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Reaching victims in the home: training Wheatley Housing Group

Having trained in Youth and Community Work, Fiona McMullen worked in a Criminal Justice Setting for several years before joining ASSIST where she is now Operations Manager, responsible for Glasgow and Lanarkshire services and the Children’s Advocacy Service. Fiona is also an Associate Trainer for SafeLives, training the Crown Office and Procurator Fiscal Service, Housing and Health services, as well as delivering DA Matters, a culture change programme to train Scotland’s 14,000 police officers on responding to domestic abuse. In this blog, Fiona talks about training Wheatley Housing Group, and the unique position housing associations have in reaching victims of domestic abuse.        

When Lucy McDonald, SafeLives’ Programme Lead for Scotland, asked me if I would like to be involved in domestic abuse training for the Wheatley Group I was immediately interested.  Having worked in a large IDAA service for 15 years I’ve seen first-hand that housing can be a huge barrier for victims experiencing domestic abuse, often resulting in them being unable to leave high risk situations. The narrative around safety and domestic abuse is often centred on the victim leaving yet we should be asking why that is; when the least disruption is felt by the perpetrator. Strides have been taken in Scotland to link up the response to domestic abuse and the home and our housing associations play a key part. Housing associations are one of the few agencies that have legitimacy to be in the homes of victims and may be the only ones with any regular contact. They have the potential to identify ‘invisible’ victims of domestic abuse who may not yet have reported to the police.

Andrea, another SafeLives trainer, and I delivered several risk identification training days to Wheatley staff. Evaluations were positive, and the staff team were incredibly engaged, recognising the importance of their role and wanting to know more about how they could respond appropriately and safely. From those initial sessions came a request from Wheatley to roll out a one-day training programme to approximately 500 staff, using a Train the Trainer model. After collaboration with our colleagues in Wheatley, we decided on what would be important to include the key messages required to support the staff in their learning.

Engaging – I have not come away with ‘the fear’ which is the first time for at training on this topic. Thank you

As well as the face to face element of the delivery, SafeLives created an e-learning package to support the training, covering things such as the new domestic abuse legislation, risk identification and local support services.

The SafeLives team then produced a two day Train the Trainer package that would be delivered to both SafeLives domestic abuse expert trainers and selected Wheatley staff, giving them the opportunity to test the materials in a safe and constructive way. The innovate delivery model to Wheatley was set up for two trainers, one a DA specialist and the other a housing expert. This gave credibility to the training and modelled working in partnership. The trainers from housing knew first-hand of the challenges facing frontline workers and were able to answer questions and reassure them that they would be supported.

I was fortunate enough to deliver several of the days along with housing trainers and the whole experience was amazing. I initially felt there may be some resistance but instead I met enthusiastic learners keen to participate who truly wanted the best for the clients they worked with.  Word quickly spread that it was an interesting, participative training which will have helped with the levels of engagement we had. The training was designed to appeal to different learning styles with a mixture of presentation, small group exercises and skills practice. Anyone who has ever been a trainer will know not to call it roleplay!

The course is very real and gives you more confidence in how to support someone experiencing domestic abuse

In attendance were staff from different job roles within Wheatley – all of whom could come across victims of domestic abuse in different ways. This may be when the perpetrator is not paying the rent or regularly damages the property, or when the victim asks for a management transfer, or if there are noise complaints. All of these present the opportunity to ask the question, follow it up with risk assessment if appropriate, complete safety planning and referrals into other processes such as MARAC. Workers felt reassured that the multi-agency processes in place meant that they wouldn’t be managing high risk victims on their own. They also have an internal group protection team who are the ‘go to’ for anything that arises from the training or when they begin to put the approach into practice.

The face-to-face training was recently completed and we were delighted to learn that Wheatley Group had been nominated for a Chartered Institute of Housing (CIH) award for the learning around domestic abuse that came from the collaboration with SafeLives and the work we did together.  Housing staff have a unique role in working directly with adult victims, children and the person using abuse.  It’s a great step forward to be building on safe and informed practice when it comes to domestic abuse.

