We present our results under the following thematic headings: 1) making general practice accessible for DVA care 2) general practice team-working to identify DVA 3) adapting to remote consultations about DVA, and 4) experiences of onward referral for specialist DVA support. These are summarised in Table 2:
Table 2: Themes and sub-themes
Theme
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Sub-themes
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Making general practice accessible for DVA care
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Encouraging patients to come forward to discuss DVA
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Adapting triage processes for appointments
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General practice team-working to identify DVA
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Reception and administrative teams recognising DVA
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Collaborating within the practice to identify DVA
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Using external information to identify DVA
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Adapting to remote consultations about DVA
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Arranging consultations safely
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Identifying cues for discussing DVA remotely
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Transitioning from remote to face-to-face to facilitate disclosure
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Experiences of onward referrals for specialist DVA support
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Making general practice accessible for DVA care
Ensuring that patients affected by DVA could safely access general practice was a challenge during periods of reduced access to services, particularly lockdowns. Patients affected by DVA were perceived as less likely to seek help, so staff undertook activities promoting their willingness to discuss DVA, such as posting on social media. Practices also adapted triaging processes enabling access to face-to-face consultations, given that patients were less likely to be able to disclose DVA over the phone.
Encouraging patients to come forward to discuss DVA
Concerns about the impact of the pandemic on DVA among participants focused on the impact of infection control adaptations during the early pandemic period, when all initial contacts were undertaken remotely by telephone or online consultation. GP3 recalled anxieties that patients would not come forward about DVA during the pandemic, in part because of concerns about infection and also because ‘people were told not to bother their doctors about things’ (GP6).
One support worker (AE1) explained that the fear of being isolated or alone, including when unwell, might influence whether patients would access support:
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)
Conversely, participants discussed how widespread media coverage about the escalating rates of DVA during the lockdown might promote care-seeking from those affected and awareness in primary care. This was in addition to public encouragement for people to contact their general practice if suffering from DVA.
… I know it's because, as I say, they advertise in the media, TV, GP series, 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
Strategies that practices used pre-pandemic to signal their willingness to support patients experiencing DVA, such as displaying posters, were compromised during the pandemic. Recognising this, some practices adapted their strategies, for example adding information to practice websites or social media to offer support and information for those experiencing DVA.
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)
Adapting triage processes for appointments
For many practices, a significant change to their working practices during the early stages of the pandemic was the requirement to move to ‘total triage’. Patients were asked to give a reason for their consultation via phone or online and then allocated either a telephone, video or face-to-face appointment. Participants reflected on the implications of this policy on access to care, including whether patients would be able to participate safely in this screening process.
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)
The impact was considered for patients who were intending to disclose DVA and those for whom disclosure might arise in the consultation.
This triage process also included COVID screening, where anyone with respiratory symptoms would not be able to come into the practice. Some staff were concerned this could prevent those in need accessing a face-to-face appointment, particularly if physical symptoms were a ‘cover story’ to gain a face-to-face appointment.
Asking why someone wanted an appointment could act as a barrier if a patient was unable to safely disclose DVA as a reason. Some practices improvised solutions where, if DVA was flagged on their record, patients would, by default, be invited for a face-to-face appointment. An advantage of the COVID rules was that it became easier to see patients alone. This could help create private spaces for care:
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
Teams worked together to identify patients who might be affected by DVA. The role of reception and administrative teams in identification, both in noticing signs of abuse and collating information from external bodies about DVA, remained vital during the pandemic, including managing the initial point of contact. Training about DVA adapted to reflect the challenges of the pandemic supported this.
Reception and administrative teams recognising DVA
Practice teams often worked collaboratively to identify patients experiencing DVA, drawing on the opportunities to observe signs of abuse or highlight external information.
While the pandemic limited the number of patients physically visiting the practice, many unusual behaviours were noticed by receptionists and administrators who could then share them with the wider practice team. Participants spoke about a range of situations which might prompt them to raise the issue of DVA with colleagues, including patients not picking up prescriptions, missed appointments, unusual telephone conversations, and seeing or hearing partners or family members exhibiting controlling behaviour.
The ability of receptionists and administrators to notice and act on these behaviours was facilitated by training, awareness and preparedness. All participants in this study had received training in recognising and safely responding to DVA. The AEs involved in training recognised the importance of the non-clinical roles.
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
Before and during the pandemic, regular discussion of potential DVA cases at practice meetings enabled bringing together diverse observations and identifying ways to offer support. This could include opportunities to discuss external information that had come into the practice or initial contact encounters where the reception teams wanted to share uncertainty or seek advice. These also created opportunities to highlight patients potentially affected by DVA to the wider practice team
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)
Some reception and administration participants felt there was better collaboration between themselves and clinicians.
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
Reception and administration teams’ process information communicated to the practice, a critical aspect of supporting patients affected by DVA. Information about DVA can enter primary care from a number of routes including other health settings (e.g. emergency services, sexual health services, ante-natal clinics), police, safeguarding teams, and in medical records of newly registered patients. These records can include references to both historic and recent experience of DVA.
Receptionists and administrators told us how documentation of DVA in patient notes, including alerts, could be used to guide both triage requests for clinical consultations and help the team consider how they could offer safe access to care and support.
