Managing concerns about domestic violence can be a challenging area for GPs, not just because of the emotive nature of the subject but also the medicolegal issues that it raises.
In February 2016, NICE will publish their domestic violence quality standard which will provide healthcare professionals and the public with guidance on best practice in this area.
The current definition of domestic violence encompasses ‘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’.
Domestic violence is not limited to physical abuse, and can include psychological, sexual, financial and emotional abuse, as well as forced marriages, honour crimes and female genital mutilation. It is therefore important that GPs are vigilant in recognising that domestic violence can affect a wider demographic than might previously have been considered.
What should GPs do if they suspect domestic violence?
Medical Protection has received over 100 calls in the past 12 months from members relating to their professional obligations when providing care for victims of domestic violence.
Common situations involving domestic violence, where doctors seek advice include when records are requested by authorities such as social services; being asked to report on injuries by the police for criminal investigations; and concerns raised by third parties (such as other family members or neighbours) about suspicions of domestic violence.
A doctor who is aware or suspects that their patient is a victim of domestic violence should address their concerns with the patient first, while providing medical attention and psychological support.
When authorities such as social services or the police, for example, request records the initial issue to consider is whether consent has been obtained. A discussion with the patient around the disclosure of information should take place to assess whether they are aware of the potential benefits or risks of doing so, and that they have the necessary capacity to undertake such a decision.
It is also important to be aware of the exceptional circumstances where information can be shared despite a refusal to consent. For example, if a victim of violence refuses police assistance, GMC confidentiality guidance says the GP may still disclose information if others, such as children, remain at risk.
GMC guidance in ‘0-18 years’ is particularly relevant here in that it places doctors under an obligation to escalate matters to the appropriate body if they have reasonable grounds to believe that a child may be at risk of abuse.
If a doctor suspects female genital mutilation has been performed on a patient under 18, they have a professional duty to report this to the police, which becomes a mandatory requirement from 31 October 2015. The GMC indicates that doctors should tell the patient before disclosing information, if it is practicable and safe to do so.
GPs may also be asked to provide letters or reports in relation to injuries consistent with domestic violence raised during consultations. Having addressed the matter of consent, it is important to ensure that any documents written or signed by the GP are not false or misleading.
Where a third party such as a neighbour informs the GP of concerns, it is important to act appropriately with regard to the concerns, whilst avoiding the inadvertent disclosure of confidential information to that person.
In situations where a doctor might suspect forced marriage, it is important to bear in mind that there is specific guidance for health professionals which can be found online. This includes advice around sensitive questioning, as well as highlighting the importance of recognising that some people, especially women, may not wish to speak to a health professional who is male or who is from their own community.
If the patient requires an interpreter, it would be advisable not to use family members or individuals who are prominent or influential in the individual’s community.
The potential issues raised in these scenarios provide some indication of the difficulties of recognising domestic violence and helping victims while respecting confidentiality. They also demonstrate how the relevant guidance can help in providing a framework for decisions when domestic violence is suspected although it is, of course, important to take advice from your medical defence organisation in relation to individual circumstances where a GP is unsure how to proceed.
- Dr Bobby Nicholas is medicolegal adviser at Medical Protection