Domestic Violence Community Audit

A Report on the Introduction of Routine Enquiry into Domestic Violence in Manchester NHS
April 2006

Researchers and Authors:

Maria Kovacs

Pauline Omoboye

Caroline Taylor

Abbey Brown

Louise Murray – MMU Tutor

Acknowledgements:

Thank you to Anne, Kay and Shakeela for your contributions.

Staff and volunteers at the Pankhurst for always making us feel so welcome.

Women’s Aid Outreach workers for supporting women to take part.

Alison Surtees, Creative Industry in Salford, for the advice and training on cameras.

MMU’s Community Audit and Evaluation Centre and the Home Office Active Learning for Active Citizenship program.

The NHS Domestic Violence Project: Caroline for your enthusiastic support and Abbey for all your work.

Thank you to all staff who agreed to take part in the community audit.

Contents

AcknowledgementsPage 2

Summary of FindingsPage 4

Summary of RecommendationsPage 5

Introduction & Project OutlinePage 6

Background and Definitions:

Domestic Violence and Health in ManchesterPage 8

Domestic Violence Community Audit - MethodologyPage 11

FindingsPage 15

RecommendationsPage 25

A Checklist Poster for Health SettingsPage 30

AppendicesPage 31

All poems copyright to Pauline Omoboye:

Peoples ChoicePage 7

Beating The DoorPage 14

At Your ServicePage 29

Summary of Findings

The introduction of routine enquiry of women’s experiences of domestic violence is a key challenge facing the NHS. The Community Audit group is clear that such a significant change will not be achieved overnight or without a certain amount of challenge and discomfort. These findings may make challenging reading for some. Government focus on health professional’s new duties to assist women experiencing domestic violence has already resulted in some important changes in Manchester. More remains to be achieved, however, if this change is to be significant and sustained.

The community audit looked at the environment supporting routine enquiry in 6 key Manchester NHS health settings. This environment should both support professionals to make routine enquiry and enable women to disclose domestic violence and gain access to appropriate advice, information and support. Key findings were that:

Staff interviewed were generally very sympathetic to the need to respond appropriately to women experiencing domestic violence. However, there was a lack of awareness of how to do this effectively in most (not all) settings.
There was limited and sometimes confused knowledge of the main domestic violence advice, advocacy and support services in Manchester. Worryingly, there appears to be very few referrals to these services.
Participation in domestic violence training was limited in most settings.
Most settings displayed posters in public areas promoting domestic violence services. However, one key setting had no domestic violence information at all in public areas.
Leaflets or cards, which patients might take away with them, were not available in half the settings public areas and not at all in more discrete areas such as toilets.
Systems for updating literature were generally reactive and lacked priority. More could be done to support staff responsible for updating posters and leaflets.
No specific domestic violence information was available in community languages in any setting.
In certain settings the safety of minority ethnic women may well be being compromised by the practice of using relatives/friends to interpret.
Generally staff demonstrated a high level of awareness of the importance of confidentiality, their professional responsibilities and agreed practices to support patient confidentiality. Good practice has been developed in the management of patient files to assure confidentiality and safety. However, certain practices that could undermine patient safety and confidentiality were evident in some settings.

Findings in full are available on pages 15 to 23.

Summary of Recommendations

If routine enquiry is to be a significant intervention supporting the improved health of women and children Manchester more will need to be done. These recommendations are offered as an approach, which might assist this. Recommendations are made in direct response to the findings of the community audit and appear in full at the end of this report.

Key recommendations include:

Basic domestic violence awareness and annual refresher training should be mandatory for all staff and should equip them to respond appropriately and supportively to patients.

All staff need greater awareness of the key Manchester domestic violence advice, advocacy and support services available to support their interventions. In particular all staff should be aware of the NHS Domestic Violence Advice, Advocacy and Support Service.

There should be a clear expectation that NHS services make referrals to domestic violence advice, advocacy and support services. The number of referrals made in each setting should be monitored through the Manchester NHS Domestic Violence Project.

Staff awareness of the dangers of using friends or relatives to interpret needs to be raised and unsafe practices need to be challenged.

Services should review their systems for updating domestic violence literature, taking account of the limitations and opportunities offered by the environment. A lead information contact should be identified.

The Manchester NHS Domestic Violence Project should develop a proactive information order system to support the lead information contact in all NHS settings.

Safety audits should be conducted which include the review of key practices to ensure that patient confidentiality and safety is maintained.

Adult patients should be informed that they would normally be seen individually and professionals conducting consultations should routinely offer these on an individual basis.

More consideration should be given to the needs of children when supporting a woman who raises the issue of domestic violence.