I got great advice and will help with my role as a Housing Official.

For more information on domestic abuse training programmes email training@safelives.org.uk.

Your story matters; let us listen

In this blog, two members of our Whole Lives Scotland team, Jen and Lindsay, explain why it is so important we hear from survivors across Scotland to inform our work. 

Have you experienced domestic abuse in Scotland? Your story matters; let us listen.

Scotland has much to be proud of when we talk about how we support survivors of domestic abuse. There is gold standard legislation that recognises the whole family impact of abuse, backed up with an informed and proactive police force. We have a network of passionate and skilled Women’s Aid and other domestic abuse specialists’ organisations providing first class support and practice, as well as ground-breaking research. But we can always do better. And it’s that desire from everyone working in domestic abuse, from policy to practice, to improve how we support survivors despite the immense challenges in trying times that makes Scotland special. And we can’t do that without listening. To partners and organisations, but most importantly, to survivors.

“I never went to the police, never went to the hospital.  I thought ‘I need to deal with this, I need to deal with this, I need to deal with this’. And although I knew who to access. I couldn’t do it.”

In 2018, SafeLives was awarded funding from the National Lottery Community Fund, enabling us to work with four local authorities in Scotland to help them look at what’s working in the area for victims of domestic abuse, and what could be better.

Here at SafeLives, we don’t carry out any frontline work. We use data and evidence to transform system wide responses to abuse, supporting practitioners and ensuring the voice of those with lived experience is at the heart of everything we do. For this project we’ve been speaking to practitioners and looking at statistics, reading strategy and policy and hearing first-hand from workers what is helping and what could be done better. We are also consulting with people who have lived experience, exploring this in workshops and focus groups. Some of them are carrying on this work with us in co-production groups, looking at our findings and the tools and resources we plan to offer each area in response, and helping us understand if we’ve got the right idea.

Hearing about someone’s experience of support is incredibly important. But what is equally necessary is to understand what happened for those who didn’t or couldn’t get help. We don’t think that people are hard to reach, we believe that for some it’s the systems that make it hard. 

In order to make sure we hear all voices; we’re running a national survivor survey across Scotland from the 15th of October for anyone who has experienced domestic abuse. It is completely confidential and will be used to build a picture for Scotland and directly inform what we do.

We’re asking – what did you need in those moments that wasn’t there? What made a difference to you? How can we make sure that those who need help get the right help at the right time?

“They were so supportive.  They had obviously seen all different areas of abuse, so they, I didn’t have to over explain myself. They got me.”

Complete our survivor survey

Find out more about our Whole Lives Scotland work 

 

 

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The importance of specialist mental health interventions for children experiencing domestic abuse

Janina Engler-Williams is a Research Analyst at SafeLives. In this blog she explores our Children's Insights dataset, and what the data shows about the benefits of specialist mental health support

The link between mental health and domestic abuse is one that is both crucial and complicated. As highlighted in our seventh spotlight, domestic abuse often has a long lasting and damaging effect on the mental health of survivors. Anybody can be affected by abuse – just like anybody can experience mental health issues – and as a result, providing mental health support to survivors of domestic abuse requires interventions which take into account their unique and specific circumstances.

This is particularly true of children and young people experiencing abuse at home. Recognising the negative effects exposure to abuse can have on the mental health of young people is vital to understanding how best to respond to the whole family. We recently published our Insights children and young people national dataset, drawn from specialist children’s domestic abuse services across the UK supporting survivors below the age of 18.

One of the most striking insights from our data was that a third of children and young people who had been exposed to abuse in their household were suffering from mental health issues. For children being subjected to direct abuse at home, the proportion was even higher, with caseworkers identifying that two in four children accessing support had mental health issues.

Notably, the figures for children and young people experiencing mental health issues as a result of abuse are similar to those in the adult dataset, an important indicator that we need to be taking the mental health of survivors under 18 just as seriously as adult survivors. However, it is also important to highlight how mental health issues can look different for young survivors, in order for services to fully understand how to tailor mental health support specifically to them.  

