Background
The primary care response to DVA
Covid-19 and the transition to remote consulting in primary care
Methods
Sampling and recruitment
Characteristic | N (%) |
---|---|
Type of healthcare professional | |
Advocate educator (AE) | 7 (33) |
GP | 8 (38) |
Practice manager (PM) | 3 (14) |
Reception team (Admin) | 3 (15) |
Gender | |
Female | 20 (95) |
Male | 1 (5) |
Years spent working in sector | |
0–3 | 2 (10) |
4–9 | 9 (43) |
10–20 | 2 (10) |
20 + | 3 (14) |
Not specified | 5 (24) |
Data collection and analysis
Patient and Public Involvement and Engagement (PPI&E)
Ethics
Results
Theme | Sub-themes |
---|---|
Making general practice accessible for DVA care | Encouraging patients to come forward to discuss DVA |
Interface with external media and communications | |
Adapting triage processes for appointments | |
General practice team-working to identify DVA | Reception and administrative teams recognising DVA |
Collaborating within the practice to identify DVA | |
Using external information to identify DVA | |
Adapting to remote consultations about DVA | Arranging consultations safely |
Identifying cues for discussing DVA remotely | |
Transitioning from remote to face-to-face to facilitate disclosure | |
Experiences of onward referrals for specialist DVA support |
Making general practice accessible for DVA care
Encouraging patients to come forward to discuss DVA
Just the absolute fear of people not coming forward about domestic violence, and also their increased risk of domestic violence during the pandemic. We have all been really concerned about that. And the concerns at the way we have been asked to consult. And the fact that people were told not to bother their doctors about things was my main concern GP6
People that would normally think, “Right, actually, this is becoming quite risky because you are not acting in a way I would want, and the children are seeing things they shouldn’t do.” But it is that fear of being on your own as well because people are quite anxious because of COVID (AE1)
I remember guiding our admin staff to post lots of information on our Instagram page, we updated our website with lots of DVA information on it. So, at any point along the way, at least it was visible, what to do, where to go, how to contact...replacing the waiting room information (GP2)
Interface with external media and communications
… I know it's because, as I say, they advertise in the media, TV, GP series [TV programme about GP practice], about abuse and they're maybe identifying it themselves... I think doctors are thinking more about it because it's been on the news that it's more likely to be happening. GP7
Adapting triage processes for appointments
We had to divert to online consultations as well where they would fill in a form. And, again, if somebody is being controlled at home, they’ll have access to that. So, they couldn’t be honest in those forms either. So, we would never know unless somebody walked through the door really (PM2)
But in relation to the domestic violence, a lot of people that perhaps used to come to the doctors with a minor thing to, kind of, create a situation where they could disclose something, they couldn’t because… We were doing telephone triaging and we were doing telephone consultations, but their partners tended to be there. So, they couldn’t say what they needed to say.So they might have come in because of their bad back and then you end up talking about, you know, historical or contemporary domestic abuse or domestic violence. There isn’t the same opportunity for that to occur in lockdown because you are not sitting there in the room, in a place of safety.GP1
And they might come up with, “Oh, I’ve got a cold.” We would just say straightaway, “Well, you can’t come in.” Because it could be COVID. But that could be the cover story and the receptionist is not going to know that and neither is the doctor PM2
The other good thing with the pandemic is though, that you can actually without causing too much alarm or upset, you can ask the partner not to come in.” (Admin1)
General practice team-working between clinicians and administrative staff to identify DVA
Reception and administrative teams recognising DVA
Because this young lady didn’t pick her prescription up on the one week, her weekly prescription…And she was highlighted as a very at-risk patient, for historical domestic violence….[] So, I relayed that back to the doctor and she went and did the visit. And she has actually gone into a refuge now, a fortnight ago. Admin 3
It starts with having the IRIS information, the website, having the posters up, so creating that… You know, making sure that the admin staff are trained around domestic abuse to create that practice that becomes a safe space. Initially, when the woman walks in, she can see that, “Okay, this is a place where I can talk about domestic abuse.” (AE2)
Collaborating within the practice to identify DVA
We feedback to each other. And it might be that nothing comes of it…. So, everybody in the practice is aware of that person. So, if they do ring up, we’re more aware, the girls on reception would be more aware of that phone call and would perhaps not be dismissive of it and try and treat it a bit differently to others. (PM2)
The doctor actually sends us messages, to say, “Keep an eye on these names.” So, they’ll send us a message to, if we see anything, let them know. So, we’re working more together now. (Admin3)
Using external information to identify DVA
Upstairs in the offices they’re pretty good at picking up on the latest information that’s out there and then kind of passing it down, and then we kind of adapt it, we have sort of weekly meetings with management, with the leads and things like that and we discuss how we’re going to do it or what we can do. If it was something domestic violence related, we would just give them a same day appointment. (Admin 1)
[T]hat is how the practice does it. They ask to put the information on that manage button so everyone in the practice is aware, so if they ring up for an appointment you can see, “This patient could be in danger of domestic violence. Please make sure you give an appointment,” so they get an appointment that day. But they wouldn’t be fobbed off. They wouldn’t be told, “No, we haven’t got anything for you.” We would ask the duty GP and get them in on that day. PM1
Adapting to pandemic consultations and recognising DVA
Arranging consultations safely
You are talking to someone on the phone and there might be an abusive person in the background. How are you as the patient going to reveal something to the GP? Where is the trust, where is the security? So, I think this has all changed. The opportunities to detect abuse and violence have been diminished (GP1)
