Practice blog

Q&A with Dr Tara Jones - Surrey's GP response to domestic abuse


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.

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[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.

Transforming the primary health response to domestic abuse in the Royal Borough of Kensington and Chelsea

Iza Rana is an IRIS Advocate Educator with Advance Charity. The IRIS model is a domestic abuse and violence training, support and referral programme for GP practices. In this blog, Iza reflects on the introduction of the IRIS model to the Royal Borough of Kensington and Chelsea.  

The IRIS Programme in RBKC is being delivered by Advance Charity, looking to improve the healthcare response. We are an independent, client-led specialist domestic violence charity providing crisis intervention and on-going support to women experiencing domestic violence. We aim to empower women and improve the quality of life for them and their families in a variety of ways including working in partnership with other agencies. 

We are very excited about the developments since the launch of the IRIS programme locally in May 2019. We have trained ten surgeries thus far, with another two booked and in the process of receiving training.  A further seven surgeries have shown an interest in signing up, with a total of 19 surgeries currently involved in the programme.  

We have received wonderful feedback from those who have attended the training so far.  All clinicians trained have shared extremely positive feedback, saying they would highly recommend the training to colleagues. 

  • “This has been a very informative and educational session, most importantly this will be very beneficial for the local community and I look forward to an active engagement in the process” GP 

  • “Simplifying the referral process has been helpful” Nurse 

  • “A very good, educational session, even the role play! Clear and informative” GP 

  • “I think the course has given me some confidence asking patients about DV” GP 

  • “Interesting, interactive, lots to think about” GP 

  • “Happy to learn and have more information about DV” Receptionist 

  • “Brilliant training, best DVA training” GP 

  • “Lots of food for thought, good referral pathway” GP 

  • “Very Insightful, lots to learn” GP

Training is only one part of the IRIS programme and what makes it special is that it includes a simple referral and care pathway for clinicians to refer into a specialist worker, the IRIS Advocate Educator.  Since delivering our first training in practices, we have started to receive referrals.  Currently, we have received five referrals resulting in three women starting to access support and engaging with the Advocate Educators within their respective surgeries. While this is a good start, we will be continuing to follow up with practices that have had the training to promote engagement and encourage identification and referrals.  We will also be offering mop up training sessions for clinicians who may have missed clinical session one, as well as starting drop-in sessions in surgeries that received training.  As well as this, we will attend practice meetings to continue raising awareness about the IRIS programme.  

Recently an external observer, Dr Keerty Nakray from India, joined one of the training sessions. She hopes to take the IRIS model to Bihar in India and was very complimentary of our delivery, and the IRIS model itself. We look forward to following the progress of this project which the national IRISi team are leading on.  

For us at Advance, it’s all hands on deck to support clinicians and staff in trained practices to recognise domestic abuse in their patients, ask them about it and offer a referral.  Coupled with this, we will continue to train the remaining surgeries in RBKC. Onwards and upwards! 

Improving the health response to domestic abuse in Blackpool

The IRIS model is a domestic abuse training, support and referral programme for GP practices. The practices are given training and referral pathways to specialist domestic abuse agencies. It is a model of best practice and has been found to be effective in increasing referrals to domestic abuse agencies from trained GP surgeries. In this blog, Clare, an IRIS Advocate Educator (AE), reflects on the three months since the IRIS programme launched in Blackpool after several months of planning with the Pathfinder team, colleagues in health, the local authority and specialist VAWG sector.

28th May 2019 Blackpool began its IRIS training.  

Following the 3 days training from Mel and Hazel from IRISi, we were raring to go and we went live on Monday 3rd June 2019!  

Since then we have been raising awareness, letting people know who we are and promoting the IRIS model to our 18 practices, with the aim of improving GPs’ response to domestic abuse for the 165,000 residents of Blackpool. 

With an abundance of safeguarding experience and passion behind us we were off! 

By the end of the first four weeks, 11 practices had signed up to the IRIS model. By week eight, 16 practices had signed up and 14 training sessions had been delivered! 