A good example of this is making the link between domestic abuse, negative behaviour and mental health. Case workers found that almost half of the children in our dataset said that they had self-esteem issues and low confidence upon accessing support. A third of young people were also demonstrating risk taking behaviour, and two in three boys in our dataset were displaying destructive coping mechanisms. Shockingly, case workers found that one in five children also felt a sense of blame or responsibility for the abuse they were witnessing.

We know from our Insights dataset that when mental health interventions that are specifically tailored to the needs of children and young people are implemented, the results are overwhelmingly positive. In particular, interventions that address the whole family as well as the living and learning environment of the child are central to providing effective mental health support. This could include delivering joint parent and child support sessions, and ensuring mental health interventions are delivered alongside interventions that focus on family relationships.

Our data revealed that almost all children and young people who received 1-2-1 support sessions as part of mental health support, reported an improvement in their wellbeing directly as a result of this. Almost all the children in our dataset who were supported to access some form of counselling felt less of a sense of blame afterwards. Four in five children were demonstrating healthier coping mechanisms after specialist support and three quarters felt happier in their living and learning environment after mental health interventions.  

Children and young people are dealing with a myriad of complicated social and emotional pressures in the classroom, playground and at home every day. Understandably, these factors alone have an impact on young people’s mental health. However, what our latest dataset reveals is that children and young people living in an environment where they are constantly scared and exposed to abuse face additional vulnerabilities to their mental health which need to be taken into account. The mental health needs of young survivors cannot be tackled in isolation, and our children and young people’s dataset gives us an important insight into how interventions which include family, friends and the learning environment of children are crucial to giving young people the support they need to tackle their mental health challenges and move forward to live a happier healthier life. 

The difference data can make

Emma Retter, Research Analyst at SafeLives, looks at how the collection of data can provide the vital support survivors need. 

The UK definition of domestic abuse is “any incident or pattern of incidents of controlling, coercive, threatening behaviour, violence or abuse between those aged 16 or over who are, or have been, intimate partners or family members regardless of gender or sexuality. The abuse can encompass, but is not limited to psychological, physical, sexual, financial, emotional.” It includes coercive control, which is an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.

Each year an estimated 2 million adults in England and Wales experience some form of domestic abuse – 1.3 million female victims/survivors and 695,000 male victims/survivors.[1] These figures are likely to be an underestimate, because all types of domestic violence and abuse are under reported in health and social research, to the police and to other services.

Data collection, therefore, is not simply a numbers game when it comes to domestic abuse. When it is collected by health staff in a consistent, effective and clear way, it creates a story. This story becomes a narrative that informs us about a community and can provide answers to what support is needed for the survivors of domestic abuse in that community. Without data, we have little evidence to show the excellent work being done in many areas of health for survivors. We also have little evidence to make a case for the extra work, extra funding and extra services that are needed for those survivors that are falling through the gaps in support. And as we know, health services have a key role in finding these gaps. This blog will look at why the collection of data can provide the vital support survivors need and give a few examples of what the most effective data is to collect within a health setting.

Health Data and ‘Hidden’ Victims

Survivors of domestic abuse do not always telephone the police for help. The latest Crime Survey for England and Wales, released in November 2018, informed us that only around one in six survivors told the police about the abuse they were suffering.[2] We know that the police refer two thirds of all survivors to Marac[3]. So how do we find and provide support to the other survivors out there? How do we understand their story and the specific support that they need? And how do we know if there are services there to support them?

SafeLives have produced a series of Spotlights[4] which brings together insight from survivors, practitioners, academics and other experts, alongside our own data and focuses on these groups of victims who may be 'hidden' from services or face additional barriers to accessing support. The first spotlight focuses on older people and domestic abuse. SafeLives found that older victims experience abuse for twice as long before seeking help as those aged under 61 and nearly half have a disability. It was also found that older clients are hugely underrepresented among domestic abuse services.[5] If a patient discloses domestic abuse to a health setting, simply capturing their age can make all the difference to the local and national picture. It is usually younger women and children who are shown in campaigns around domestic abuse.  Older people can sometimes be forgotten about. But, if your health practice captures the age of a survivor of abuse and begin to see a pattern emerging of domestic abuse in an older generation, this can lead to the older survivors having more targeted specific support. Domestic abuse workers, such as a Health Independent Domestic Violence Advisor (Idva) in the hospital, or an Iris Advocate Educator in the GP, can use this data to ensure their service is fully accessible to older victims. If there is no domestic abuse worker in the health setting, this information can be incredibly important to show that support within a health setting can reach these older survivors of domestic abuse. Commissioners can use this data to come to an informed decision about where money and funding should be placed.

