Training GPs to identify domestic violence leads to dramatic increase in finding victims

A training programme that teaches GPs how to identify domestic violence and abuse (DVA) victims has led to a 30-fold increase in DVA referrals, according to a collaborative study of 205 general practices led by Queen Mary University of London, in partnership with the Centre for Academic Primary Care, Bristol Medical School.

Across the world, 'lockdowns' in response to the COVID-19 pandemic are putting women at increased risk of DVA. In England, the National Domestic Abuse Helpline, run by Refuge, has seen a 50 per cent increase in calls compared to pre-COVID-19, along with a 400 per cent increase in web traffic

In most settings, including high-income countries, healthcare is still not responding adequately to DVA. The World Health Organization, National Institute for Health and Care Excellence (NICE) and Department of Health and Social Care have called for greater health sector involvement in helping those affected.

IRIS (Identification and Referral to Improve Safety) is a training and support programme to help primary care teams identify and refer women affected by DVA. It involves training the whole primary care team at GP practices (GPs, nurses, practice managers and healthcare assistants and ancillary staff) in identifying DVA in their patients.

This includes adapting electronic medical records to prompt health workers to ask further questions about DVA, when presented with clinical conditions such as depression, anxiety or injury. The programme also includes a simple referral pathway to a named DVA advocate, ensuring direct access for women to specialist services.

The latest research, published in the journal BMC Medicine, looked at 205 general practices across London over four years. It compared practices in four London boroughs which had implemented the IRIS DVA training and referral programme, with general practices in a fifth borough which only had a stand-alone education session.

The study found that the benefits seen in the 144 practices receiving the full IRIS DVA programme were substantial, increasing DVA referrals 30-fold, with no increase in the 61 practices in a comparator borough. IRIS also led to a 27 per cent increase in new identification of women affected by DVA in the implementation borough, but not in the comparator borough.

Beth, who used the DVA service as a result of the IRIS programme, said: "IRIS were the first people to get right into my life and begin to make that difference. I had stressed repeatedly about what was happening to many professionals in the past but no-one could really help to make it stop. By the time IRIS became involved I was exhausted. My Advocate Educator was incredible, so knowledgeable, patient and intent on transforming my stuck situation. I will always feel beyond grateful to her and the team at IRIS for giving me the freedom I have now. The children and I are now safe and happy. It feels amazing."

Study lead Dr Alex Sohal from Queen Mary University of London said: "This new work shows that implementation of the IRIS programme surprisingly remains highly effective at scale in day to day general practice. It allows GPs to engage constructively with DVA rather than turning their back on this vulnerable group of patients."

A previous smaller randomised controlled trial in London and Bristol found IRIS to be very effective in identifying and referring women facing domestic abuse. The IRIS programme has been funded in 41 English and Welsh sites, but in one quarter of those, funding has since stopped despite the programme being effective

Co-author Professor Chris Griffiths from Queen Mary University of London, said: "Health commissioners can now commission this programme with the confidence that it works in practice. IRIS can help GPs respond to the increased needs of women during COVID-19. Our work shows that the Mayor of London's recent investment in rolling out the IRIS DVA programme across a further seven London boroughs is an excellent use of resource. Boroughs and Violence Reduction Units across the UK should follow this lead."

Professor Rosalind Raine (Director, NIHR ARC North Thames) said: "We were delighted to be able to fund this research, which has profound implications for women and their families in great need. Our findings are timely given the new Domestic Abuse Bill in which the Government has committed to investing in domestic abuse training for responding agencies and professionals."

Co-author Professor Gene Feder of University of Bristol said: "This is a landmark study, showing that an evidence-based DVA programme commissioned within the NHS is effective and sustainable in general practice. Our findings strengthen the case for the implementation of IRIS across the whole NHS and further development of a global primary care based response to DVA."

The social enterprise IRISi, who work to improve the healthcare response to gender-based violence, have recently been helping GP teams to continue to respond to domestic abuse during the COVID-19 lockdowns, by releasing guidance on how to apply IRIS during telephone and video consultations with their patients.

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The study was funded by the National Institute for Health Research through the NIHR North Thames Applied Research Collaboration (formerly NIHR CLAHRC North Thames).

For support, call the Freephone 24-h National Domestic Abuse Helpline, run by Refuge, on 0808 2000 247, or visit http://www.nationaldahelpline.org.uk.

For more information, please contact:

Joel Winston
Communications Manager (School of Medicine and Dentistry)
Queen Mary University of London
j.winston@qmul.ac.uk
Tel: +44 (0)7968 267 064

* Research paper: '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'. Alex Hardip Sohal, Gene Feder, Kambiz Boomla, Anna Dowrick, Richard Hooper, Annie Howell, Medina Johnson, Natalia Lewis, Clare Robinson, Sandra Eldridge & Chris Griffiths. BMC Medicine volume 18, Article number: 48 (2020).

Available here: https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-020-1506-3

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