With this, the referrals started to come in. 

The training and the IRIS model were very well received, and we were overwhelmed by the openness and willingness of the Blackpool practices to embrace this new offer.  

Feedback we received included: 

  • Excellent service, excellent delivery of training, approachable staff 

  • Very useful, informative and a much needed service, great job  

  • I hope this service continue and doesn’t have funding pulled in the future. There is a big need for support for these people  

We are now on week 15. 23 training sessions have been delivered; over 150 clinicians and practice staff have been trained; 19 direct referrals have been made and 13 women are currently receiving advocacy support from the Advocate Educator (AE).   

Working in the same office as our clinical lead and being a part of the Safeguarding Team in has been fantastic and possibly a key to our success so far.  

We have been looking at ways of to ensure our whole workforce and other key stakeholders are aware of the project. So far, we have presented at a Fylde Coast Women’s Aid conference, a health visiting forum, the midwifery forum and the district nursing forum.  

Dates have been set to inform all immediate response police officers about the service so they can inform victims of pathways of support via their general practices.  

Case Study: 

An elderly woman had presented at her GP practice a significant number of times for various medical reasons. She had also mentioned having issues in her relationship. 

Her GP was trained by the IRIS team and within days of being trained the GP was able to recognise the signs and symptoms of domestic abuse.  She made a referral into the local IRIS service. This patient is now receiving support at the surgery from the Advocate Educator.  

“I just wanted to say thank you so much.  It sounds stupid but you have helped me a lot, being able to talk to someone who understands. Today was brave for me. Being able to face how I am feeling, so a massive thanks” - Patient

We have visited IRIS sites in Bolton and Manchester and have found this hugely helpful; they were welcoming and approachable. The national IRIS networking event run by IRISi in Birmingham was also extremely beneficial to building relationships with our closest IRIS sites.  

A successful start.  Here’s to the next 6 months.  

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Best practice responding to domestic violence and abuse in primary care

Annie Howells is the Programme Director for IRIS. The IRIS model is a domestic abuse and violence training, support and referral programme for GP practices. In this blog Annie reflects on the best practice in responding to domestic abuse in primary care. 

We know that domestic violence and abuse (DVA) is a major public health problem with devastating health consequences for women, men and children. DVA has far-reaching consequences for families and communities and is an enormous cost to the NHS. The NHS is often the first point of contact for people who have experienced violence and the response they receive is critical. In fact, the initial reaction of the person they tell and the follow-up within and beyond the NHS can have a profound effect on their future and can impact on their ability to re-establish their life. It is clearly essential that primary care responds to and helps prevent further DVA. So, what should this response look like? 

To begin with, primary care teams need training, not one-off training but on-going training and support that provides information, resources and practical tools for the whole team. This enables clinicians to recognise the signs of DVA, to start making sense of patients presenting symptoms and begin to understand the potential reasons for repeat visits to the surgery: 

“By becoming more aware of the signs and symptoms that suggest abuse…I became much more aware of patients who were living with abuse and the negative impact that this was having on their health outcomes…the penny drops” - GP on the IRIS programme  

To respond appropriately is having the knowledge of how to ask patients about their experiences of DVA in the first place. Through training and on-going support, clinicians gain essential skills in how to ask direct questions about patients’ experiences of DVA. It also prepares them to be ready to hear the answer and to give supportive key messages to patients when they most need it. We know that clinicians want to support their patients affected and so we need to be providing tools and resources to enable this. 

A best practice response clearly includes offering patients a referral to a specialist, independent, DVA service. The more knowledge the primary care teams have of this service the better. Following simple care pathways, which must account for children and risk, appropriate support can be accessed for survivors and perpetrators. Primary care is a busy place and the simpler the referral process the more accessible it becomes. A referral to a named advocate within a specialist service is better for everyone; the clinician, the advocate and most importantly the patient. The advocate can then walk alongside the patient and provide the specialist support they deserve. 