SafeLives Cry for Health[6] report gave a wealth of evidence to show that health settings are able to reach a different profile of people than community-based services. As one Senior hospital Idva stated:

“I think we are meeting people who are hidden from society”

Health services are key to capturing individuals who are sometimes cut off from society. When these individuals access a health service and are asked about domestic abuse, a disclosure and referral to the right support can be life changing. However, the picture that can be drawn from understanding a little more about each patient who discloses abuse can be life changing for a community. A few examples of the eight spotlights include: Disabled people, Young People, ‘Honour’ based violence and forced marriage and LGBT+.

What Data to Collect?

There is no universal best way to collect data. What is important is that data is collected is confidential. Any notes made regarding the abuse must not be accessible anyone outside of the patients health care as this can put an individual at serious risk of harm.  

How a health setting collects data will change with the health setting, the area and the systems that are in place in the service. However, there are a few key questions that can really make a difference to the provision of domestic abuse support to an individual and in a community:

Action Taken

Information as to where the patient has been referred to and action taken by health professionals is important to record for the patient’s safety. If a referral to a multi-agency setting or a specialist service is made, it is important that the health setting has confirmation that the referral has been accepted.  Making a note of who you are referring patient’s to also highlights links between specialist services and health settings. This can lead to joined up working between health settings and specialist services which can further the support and safety of patients and staff alike.

Demographics

The gender, age, sexual orientation and ethnicity of a patient is important to capture. These demographics can have an impact on how a patient feels regarding access to support and the specific support they need. A male survivor of domestic abuse may have very different needs to a female survivor. A 16-year-old survivor may have very different needs to a 45-year-old survivor. A Black or ‘Minority Ethnic’ (BME) survivor of abuse may have different needs to that of a non BME survivor. It is important all survivors of abuse receive the support specific to them. Without knowing the demographics of survivors of abuse, we are unable to provide the right support. By collecting this demographic data and piecing together who the clients are that are approaching health for support, the right support at the right time can be put in place for all survivors of abuse. 

Children

The presence of children in the household or soon to be in the household is important, not only to ensure that children can receive support but for safeguarding purposes.

Relationship to Perpetrator        

Does the patient live with the perpetrator? Is the perpetrator the patient’s carer? Are there multiple perpetrators? These questions are important for the safety of the survivor. It is also important in relation to the support given. A patient facing violence from their son or daughter may need very different support to someone being stalked by their ex-partner.

Is there a risk of Forced Marriage or ‘Honour’ Based Violence?

In order for the specific support that survivors need in relation to forced marriage and ‘honour’ based violence, it is vital that this information is collected.

Pathfinder Good Practice

Practice in terms of data collection around domestic abuse has differed in all of the Pathfinder sites. No two sites or teams have been the same! We thought we’d use one example here of a Safeguarding team at one of the sites.

The safeguarding team currently uses a simple excel spreadsheet to track the demographics of patients who are victims of abuse, which departments the patients are being referred from, notes on the disclosure by the patient and finally, the actions of the hospital. This simple excel spreadsheet not only shows the support the client needs and the actions of the staff, but it also allows the Safeguarding team to see where referrals are coming from and, more importantly, which departments are not referring domestic abuse and so may need some more training!

We all know and understand how busy health professionals are. However, recording a few simple details on an excel spreadsheet each time a disclosure relating to domestic abuse takes place can really make the difference to patients in health settings and may lead to lives being saved.

Back to hospital Pathfinder profile.


