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Wednesday 26 October 2016
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Suffering in silence

It can be hard to reach victims of domestic violence and it’s unlikely they will seek help. In Swindon a pilot has been set up so that general practices are in a position to help those unable to come forward

Domestic violence is an area in which the statistics are almost unbelievable. Horrifyingly, two women are killed every week in England and Wales by a current or former partner (Office of National Statistics, 2015).
Overall it is thought one-in-four women in England and Wales will experience domestic violence in their lifetimes and 8% will suffer domestic violence in any given year (figures from the Crime Survey of England and Wales, 2013/14). And Home Office research has found domestic violence has a higher rate of repeat victimisation than any other crime.
A recent (subs December 2015) report by Her Majesty’s Inspectorate of Constabulary found recorded cases of domestic abuse related crimes – including violent, physical, sexual, psychological, emotional or financial abuse – had increased by a third (31%) between 2013 and 2015. It is thought the rise could be partly due to better recording of such incidents by police and forces actively encouraging victims to come forward, as part of a “determined effort” by police to make domestic abuse a priority.
Yet domestic abuse remains a crime that police and health professionals believe is largely hidden – with victims mainly suffering in silence. Coupled with stigma and ignorance about what constitutes domestic abuse (eg, that it has to be physical or can’t be committed against men), considerable work is needed to ensure victims access and receive help and support.

A wider focus
Traditionally, domestic abuse support has taken place mostly in refuges run by domestic abuse charities after victims have left their homes, or through support and advice offered in settings run by specialist services. Now moves are being undertaken to take more support out into the community in a wider variety of settings.  
“Going into a refuge, which means leaving the area where they live, is not the best option for everybody, particularly when there are children at school or good family support in place that clients do not want to leave behind,” says Zoey Peather of Swindon Women’s Aid. A community outreach worker who used to work as a primary care administrator, Peather works with five GP practices in Swindon in a year-long pilot outreach scheme that takes Women’s Aid services directly into primary care.
After coming into post in May 2015, Peather chose the practices to approach about the project after examining the demographics of referrals to Women’s Aid refuges in Swindon. She also looked at where practices with people are known to have been a victim of domestic abuse on their patient lists. Based in locations with a geographical spread, the practices are based around the town, although two are in the SN3 postcode, which is among the most deprived in Swindon.
“When police attend a domestic violence incident they refer into health services and social services. But referrals into the service [Women’s Aid] were not coming from health professionals. In the baseline assessment we carry out with new clients we ask if they have discussed their issues with a health professional and I have met women who have been referred to us by GPs, but generally there is not enough of an ongoing relationship between domestic violence services and health care,” says Peather. “This is not just the picture in Swindon, but the national picture.”  
She adds: “There are numerous reasons for this. Women’s Aid is a charity and often GPs are used to working with funded services and don’t know what help is available to those suffering domestic violence. But there is a huge role that GPs can play.”

In practice
The outreach scheme consists of both providing a community-based advice and support service to patients in the form of drop in clinics in practices, which began in the autumn, and domestic abuse awareness training for practice staff and GPs.
“Ideally, training would be provided for everyone from receptionists to nurses to health visitors,” says Peather. “But it was important that this service is GP led.”
The training covers issues such as the types of abuse that domestic abuse can include, how it can present – it does not have to include physical violence – and can affect adults of any age. Face-to-face training for staff is planned for all participating surgeries.
Peather explains that patients may frequently visit a GP with seemingly unrelated problems such as digestive or bowel issues or depression and anxiety that may be caused by the stress of being in an abusive relationship.
“It may be as much about social and emotional problems as physical ones. But what tends to happen is that GPs treat the symptoms and not the cause. If we can raise awareness of domestic violence then health professionals can be helped to realise something is not adding up,” she says. “For example, do you never see this patient alone? That can then help aid disclosure.”   
Dr Karen Irwin, partner at Abbey Meads Medical Group, Swindon, agrees that GPs may not feel comfortable referring clients on to services such as Women’s Aid but says it works well when such a service can come directly to a practice. “GPs are very good at dealing with clinical issues but often patients need advice and reassurance on these sort of social issues, which as GPs we can’t give,” she says.
Practice manager Cath Turner at Priory Road Medical Centre, Swindon, agrees. “The fact is, in a 10-minute consultation [with a GP] it can be difficult for patients to talk about what is really bothering them,” she says.
“But as a practice we are trying to be more proactive in identifying those patients of concern and how we improve our communication with them about difficult issues, rather than finding out about them when secondary care gets involved.”
Sandy Jack, practice manager at Swindon’s Kingswood Surgery, says that currently domestic violence often only comes to the attention of primary care in the form of a police report after an incident.
“We intend to have all the staff –  from admin to GPs – trained in this, so they all have the same ethos when a patient is opposite them. We know how important the receptionists are for offering a good service and any of our staff can talk to Zoey [Peather] about a patient who might want to see her. It is about going over and above our baseline and accessing hard to reach patients,” adds Jack.  

The role of primary care
Referrals from additional services such as midwifery and health visiting could be crucial as around 30% of all domestic violence begins in pregnancy. Such services could also be a useful cover for women seeking advice on domestic abuse issues. At Swindon’s Hawthorn Medical Centre, the drop-in service is held at the same time as a midwife holds a clinic.
Practice manager Angela Brunning from Hawthorn Medical Centre,  Swindon, says participating in the pilot is recognition that primary care is increasingly functioning as an extension of social care.
“I like anything that aims to improve the care we provide for patients and as a GP practice what we provide is not just about primary health anymore. Providing services like the outreach is probably the way we need to be, in addition to the counselling, midwifery and physiotherapy care we offer in the surgery. It all impacts on the physical and mental health of our patients.”  
Practices participating in the scheme have put time and space aside for Peather to host drop in clinics where any patient can come and see her without an appointment, or where patients referred by practice staff can have a pre-booked appointment. Each practice advertises the scheme with posters and small cards available in reception for patients to pick up.
“A GP practice is a comfortable safe place and if someone is in a controlling relationship it may be one of the few places they can go alone,” adds Peather.
Basing the service in GP premises has been extremely beneficial in establishing relationships and encouraging practice staff in having confidence in referring patients to her, she adds.

One issue for practices hosting the scheme will be on how to measure the impact of the pilot.
Turner says that if a patient suffering from domestic abuse becomes known to a practice they will then be able to code them or their children as a ‘person in need of care and support’.
An increase in referrals to Women’s Aid will be another indicator.
Although several of the drop in clinics had already started seeing clients after just a few weeks, Dr Irwin has concerns that the pilot may not have enough time to become established and help as many patients as it could. “It may take some time for patients to feel relaxed about using this service and start self-referring.
“A service like this needs to be around longer term for everyone to feel the benefit.”

Emma Dent, freelance health reporter.