Viewpoint: Why NICE guidance on domestic abuse needs to be updated

Dr Vasumathy Sivarajasingam explains why screening for domestic abuse should be standard practice in primary care.

Dr Vasumathy Sivarajasingam
Dr Vasumathy Sivarajasingam

A recently published document The Hidden Pandemic on Domestic Abuse Awareness for Health & Care Workers during COVID-19 is an excellent resource for the health professionals and gives tips on how to support victims of domestic abuse during the pandemic. It reiterates how domestic abuse affects people from all walks of life and highlights that healthcare professionals play a central role in identifying both victims and perpetrators.

The pandemic has had a significant impact on those experiencing domestic abuse. According to SafeLives, a charity working to end domestic abuse, over 61% of people experiencing domestic abuse feel they are unable to access support via the telephone or online because the perpetrator was always with them and they are too frightened to ask for help.

With less support and freedom to ask for help, the abuse can be more frequent and severe. The stress generated from health concerns, sudden financial challenges and lockdown has been shown to increase psychological distress - all negatively affect mental health, wellbeing and intensify the risk of domestic abuse taking place.1

What can GPs do?

So what can GPs and primary care teams do to further improve our practice when encountering survivors of domestic abuse, both during the pandemic and afterwards?

NICE does not recommend routine screening for or making enquiries about domestic abuse.2 However, the Pathfinder Toolkit developed by SafeLives after working with CCGs, NHS trusts and local authorities, recommends that GPs make inquiries, setting a low threshold for asking questions.3

As GPs, we are often the main point of contact for the majority of patients in the community. Patients are often at different stages in their willingness to open up about their experiences of domestic abuse. We are frequently able to develop a good relationship with a patient over time, which increases the chance of them disclosing abuse and seeking help. We are also well placed to have an open conversation with most of our patients.

Asking all patients about their experiences of domestic abuse during daily routine clinics, will aid early identification and offer appropriate support to our victims and perpetrators, before the problem getting worse. I believe NICE guidelines should be updated to reflect this.

NICE guidelines need updating

Evidence suggests that routine screening for domestic abuse improves victim identification in healthcare settings.4

The US is one of the few countries with a policy of screening for DA but, as this editorial points out, some of the evidence for screening in healthcare settings is contradictory.5

There are no head-to-head trials of screening versus clinical inquiry, so we do not know which is more effective; but screening programmes are not all that different from targeted inquiry approaches.5

Lack of time is a barrier to effective screening for victims of domestic abuse, but this can be overcome by self-administered screening.6 Many doctors do not implement screening not only because of time constraints, lack of training, and discomfort with asking about abuse, but also because they are sceptical about the evidence base.5

It is also challenging for clinicians to know how best to phrase questions, especially during remote consultations (such as video, email and telephone) and in a busy clinic. With video and telephone consultations, it is hard to assess who is present while the call takes place, and victims of domestic abuse may find it difficult to say what is happening to them.

A webinar on family violence during the COVID-19 crisis by the World Organization of Family Doctors in May 2020 emphasised that any contact between the patient and the healthcare system is a window of opportunity to diagnose abuse or neglect.

Asking all patients standard questions can help with this and at the same time it also highlights to victims that they are not alone in their experiences.

Given the unprecedented challenges posed by the pandemic and with a digital first primary care ambition from NHS England, I believe it is good clinical practice to ask all patients about abuse routinely, even where there are no indicators of abuse. This was demonstrated by a recent pilot in our practice.

By doing this, we not only identify victims, but also raise public awareness of abuse. Furthermore, this may even prompt perpetrators of abuse to recognise and seek support.

NICE guidance, which was published in 2016, is no longer fit for purpose. It is based on a situation where the majority of patient contacts and modes of consultations face-to-face.

With new ways of working and conducting consultations it is vital that we are open minded in our approach to identify and support our patients experiencing abuse. Digital and remote consultations will continue after the pandemic and I believe NICE guidelines on domestic abuse should be reviewed with a view to incorporate routine screening in general practice.

By routinely screening our patients in our daily clinics, we not only improve the identification of DA victims, but also help raise awareness, which in turn may encourage people to talk about the issues more openly.

How healthcare teams can support victims of domestic abuse
  • Keep and share an easily accessible online folder containing information on domestic abuse; safeguarding policies and a list of support services that you can signpost people to.
  • Know who your DA champions are - have in-depth training on domestic abuse, so are excellent sources of advice, support and knowledge.
  • Ensure that you attend ‘DA Awareness’ training and are familiar with your organisation’s procedures addressing domestic abuse.

Source: The Hidden Pandemic on Domestic Abuse Awareness for Health & Care Workers during Covid-19

  • Dr Vasumathy Sivarajasingam is a GP in west London

References

  1. Dave M and Patel N. Domestic violence during the COVID-19 pandemic. BMJ Opinion, 7 May 2020. https://blogs.bmj.com/bmj/2020/05/07/domestic-violence-during-the-covid-19-pandemic/
  2. NICE. Domestic violence and abuse. QS116, February 2016. https://www.nice.org.uk/qs116
  3. Safe Lives. Health Pathfinder safelives.org.uk/health-pathfinder
  4. O’Doherty L, Hegarty K, Ramsay J et al. Screening women for intimate partner violence in healthcare settings (Review). Cochrane Database Syst Rev 2015; (8): CD007007
  5. Feder G. Beyond Identification of Patients Experiencing Intimate Partner Violence. Am Fam Physician 2016; 94(8): 600-5.
  6. Chen P, Rovi S, Johnson M. Costs effectiveness of domestic violence screening in primary care settings: a comparison of 3 methods. J Community Med Health Educ 2013; 3: 253

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