these are the services, this is how you access them and this is what is offered if you do send someone to them. I think that’s been really helpful.
ML: Other than that, what are some examples of good practice you have come across in your work?
TJ: What’s been interesting is where you do training and you train two GPs or two GP practices and some will go on to make lots of referrals and some won’t make any at all. And we’ve been talking about how to get round that and actually why that might be. I think one of the things to can do is get to know the practices. That’s hard in a big area but actually it builds those relationships.
ML: And how do you get to know practices, especially in large areas like Surrey?
TJ: We introduced a network of safeguarding forums. We took two lots of training- one is a formal lecture theatre-based full-day event, and then we have forums. We’re actually doing the forums at the moment- they’re based in each CCG area so they’re quite localised, they happen at lunchtime so they’re much more informal. For us, they’re often an opportunity to get to know the practices and the colleagues from those practices. We can also get to know what the local issues are, because our domestic abuse services are slightly different in different areas so work out ‘why is this slightly different here or what issues are coming up here’. Getting a sense of what the local landscape is. If you’re covering a big area, it’s different to if you’re in one small London borough. But if you’re covering a whole county, there are massively different issues depending on different parts of the county. I'm involved in the domestic homicide reviews and it’s very interesting- we had two running simultaneously. One, the GP engaged with the perpetrator-it was great work, really good continuity, really good support. It was an unusual domestic homicide review in that there was no background of domestic abuse. The other one could not have been more different- there was no recognition that someone was experiencing domestic abuse. So going through the DHR process and seeing how different that response was and led me to think what can we do to iron out those differences as much as we can.
ML: Can we support or challenge perpetrators in health services?
TJ: It’s interesting. Like I said, this was a very atypical case, but it was interesting to hear comment about how much can we do in primary care. Having been a GP for over 20 years actually how often did I even think or have a suspicion… maybe the victim had said something. How often did I know with certainty that an individual was a perpetrator? Very, very rarely. So in terms of that, how much work can we do? I'm not sure.
ML: How can GPs surgeries monitor and support children?
TJ: I think again it’s about identification but also a slightly difficult thing of having a woman who has made a disclosure to you and now you’re saying she has children and that’s created a potential safeguarding issue- how do you deal with that? We’re just at the moment starting a model a lot more early help at the lower level of safeguarding. It’s about explaining why we’re sharing information and why it’s going to be helpful. It’s the recognition but also, again, what services are there and if I'm saying to a victim ‘I want to offer you this to support your children’ if I can explain that and sell it as to why it’s helpful to you and your children, instead of I'm making a referral to children’s services and the first thing people think is ‘you’re going to take my children away’. It’s that explaining what role social care can have. I think that the early side will be beneficial there because it never even goes there so it destigmatises it.
ML: Do you think the fact that GPs can have more of a relationship with a patient makes a difference there?
TJ: I do. The only thing that I do caution a little bit is that primary care isn’t like what it was even 15, 20 years ago. There isn’t always that continuity, but we can achieve continuity when we choose too. If I really want to see someone again, I will make sure to book them to come back. You're not going to have that in A&E or an outpatient mental health service. although it’s not a given the way it was 15 years ago, it’s still possible. I think that’s why GPs are still very trusted by patients, because you do build a relationship with them over time.
ML: So do you think that the most vulnerable victims and children or those at highest risk could be the ones that do have that continuity?
TJ: That’s something we really try to encourage and that’s something good to get out there. We know we can’t do that for everyone and lots of patients don’t need it or even want it- lots of patients want the convenience of an appointment with anybody at a particular date or time. But I think that encouraging continuity where there are complexities or vulnerabilities is something we should be doing.
[i] The IRIS model is a domestic abuse and violence training, support and referral programme for GP practices. The practices are given training and referral pathways to specialist domestic abuse agencies. This model of best practice and has been evaluated to be effective in increasing referrals to domestic abuse agencies from trained GP surgeries.