Domestic violence and abuse – GP Tips
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?
“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.
·
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
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 Med 2012:367;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.
Resources for patients