[1] Home Office (2019), The economic and social cost of domestic abuse

[2] Domestic abuse: findings from the Crime Survey for England and Wales - Appendix tables, Appendix Table 25:  Why the victim did not tell the police about the partner abuse experienced in the last year, year ending March 2018 CSEW1, November 2018 https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/datasets/domesticabusefindingsfromthecrimesurveyforenglandandwalesappendixtables

[3] Latest Marac National Dataset, 12 months 01/04/2018 to 31/03/2019, SafeLives, http://www.safelives.org.uk/practice-support/resources-marac-meetings/latest-marac-data

[6] SafeLives, A Cry for Health, Why we must invest in domestic abuse services in hospitals, November 2016 http://www.safelives.org.uk/sites/default/files/resources/SAFJ4993_Themis_report_WEBcorrect.pdf

Establishing best practice response to domestic abuse within acute health

Donna Allender is the Pathfinder Domestic Abuse Project Lead Officer for the Somerset Clinical Commissioning Group (CCG). Having previously led the development of the Health IDVA service within an acute hospital she is keen to capitalise on the expertise of the Pathfinder consortium in scoping a sustainable domestic abuse model across targeted health services with the Somerset CCG area.

In Somerset an estimated 13,200 women have been impacted by domestic abuse within the last year, 2139 of these are accessing support via our community-led domestic abuse service, 58% of which are police led referrals.

With only 1 in 5 survivors of abuse reporting to the police, there are an estimated 11,062 women potentially requiring early intervention and prevention. Thus it is vital that health play a proactive role in identifying and responding to patients exposed to domestic violence and abuse.

Whilst this report identifies the risk to women within our communities it in no way excludes the impact on children or the estimated 7,700 males that have been exposed to domestic abuse within the last year.

The estimated annual cost of domestic abuse to services within Somerset is £33.5 million (not including the human and emotional cost). £15 million of this is related to healthcare.

In the spirit of sharing best practice, I detail some of the activities that Somerset has progressed within our Acute Hospitals. It is by no means exhaustive and requires continual assessment and revision. With an annual average of 100,000+ patients passing through the Emergency Departments of our Acute Hospitals, embedding the NICE Quality Standard 2016, in a way that is effective and efficient is an evolving process.

First and foremost it was important to understand the challenges within the clinical setting; environmental time pressures, medical priority, patient interface, safeguarding knowledge and skills. It was noted that whilst there was a breadth of experience in delivering a measured, empathic first response to patient care and that all teams were fully aware of their statutory safeguarding responsibilities. Opening up the topic of domestic abuse, responding effectively to disclosure, assessing risk and referring to appropriate services was an area that many practitioners still felt very uncomfortable about.

We also identified that whilst robust safeguarding policies and procedures existed, domestic abuse was a feature rather than a detailed protocol for response. Domestic abuse was included in mandatory safeguarding training. However, again as a feature rather than a targeted programme designed to progress clinical enquiry, risk assessment and referral to specialist support.

The value of building relationships with the clinical team cannot be underestimated. Demonstrating a willingness to understand the day to day challenges and devising workable solutions that support medical teams to deliver interventions in a timely and appropriate way, not only enables the Trust to more specifically embed the NICE quality standard - driving measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – but also supports the clinician in feeling confident when delivering meaningful patient engagement.

One of our overarching aims was to embed an Emergency Department response that communicated to our patients that we recognise the impact of violence and abuse on health and wellbeing. That they are not alone and that we can offer appropriate routes to help and support.

Single Person Triage

At registration, all patients are informed that we conduct single person triage and that those accompanying them will be asked to remain in the waiting room until the triage outcome has been determined. Of course, we operate this within reason. If patients have additional support needs that require a carer to be present then this is accommodated.

Clinical Enquiry

At the point of triage, all patients 16 years and above, male and female are routinely asked about domestic abuse. However, this is largely designed to inform the patient that we are listening, available and confident in our response to violence and abuse at home.