I actually said to the woman, “Just tell me a yes or no answer. Are you able to speak?” and the answer was, “No.” It was like, “Right, okay. Let’s arrange a time when you think you are going to be on your own, that you can speak.” (GP5)
Identifying cues for discussing DVA remotely
I found myself having to be a bit blunter in some ways in the questioning. Because patients have not really picked up on my non-verbal communication either. So, yes, it has been tricky, harder to pick up on the cues and harder to bring them up. (GP5)
You’re looking at the tone of the voice. Do you feel that they’re not answering your questions in an easy manner? Is somebody in the background telling them what to say? Is what they’re saying quite almost short answers that they just seem to be not easy with discussion, that you’ve got a feeling that just, something isn’t quite right because obviously, it’s difficult on telephone. (GP8)
Not that I am saying we would ever purposely ignore bad or domestic violence, but like I said, do we end up going that extra mile to that person that really needs it? (GP5)
[T]he groups that don’t speak English. For me, it’s pretty impossible, if I’m honest. By the time you pick them up as a patient and sorted out a telephone interpreter, you’re already probably, 20 minutes into the consultation. Then, you’ve got to then speak to them through the interpreter.They, for me, would be very, very difficult. Even as a doctor, to have the patient centre resolve what they’ve actually rang up for, pick up the cues, question more on that. It’s a very patient doctor, who’s got a lot of time on their hands, that can push on that. [] houses that are full, jam-packed, of family members. When are you going to get a room, a quiet room where there’s nobody else in the room when you’re talking to them? You’ve got a family member that’s there in the background, interpreting and you’re trying to talk on their behalf. It’s difficult GP8
Transitioning from remote to face-to-face to facilitate care
For example, if a patient calls about feeling overwhelmed or mood, then we always ask about, “Who is at home with you? […] “Who do you live with? […] If they say, “I live with a partner,” I just, very non-judgmentally, say, “And everything is okay between you and your partner?” (GP3)I am just talking about those no answers or those subtle cues for patients who have not called to report that, but that is something on their mind. Maybe those are the ones which might not divulge it as much. (GP3)
[I]f I was suspicious of DV, they'd be coming in. And I would be discussing and supporting, if need be, reviewing every week, depending on the level of risk…. So I just said, “If anybody asks you, it's for a female examination. And I can't do that over the phone, and I can't do that visually. So, I can check, I think it's best you come in. Certain clinical conditions cannot be done on the phone.”GP2
I’ve been a GP at this practice for a few years now. Some of the people, I may have already known and know a face due to previous consultations pre-pandemic. That, in terms of rapport, is easier than if you’ve never, ever, ever, laid eyes on them and never interacted with them before. (GP4)
I said to her, “How are you getting on?” She said, “My benefits came through.” Then she burst into tears and said, “But he took all my money.” “Threw coffee at me”. So, then I had a word with [name of GP] and it was a referral, and it was different other things. … []..before she may not have said anything, because she might have just- she probably would have thought, “How can I go to the doctors and ask for that?” (Admin 1)
[A]s a GP, remote consultation is lovely. It’s a great change to my week and my working week, around the kids and all that kind of stuff. It’s fabulous. You don’t feel part of the practice, necessarily. You’re quite isolated on your own. So, you probably don’t have the same chats with your colleagues and all that kind of stuff, that you would normally do.GP8
There are doctors all over the place now, which has been really promoted because of what happened over COVID, that are now working remotely and there’s none of the training. There’s nothing, at all, to do with domestic abuse. If you think of how hard it is to know what cues you’re looking for and what you do and what you do say and what you don’t say and all that kind of stuff. I think it’s just missing a massive, massive, huge proportion of remote workers now, that haven’t had that training (GP8)
Experiences of onward referrals for specialist DVA support
Whether it’s pre-pandemic, mid-pandemic, or post-pandemic, it is just fill in a form, get it sent across. (GP4)
We’ve found that quite a lot of people are disclosing [to support services] more quickly. […] So, they are telling us more and they can do that sooner on in the process... Because we are remote and because it’s easier for people to be up-front about stuff, I think we have had a lot more disclosures of sexual abuse and serious physical abuse, sooner in the process than we normally would (AE4)
By the time that they do report the abuse has it got to the point where it is high risk when they are at the point where they think, “No, actually, something horrendous is going to happen here” (AE1)
Discussion
Summary
Comparison with existing literature
Strengths and limitations
Implications for practice and research
•It is vital to establish whether the person can speak freely and safely; have a low threshold to arrange to speak to people alone, including arranging repeated calls or face-to-face appointments at a time which the person chooses |
•You can create non-verbal opportunities for help-seeking, for example having posters in reception areas and consulting rooms that patients can look at to signal to a member of the GP practice team that they have a need for a conversation at a safe time |
•Access to primary care consultations can be difficult to negotiate. Consider accepting a simple request such as ‘a need for a face-to-face’ appointment, without questioning. Requiring requests for appointments in writing, including through online triage, can be a barrier to care, as this may not be safe or private for the person |
•While recording DVA in medical records can be an important tool for promoting safety, this is not without potential risks and complications (e.g., perpetrators trying to access victim’s medical records). Practice team awareness of these risks and the development of safe and confidential strategies and systems when communicating as a GP team are essential |
•Kindness, and developing trust and rapport enable care for people affected by DVA; continuity of care supports this and can be actively nurtured |