Introduction and Project Outline

Introduction

In September 2005 a group of 6 women volunteers started work on a participatory research project focussing on Domestic Violence. Women in this group had all used and/or volunteered in Domestic Violence Services and came together to use their experiences to help facilitate change through an action research project. Manchester Metropolitan University Community Audit and Evaluation Centre (CAEC) and the Manchester NHS Domestic Violence Project worked in partnership to support this group.

This research focuses on the implementation of routine enquiry of women’s experiences of domestic violence with specific attention given to the environmental context needed to support this significant change. The background to the project, including further information on CAEC and the NHS Domestic Violence Project, Domestic Violence and Health in Manchester is presented below. This is followed by a more detailed examination of the Community Audit Methodology.

Community Audit

Community Audit is a University accredited course developed for students studying for a professional qualification in Youth and Community Work. ManchesterMetropolitanUniversity’s Community Audit and Evaluation Centre received Home Office funding to develop Community Audit as part of the Active Learning through Active Citizenship (ALAC) Greater Manchester Hub. A number of community groups have used Community Audit to consider the needs of their community and/or evaluate how well these are being met through services or projects. The course approach values informal education and critical dialogue with high levels of community participation. In this group the research was community lead, all women having experiences of both domestic violence and health services. Community Audit fully considers barriers to participation and prioritises inclusivity and a partnership approach alongside consideration of a range of research methods and methodology.

Manchester NHS Domestic Violence Project

Health Services have both duties and opportunities to address Domestic Violence. In Manchester the NHS Domestic Violence Project takes the lead in developing policy, strategy, minimum standards, commissioning appropriate services and promoting best practice. This work is guided and supported by a steering group, whose members are representatives from all Manchester Trusts and specialist health areas. This work also needs to be informed by service users who have experienced domestic violence thereby contributing to the Trusts’ Patient and Public Involvement Strategies. The Community Audit approach is one concrete way in which user involvement will support change within the NHS, ensuring that service development is open to the scrutiny of and informed by service users.

Peoples Choice
Throughout this course I want to get a clear meaning
The full picture
The truth
And clear facts
I want to highlight a subject that matters
I want to strengthen, understand and combat
I want to listen to voices of importance
Work in partnership, challenge and resist
Achieve results, review services, be empowered
Work on an inexhaustible list
I want to make a difference to my local community
Look at policies, practice, guidelines and more
Look at values, shape our future, have an impact
Be more effective than ever before
With our group I want to show the importance
Of working together as a team with an aim
Show how with equality, diversity and co-operation
Collective confidence can enhance our game
I want to show our ability, give social justice
With support, stimulation and expertise
And our commitment and richness of experience
Through this audit will highlight these needs
And we will know when we’ve reached what we’ve aimed for
Because the evidence will be clear for all to see
In a video, book or a document
And we can stand tall and say change came through me!
Pauline Omoboye
November 2005
Background and Definitions: Domestic Violence and Health in Manchester

The Department of Health defines ‘Domestic Violence’ as:

“ Physical violence, sexual violence, emotional and psychological abuse, and financial abuse. It therefore describes a continuum of behaviour ranging from verbal abuse, through threats and intimidation, manipulative behaviour, physical and sexual assault, to rape and even homicide. The purpose of this behaviour is to enable the perpetrator to exercise power and control over the victim. The vast majority of such violence, and the most severe and chronic incidents, are perpetrated by men against women and their children.”

In Manchester, it is estimated that 40,005 women (aged over 19) will experience domestic violence in their lifetime and that 17,780 of these will experience domestic violence on an annual basis. The health impact of Domestic Violence is broad ranging and severe, including both short and longer-term effects on physical and mental health. Research identifying these health impacts is well summarised in recent Government publications[1].

Physical health effects include:

Injuries as a result of assault – domestic violence is the leading cause of injury for women aged 14-44
Chronic physical health problems
15 times more likely to abuse alcohol
9 times more likely to abuse drugs
Loss of hearing, vision and physical disfigurement

Mental health effects include:

Higher rates of depression, anxiety, self harm
3 times more likely to attempt suicide
4 times increased risk of post-traumatic stress disorder

Pregnancy:

23% of women are at risk of domestic violence during pregnancy
37% of women physically assaulted are assaulted for the first time during pregnancy

2 times more likely to experience miscarriage
Increased rates of unintended pregnancies and terminations

Every week in the UK two women are killed by current or former partners[2]. Domestic Violence accounts for one quarter of all violent crime[3]and as such is a major strategic issue to be tackled by Crime and Disorder Partnerships. Primary Care Trusts became responsible authorities within these Partnerships on 30th April 2004.