Given that a high percentage of domestic abuse survivors presenting within health are often in a pre-contemplative stage, i.e. either not identifying that their experience is classified as domestic abuse or simply not be ready to engage in support. We must open up the question beyond the traditional ‘Are you at risk of domestic abuse?’

The way we ask the question is dependent upon the presenting situation, for example; our guidance for triage is:

“Given the widespread nature of violence and abuse, we routinely screen for risks at home”, “Is there anyone at home that has threatened to hurt you or someone that you care about?”

Whereas our guidance for maternity may be framed in the following way:

“Women exposed to abuse at home are particularly vulnerable to pre and post-natal stress”, “Is there anyone at home that makes you feel unsafe? Anyone who’s behaviour concerns you”?

More generic lines of enquiry may be:

“Not everyone recognises that they are in an abusive relationship”, Does anyone consistently put you down or belittle you? Threaten or intimidate you?

“How are you coping at home? Is there anything that you are worried about? Anyone that makes you feel unsafe or that you are frightened of?”

Clinical Capsules

Our enquiry does not stop at triage. When the patient moves into other areas of the Emergency Department for further assessment, clinicians have access to a clinical code that is embedded into their clinical recording pathway. If concerns have been identified at triage or the presenting complaint has a number of safeguarding indicators that denote domestically abusive activity, the clinician can use the code and a series of simple questions appear within the clinical notes.

  • When was the last escalated incident, what happened?
  • Is this the first injury that the patient has sustained? How does it compare to previous injuries?
  • Does the abuser intimidate or threaten the patient?
  • Would the patient describe their abuser as controlling or psychologically abusive?
  • Are the abuser's behaviours getting worse, are the incidents of conflict happening more frequently?
  • Identify the location of the alleged abuser, and if the patient is frightened of them?
  • What is it that the patient is frightened of?

The questions are designed to offer a framework of assessment that is conversational, whilst prompting disclosure that informs us about the severity and frequency of the abusive activity surrounding the patient.

If the patient consents to engage with the domestic abuse specialist, the clinician can generate an automatic referral to the safeguarding team via the electronic clinical record.

First Response

Supporting clinical enquiry is our Emergency Department First Response Procedure. A simple yet detailed protocol on how to respond to disclosure, assess risk and refer to specialist Health IDVA support.

Advice ranges from reassuring the patient that their disclosure will not be shared with the abuser, encouraging engagement with the hospital IDVA service, to specific risk assessment and safety planning measures. Links to this pathway are available.

Level 3 Safeguarding Training for Domestic Violence and Abuse

A key element in driving best practice response is of course training; the content of the training is designed to meet the NICE Quality Standard, universal level 1 & 2 targeted training for domestic violence and abuse and Level 3 Adult Safeguarding Competencies (which is an intercollegiate document).

This is a full day of mandatory training for the Emergency Department that aims to embed best practice by enhancing knowledge, skills and confidence when delivering safe actions and interventions to patients at risk of violence and abuse. It includes interpersonal violence and the role of the Emergency Department, establishing professional curiosity, domestic violence and abuse (Honour Based Violence, Sexual Violence, Older Patients at Risk, Complex Need), clinical enquiry, risk assessment and referral pathways.

Service feedback:

Having an IDVA working directly with the ED team has been invaluable. A comprehensive training programme delivered by the IDVA empowered staff to carry out routine enquiry and manage patient disclosures sensitively. As the project has evolved the IDVA was able to share powerful accounts of successful interventions that the staff had been involved with and the positive impact the support of the IDVA had then made to the patients. Having this special advocate embedded as part of the team and making safeguarding around domestic violence part of our everyday culture cannot be underestimated.

- Nurse Consultant Emergency Medicine

The Health IDVA role has continually developed within the Trust, providing a clear process for evidence-informed practice within the organisation. The IDVA has shared valuable skills and knowledge with the safeguarding team, ensuring that the service is not only sustainable but that survivors of domestic violence and abuse may access a responsive and supportive service even in the absence of the IDVA. This service is now indispensable, ever-evolving, and as a trust, we are very excited about where this development is taking us.

- Associate Director Quality Governance and Safeguarding

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