Evidence
Alert

Support programme for GP practices increases referrals for domestic abuse

Many GPs take little action when they encounter women they suspect are affected by domestic abuse. A training and support programme used by hundreds of practices across several London boroughs was successful in increasing referrals to specialist services, a study found.

The research shows that the right interventions can help doctors and nurses ensure that women access the assistance and support they need. This is especially important given that reported cases of domestic abuse have risen since the start of the coronavirus pandemic.

Specific training, dedicated staff, a prompt on the GPs’ screen when they access electronic medical records and a simple referral pathway to a named advocate are among the steps that help boost referrals.

Such interventions were put in place a few years ago in dozens of healthcare regions across England and Wales. The programme, called IRIS, was well-received. However, it remains a challenge to ensure that funding is sustained, and it has been cut in a quarter of the regions. The study provides compelling evidence that the programme works to help vulnerable women.

What’s the issue?

Busy GPs and nurses may miss the signs of domestic abuse when they meet patients, or be unsure how to respond or who to call. As a result, in many areas, only a handful of women are referred to specialist support services each year, despite 5.7% of adults (2.4 million) experiencing domestic abuse each year in England and Wales.

A decade ago, researchers ran a clinical trial that showed IRIS – Identification and Referral to Improve Safety of Women affected by domestic abuse – significantly increased referrals. It convinced many health commissioners to introduce the programme across more than 1,000 general practices.

But there was no evidence that the benefits seen in the academic exercise were also being seen in the real world. That made it difficult to argue that funding for the ongoing programme should be protected and extended. Women who have suffered from domestic abuse risk losing the help it offers.

What’s new?

The study analysed the number of GP referrals of women (aged 16 and over) for domestic abuse before and after they implemented the IRIS programme. It analysed data from 2012 to 2017 from 205 surgeries across five northeast London boroughs. Four of the five boroughs had implemented and funded IRIS following the successful trial. The fifth did not use IRIS and instead invited doctors and nurses to attend a domestic abuse education session. It was used as a comparison.

The results showed that IRIS significantly increased referrals. Over four years, the 144 general practices in the four boroughs that used the scheme saw a 30-fold increase in referrals for domestic abuse. The 61 practices in the fifth borough saw no increase in referrals. The study also showed an increase in the identification of new domestic abuse cases in IRIS surgeries.

The study authors say the increase in referrals and recorded cases is largely due to the staff mix. IRIS advocate educators are specialists in domestic abuse, employed by a local abuse service. They work in partnership with administrative and clinical staff in the IRIS surgeries, and link the separate worlds of primary care and specialist domestic abuse services.

Why is this important?

The study shows that the IRIS programme works as well in the real world as it did in the original clinical trial. That is unusual in primary care research, where benefits seen in studies often melt away when exposed to the harsh realities and priorities of overstretched surgeries. The data offer strong evidence that the investment in IRIS is worth it and will reduce costs in the long run. This could help healthcare commissioners when considering implementing the programme in their regions.

The 30-fold increase in referrals for domestic abuse in the boroughs that introduced the scheme mean that many more vulnerable women are getting access to the help and support they need. But the number of referrals is still small compared to the amount of domestic abuse known to occur. Since the start of the coronavirus crisis, the National Domestic Abuse Helpline, run by Refuge, has seen a 50% increase in calls and a 400% increase in web traffic.

The success of the programme could also focus attention on other ways to address this problem.

What’s next?

The study shows that IRIS leads to many more women who experience domestic abuse being referred to specialist services. But it does not show what happens next. Further research is needed to gather evidence on the benefits to health at the population level of schemes including IRIS.

Efforts are under way to broaden the scope of the IRIS project, extending it from doctors and nurses in general practices to other primary care settings including pharmacies, sexual health clinics and dental practices. The impact in those settings will need to be assessed.

The research is closely linked to Professor Gene Feder's ongoing abuse research at the University of Bristol, and his Global Health Group's work on health systems’ responses to violence against women in Palestine, Brazil, Nepal and Sri Lanka. That work is part of NIHR’s global health research programme, to deliver measurable benefits to patients and the public in low and middle-income countries.

You may be interested to read

The full paper: Sohal AH and others. Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme. BMC Medicine. 2020;18:48.

IRISi - a national, health-focused social enterprise working to promote and improve the healthcare response to domestic abuse.

The related cost-effectiveness paper: Barbosa EC and others.  Cost-effectiveness of a domestic violence and abuse training and support programme in primary care in the real world: updated modelling based on an MRC phase IV observational pragmatic implementation study. BMJ Open 2018;8:e021256.

The related process evaluation paper: Lewis NV and others. Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory-based mixed-method process evaluation. Health Soc Care Community. 2019l;27:e298-e312.

The related qualitative paper: Dowrick A and others. Boundary spanners: Negotiating connections across primary care and domestic violence and abuse services. Social Science & Medicine. 2020;245:112687.

 

Conflict of interest

Medina Johnson is CEO of IRISi.

Funding

This research was funded by the NIHR Collaboration for Leadership in Applied Health Research and Care North Thames at Bart’s Health NHS Trust.

Commentaries

Study author

One way of looking at this paper is that the number of referrals after IRIS is still small compared to the number of cases of domestic abuse we know happen. That is not surprising as most abuse is never shared outside the home. So while we can shout out about the 30-fold increase in referrals, someone else could rightly say it’s the tip of the iceberg. But it is a massive improvement on where we were before. The thing that has changed over the last ten years in general practice is that abuse is being recognised and coded. It is a medical problem and it affects health in lots of different ways. That is why we really need the long-term stable funding to start reaching those women we have missed so far.

Alex H Sohal, GP in Tower Hamlets, London, and Honorary Senior Clinical Lecturer at the Institute of Population Health Sciences, Queen Mary University of London

Study author

For many women visiting a GP who is not trained in IRIS, the signs are not picked up. Women experiencing domestic abuse will be anxious, depressed, have chronic pain and a whole load of physical and emotional symptoms that can be missed if the clinician does not know what to look out for, or does not relate those symptoms to domestic abuse. A woman might feel she is sitting there with a flashing light on her head saying ‘Ask me. Ask me’ but untrained clinicians miss those signs.

The pressures right now of home schooling, people being furloughed or out of work, can all add to what is already a challenging situation. For remote consultations, we need clinicians to ask closed and direct questions with yes/no answers. ‘Are you safe to talk right now?’ ‘Are you alone in the room?’ and so on. The answers to those questions will determine whether the clinician continues with the consultation.

Medina Johnson, CEO of IRISi, a national, health-focused social enterprise working to promote and improve the healthcare response to domestic abuse