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)
Practice managers, who had oversight for flows of information and internal alert systems, were key actors’ in ensuring that DVA could be safely recorded on patient records.
Adapting to pandemic consultations and recognising DVA
During remote consultations, without visual cues, clinicians found it more challenging to recognise the possibility of DVA. Most disclosures were received when an appointment transitioned to face-to-face.
Arranging consultations safely
Staff who had the opportunity for a face-to-face consultation could utilise these to enable conversations about DVA. Participants described how ‘disclosure is not a one-time event, it’s a process’ (AE2). While the clinical consultation was usually identified as the epicentre of the process of DVA care, the work of creating the possibility of disclosure represented a whole team effort, including preceding clinical and non-clinical encounters and actions.
Clinicians’ pre-pandemic experience made them aware that conversations addressing DVA can be sensitive and complex, requiring trust and rapport. For those with experience of receiving disclosures, their skills had largely been developed in the context of face-to-face consultations ‘where a patient feels safe, there is no one else in the room’ (GP1)
Transitioning to the telephone (or video) necessitated navigating additional practical and safety considerations, including establishing whether the patient was alone, able to speak freely, and who else might be listening, watching, or reading emails.
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)
A strategy which teams used to address this concern was asking initial questions about safety and privacy, using the flexibility of phone consulting to arrange mutually acceptable times for conversations.
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
The lack of visual cues during telephone consultations reduced opportunities to start conversations about DVA. Some participants reflected that this was ‘slightly easier on video’ but safety concerns remained as ‘you don’t know who else is in the room’ (GP6). Being unable to see and respond to body language and facial expressions made it harder to both identify unexplored concerns and to demonstrate empathy.
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)
Participants described having to rely on tone of voice and ease of interaction as a source of cues about possible abuse.
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)
These challenges could result in consultations being experienced as more transactional, focusing only on the presenting problem. It was harder to identify ‘hidden agendas’ (GP1) that may underlie the clinical presentation. The difficulty of noticing cues over the phone led some practitioners to feel less inclined to look for possible DVA during remote consultations.
I think resilience in general practice is at an all-time low[…]Some cases really, really get to you and you cannot help but shoulder a little bit of that. I think when resilience is at an all-time low for you, personally and professionally… 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)
While remote consultations and DVA disclosure were often difficult, there were concerns that some patient groups were particularly disadvantaged by remote consultations. Patients with hearing impairment, learning disabilities, or language or technology barriers (including the costs of data, access to internet and private devices) were identified as particular concerns.
You can’t get hold of interpreters, how do you then get the information you require? These doctors were saying how they can’t speak to them because they’re with their partner. (GP7)
Transitioning from remote to face-to-face to facilitate disclosure
Most DVA disclosures received by participants during the pandemic were made when clinicians moved from remote contact to a face-to-face appointment. While some of these face-to-face consultations were prompted by concerns about DVA, often they were connected to generic triaging protocols that differed between practices. Some prioritised face-to-face consultations for physical examinations, whereas others discussed the value of face-to-face appointments for mental health problems, arguing that they represented an opportunity to explore DVA.
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)
Even when clinicians perceived it was safe to discuss DVA over the telephone, they would often arrange a face-to-face follow-up, recognising that even when a referral had been arranged, they may still have additional needs or concerns that would be better explored face-to-face.
Disclosure of abuse is easier in the context of a trusted professional relationship. Participants found that having a pre-existing relationship with the patient or a previous record of DVA, could partially mitigate barriers of remote consulting and facilitate conversations about DVA.
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)
Disclosures, usually made to clinicians, were also made to other practice team members. This included non-clinicians who offer a range of advice and services to patients. These encounters created new spaces or opportunities for DVA disclosures:
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)
Although many remote consultations occurred on the phone, clinicians were usually still working in their practice building. Sometimes, including working from home when isolating, GPs worked away from their practice. This could mean that as well as being remote from patients, they were remote from their colleagues and distanced from professional support within the GP team. Although flexible working arrangements were enabling in some ways, the missed opportunities for colleague support could lead to a sense of professional isolation.
This was particularly significant for staff working for national services such as NHS 111 or digital remote consultation providers, supporting patients anywhere in the country without knowledge of local services, access to medical records, or opportunities to invite patients for face-to-face consultations. This was identified as a substantial gap in training and resource information:
There’s 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
Among participants who had access to referral pathways into specialist services via the IRIS programme, access to DVA support and services following disclosure was relatively unchanged during the pandemic.
Whether it’s pre-pandemic, mid-pandemic, or post-pandemic, it is just fill in a form, get it sent across. (GP4)
Once a referral had been made, IRIS AEs offering specialist support explained that their use of remote models of care were effective in enabling patients to share their stories, sometimes quicker than expected.
We’ve found that quite a lot of people are disclosing [to support services] more quickly. […] So, they are telling us more and they are able to 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)
Fears of isolation and illness during the pandemic made accessing care or leaving abusive relationships harder for patients supported by IRIS AEs. One potential consequence of this was that the referrals and presentations that were made were ‘later’ than they might have been or had become high-risk situations.
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)