An embedded relationship between the health sector and specialist DVA sector is essential for primary care to respond appropriately to DVA. Working together enables an on-going conversation, a consistent partnership approach that puts patients at the centre. This is integral to delivering a best practice approach, it allows for experts in the right places making services accessible and making a difference to the lives of people who really need it. 

"I just cried. I was just so relieved that somebody, that somebody just said something. And he (the GP) gave me the box of tissues and I just sat and cried and cried and cried. And he said, 'Tell me when you're ready.' And I poured it all out and that's when he said about the specialist worker. He said, there is somebody out there to help me. I'm not on my own. And if I want help, it's there and not to be ashamed of it. Which I was, really ashamed of it. And he said, 'You're not on your own. We can get you this help.' And he did. He really did."  - Survivor who disclosed to an IRIS trained GP

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Medical Power and Control Wheel

Mel Goodway, National Implementation Manager for IRIS, explains the Medical Power and Control Wheel, guiding and informing healthcare professionals of the importance of responding appropriately to victims and survivors when disclosing domestic abuse. This is part of the GP Pathfinder profile

See the Medical Power and Control Wheel.

Developed by the Domestic Violence Project in Duluth, Minnesota, the Medical Power and Control Wheel displays some of the ways in which healthcare professionals may unintentionally respond poorly to disclosures of domestic violence and abuse (DVA), collude with perpetrators and therefore increase risk, and impact the safety of the victim.  

The aim and primary use of this wheel is to guide and inform healthcare professionals of the importance of responding appropriately to victims and survivors when disclosing domestic abuse. The wheel provides examples of negative or harmful responses that may be given by healthcare professionals in response to a disclosure. A simple summary would be to say that it gives a ‘what not to do’ guide on how to communicate with a victim following disclosure. 

For example, the wheel looks at the importance of only speaking with a victim or survivor when they are alone and understanding the risk and impact of breaching confidentiality and taking the circumstance out of the patient’s hands. Additionally, it warns against asking if the patient has considered leaving the relationship or advising what they could change about their behaviour to ease the situation.

The Medical Power and Control Wheel gives these as examples of harmful responses to help healthcare professionals understand the impact this can cause a victim. We know victims and survivors trust healthcare professionals to respond to their disclosure appropriately and know how to support them following this. The above responses convey to a victim a lack of understanding about their circumstances and places blame on them for not having done something about it.  

The wheel itself is an adapted version of the Power and Control Wheel, created by the same organisation. Produced and distributed by National Centre for Domestic and Sexual Violence, the Medical Power and Control Wheel is widely recognised and used frequently within DVA training for healthcare professionals. The wheel, used in conjunction with other materials, is part of the training provided by the IRIS programme to General Practitioners across the country.  

A review of the common trends found amongst DHR’s (Domestic Homicide Reviews) completed by the Home Office stated the following in relation to healthcare professionals:  

“There have been cases where victims had made disclosures, but they had not been followed up or referred on to the appropriate agencies. In some cases, the review has stated that the healthcare professional had not known what to do when a patient disclosed domestic violence.” (Domestic Homicide Reviews Common Themes Identified as Lessons to be Learned, Home Office 2013.) 

Additionally, the research found that the crucial dynamics of power and control central to domestic abuse were not being recognised. In turn this led to a lack of  understanding about coercive control, something considered as a key risk indictor within DHR’s. As such, the use of this wheel within training is best done when in combination with the power and control wheel, along with a clear explanation as to why these responses are dangerous and damaging to victims.  

We know that healthcare settings are frequently attended and used by women experiencing domestic abuse. Additionally, for many women this is the only safe place to disclose, or the first professional to see them following an abusive incident. As such, it is integral that healthcare professionals know how to appropriately and safely respond to disclosures of DVA. Failure to do this can leave the victim feeling to blame for the abuse, unlikely to disclose again and potentially at greater risk of harm. The Medical Power and Control Wheel helps address this and ensure safety, validation and support for the patient are provided.