A primary care response to domestic abuse from research to mainstream: the IRIS story Gene Feder Domestic abuse summit 2018 London 4 th May 2018
Constance 43 year old care worker who had been my patient for 5 years. Two sons, James (13) and Tyrone (4). Partner was Tyrone s father.
Specific health sector response Domestic violence is a violation of human rights and a society-wide challenge, particularly to the education and criminal justice system. Why do we need a specific health care response? health impact of domestic violence survivors expectations of doctors evidence for effectiveness
physical health consequences (Coker et al, 2009, Coker et al, 2000) Survivors experience a range of chronic health problems including: chronic pain increased minor infectious illnesses neurological symptoms gastrointestinal disorders raised cardiovascular risk gynaecological problems
mental health consequences (Howard 2013, Golding 1999)
risks to children s physical and mental health pre and post-natal risk foetal distress, preeclampsia, low birth weight all forms of maltreatment 41% overlap with direct maltreatment long term behavioural and mental health problems
What do survivors want from doctors? before disclosure/questioning try to ensure continuity of care make it possible for women to disclose ask about (current and past) abuse when issue of partner violence raised don t pressurise women to fully disclose immediate response to disclosure ensure that the women feel that they have control over the situation, and address safety concerns response in later consultations understand the chronicity of the problem and provide follow up and continued support
a certain kind of evidence epidemiology systematic reviews and meta-analyses RCTs + nested qualitative studies & economic analyses guidelines and policy
(some) evidence of effectiveness system level programmes that improve: identification of victims of violence in health care referral to violence support/advocacy and trauma-informed psychological services individual support/advocacy and psychological interventions can reduce further violence and improve health outcomes
general practice
primary care at the centre Secondary and tertiary care Community General practice Social care
IRIS study Identification and referral to Improve Safety
IRIS model Training and support + referral pathways including safeguarding children and adults + Medical record prompts + Recording and flagging system + Advocate educator + Practice champion Health education material + Clinical enquiry + Validation + Documentation + Immediate risk check and safety assessment Identification + Referral Advocacy Emotional & Practical support Less abuse improved quality of life + mental health
crucial partnership with domestic violence advocacy organisations advocate educator specialist referral service link to local domestic violence fora and coordinated community response
Does IRIS work? cluster randomised controlled trial 1 year follow up 48 general practices in Bristol and Hackney 2007-2009
IRIS trial results
(very) cost-effective NHS cost savings of 1.07per woman per year, equivalent to UK 3155 per practice per year societal cost savings of 37/woman/year
beyond the ivory tower
translation into policy cited in Department of Health Violence Against Women and Children taskforce report as an exemplar programme cited in WHO partner violence guidelines as evidence for recommendation on training interventions part of NICE domestic violence guidelines evidence review cited as a particularly effective remedy by the Task and Finish Group for the Welsh Government s proposed Ending Violence Against Women and Domestic Abuse (Wales) Bill
commissioning guidance
Current IRIS sites Scotland Northumberland Scotland sites: sites: - Borders - Edindgurgh area - Glasgow area - Lanarkshire - West L:othian Cumberland Durham Westmorland North Riding Lancashire Yorkshire West Riding East Riding Bolton Salford Manchester Trafford Lindsey Mansfield & Ashfield Cheshire west East Cheshire Cheshire Derby Vale royal and South Notts Cheshire Lincoln Nottingham west Nottingham City Kesteven, Wales Shropshire Hereford Stafford Leicester Birmingham Sandwell Warwickshire Worcester Rutland Northants Bedford Holland Huntingdon And Peterborough Cambridge West And Isle of Ely Norfolk Suffolk East Cornwall Devon Cwm Taf Somerset Dorset Gloucester Oxford Hampshire Bucks Cardiff and the Vale Bristol South Berkshire west Berks North Somerset Gloucester Wiltshire Bath and North East Somerset Reading & Wokingham Hertford Greater London Surrey East Surrey Sussex Southampton West Portsmouth Poole Isle of Wight East Essex Kent London sites: - Hackney - Lambeth - Enfield - Camden - Islington - Tower Hamlets - Bromley - Lewisham - Southwark
Continuing effect?
Interrupted time series results IRIS increased the rate of referrals by: 30 times
IRIS into practice commissioned by CCGs and local authorities in 32 English localities and 2 Welsh health boards 56 advocate educators and 48 clinical leads trained in England > 1000 general practices trained Total IRIS practice referral to specialist agencies is > 12000
What about men?
European collaboration
global collaboration
unresolved issues tip of iceberg identification and referral of women survivors Improving outcomes for survivors and families information sharing agency vs safeguarding increasingly porous consultation poor evidence for health engagement of men as victims or perpetrators
Constance Contacted nia project in Hackney Given refuge and moved away
Thank you to survivors to their families to colleagues to funders