Simon Stevens when talking last week about the ways in which the NHS can use the new compact to work to reduce inequalities, spoke about several groups with which we need to create different and more active relationships. Tomorrow I will discuss one of these – the homeless – but today I want to highlight how the NHS can play a bigger role in the care of victims of domestic violence and abuse.
Over the last few months I have been hearing a number of GPs tell me that they are gaining a better understanding of the long-term impact of trauma upon their patients. In one practice they found that when they looked at patients who made constant use of A and E very many of them were long-term victims of trauma. Much which may have happened in childhood. (Recently I wrote about the Children’s Commissioner’s report that talked about 103,000 children growing up in families where their parents had a combination of mental illness, drug or alcohol addiction, and abuse. It is very likely that these children would experience the impact of trauma on their health for the rest of their lives).
What GPs find is that there is a very wide spread of health conditions that can emerge as a result of earlier trauma. Mental health conditions would be expected but the list also includes musculoskeletal disease and a wide range of experiences of different sorts of pain.
From the NHS’ perspective many patients come to consult their GP about a range of different conditions, but in very many cases the GP is unaware of the underlying trauma that is having such a big impact on their lives. For many it is a secret buried within them that they don’t want to acknowledge or talk about. Yet it has a major, ongoing impact on their physical and mental health.
A traumatic childhood is only one of the experiences that can affect mental and physical wellbeing. Others are more contemporary. Domestic violence and abuse is one of the more significant. Those abused over a long period of time within their homes will not only have to cope with the violence and abuse but will also have the experience of being trapped with it for many years – with no prospect of escape. This compounds the impact by normalising a non-normal experience as being part of the pattern of your life. By internalising abuse as an everyday experience the victim makes fear and anxiety just a normal part of who they are.
Such an experience will have a big impact on your mental and physical health – beyond the physical bruises and broken bones. If GPs know this is happening to their patient that knowledge could play a significant part in their making a wider intervention to deal with each physical and mental ill health issue as it comes along.
To achieve this objective the NHS needs to recognise two things – both how important a part it plays in people’s lives and how limited is its knowledge and capacity for working with people who are experiencing this domestic violence and abuse.
On the one hand we are vital to the improvement of such patients’ lives – on the other we are neither good at spotting the trauma in the first place, nor are we the organisation that can help people work to improve their lives.
Since 2012 Manchester City Council public health have been working with the NHS to commission Manchester Women’s Aid to work with victims of domestic violence. (DVA). DVA is a public health issue and its right for the NHS, through its public health arm, to commission organisations with expertise in working with – mainly women – who suffer it.
But in Manchester they have gone further and involved the NHS beyond its public health arm. With funding from Central Manchester CCG in 2015/6 and additionally from City Safeguarding they have facilitated all GP practices in Manchester to undertake training on DVA and thereby increase awareness of resources in the city for referrals.
This training and this resource is based on the IRIS model which is,
“a general practice based DVA training support and referral programme that has been evaluated in a randomised patrolled trial. Core areas of the programme are training and education, clinical enquiry care pathways and enhanced referral pathway to specialist domestic violence services”
IRIS offers training for GPs and the practice nursing team in each practice. The IRIS service is delivered by specialist domestic abuse workers called IRIS advocate educators. These are employed by Manchester Women’s Aid. IRIS not only trains the practice but provides the referral service to patients. In the year between April 2016 and March 2017 IRIS received 481 referrals from GP practices across the city of Manchester. As with most DVA this is nearly all women. In this group 9 were men.*
Through this process the GPs are able to provide very considerably additional help to nearly 500 of their patients. They achieve this through two additions to their normal skills and pattern of work.
First they are trained in looking for and discussing with their patients domestic violence and abuse. Some people who have been suffering this become expert at hiding their experience and can do so for many years. As I suggested above they present with a wide range of different mental and physical illnesses – some they themselves link to DVA but some they do not. Their GP needs to be able to recognise the links between certain types of physical and mental illness and to find a way to begin the discussion with the patient about the possibilities of their suffering abuse. This is never an easy conversation which is why both the GP and the practice nurse need training.
Secondly the primary care team also need to recognise that they will not be able to provide the expertise or potentially the services to assist their patients with the next steps they will need to take. Women’s Aid organisations have decades of expertise in working with sufferers of DVA. GPs need to know they can refer people with confidence to this specialist voluntary sector organisation.
The purpose of this example is first to show that partnerships between the NHS and voluntary sector organisations can work to considerably improve the lives of patients. We have examples of how to do this In a range of areas. These need to be on offer to a much wider population. The principle equal access for all free at the point of need that we were celebrating earlier this month demands that these services are spread across the country.
Second – when the NHS works with specialist voluntary sector organisations we can often deal with the root causes of the ill health that patients bring. On its own the NHS can do little about these root causes and we are left dealing with symptoms. By working together with civil society (and sometime other parts of the state) we can be much more effective.
Third – this is a core part of NHS work and the NHS needs to pay for that core work if we are to successfully help patients
Fourth – together with the voluntary sector we can show that there are no ‘hard to reach groups’ where the NHS offer cannot help.
If as a society we are to confront and deal with inequalities the NHS has a big role, but will only succeed with a great deal of help from civil society.
*A report on this work with older people who had suffered abuse and the IRIS work team has been published jointly by the Sustainable Housing and Urban Studies Unit at the University of Salford and Manchester Women’s Aid The IRIS Project