All children/young people living in a violent household will be psychologically and emotionally damaged by this witness experience, although their responses to these experiences will vary. In addition, the perpetrator directly abuses 50-70% of children living with an abused mother. Research also indicates long-term consequences for children’s well being. [4]

With current prevalence rates, it is estimated that 13,159 of Manchester’s girls and young women currently aged under 19 will go on to experience domestic violence as adults. 6,007 of these will experience this violence on an annual basis.

The total cost to Manchester of domestic violence is £117,129,760 a year, including a cost of £7,149,991 to health services.[5]

Government has identified that the health service is:

“uniquely placed to change public attitudes to domestic violence, and ensure that women experiencing domestic violence can access services to help them change their situation.”[6]

Health care professionals are more likely than any others to be approached by, or be in touch with, abused women and children. This puts Health services in the unique position of being able to access a broad and representative range of women and children experiencing domestic violence.

Additionally, consultation with abused women and children has indicated that they would trust and disclose to a health care professional if they were encouraged and supported to do so. This is not current practice. Government has indicated clear expectations that NHS services are modernised to address domestic violence. This is in line with broader requirements within the NHS Plan to ‘redesign the NHS around the needs of the patient’[7]. Addressing domestic violence contributes to one of the core functions of Primary Care Trusts in tackling health inequalities.

Domestic violence is the largest single reason for homeless presentations from families and single women in Manchester. In 2004-05 this accounted for 28% of families presenting as homeless (496 families) 27% of single women (267 women) and 0.9% of single men (28 men). Objective 5 of Manchester City Council’s Homelessness Strategy, (required under the Homelessness Act 2002) commits the authority to reducing the number of homeless presentations and representations:

“ By working in a holistic way, and adopting a multi-agency approach with people we rehouse, we should reduce repeat presentations by addressing the reasons for people becoming homeless.” [8]

Addressing domestic violence as a significant underlying cause of homelessness in Manchester is therefore embedded in Manchester’s Homelessness Strategy.

Health Services are required to introduce routine enquiry of domestic violence for all women using maternity services in 2008. Additionally, it is expected that good practice will promote the use of routine enquiry for all women across all health settings.
The Home Office defines routine enquiry as:
“Asking all women who are using the service direct questions about their experiences, if any, of domestic violence regardless of whether there are signs of abuse or whether violence is suspected”[9]
The introduction of routine enquiry is a key challenge, requiring change on many levels within the NHS.
Domestic Violence Community Audit - Methodology

A group of 6 women volunteers met in September 2005, responding to an invitation to work on a participatory research project focussed on Domestic Violence. Women in this group had all been involved with Domestic Violence services as service users and/or volunteers. The group agreed that their project would aim to assist the change needed to implement routine enquiry, drawing on their experiences to inform the research from a ‘service user’ perspective. All women in the group identified a key motivation for their involvement as wanting to support change that tackled domestic violence and gave women access to support and choices. In agreement with the Manchester NHS Domestic Violence Project Manager, Caroline Rowsell, the focus of the project was to consider the environmental context, which will support the introduction of routine enquiry.

The group identified that the environment, that is, setting and surroundings, included consideration of:

The physical environment and its impact on staff and patients
Information and resources available to staff and patients
Communication and contact between staff and patients
Working practices in the particular environment

The purpose of the environmental observation was to consider:

How the setting supports health professionals to routinely enquire into women’s experiences of domestic violence
How the setting supports women to disclose domestic violence and gain access to appropriate advice, information and support

The group took part in the MMU Community Audit program (see Appendix 1):

“We met to discuss what a community audit actually is and how best to carry out the research. This was done by looking at what women believe provides a good service (see opposite) and what provides a poor service. After several meetings where the group looked at several research methods, and discussed the advantages and disadvantages of each method, it was decided that it was best to incorporate a couple of different research methods to best evaluate the information that was available and required.”

The group selected 2 methods: observation of the setting, accompanied by a series of semi-structured interviews with a range of staff to ensure their perspectives and experiences were valued and included in the research.

“The interview was complied to look at the policies and procedures of the different organisations where we carried out the research. This was achieved by asking the set interview questions to members of staff within that particular health setting…where time and circumstance allowed, the interview was normally carried out with the practice manager and also with a member of reception staff. The interviews were carried out in this manner to enable discrepancies to be easily identified. Also, when read in conjunction with the observation charts, it was easy to identify the theoretical practice from the reality of the actual service being delivered”

An observation grid was devised to ensure reliability of the observation i.e. that it produced similar results under constant conditions on all occasions and was not dependent on the subjective judgement of an individual observer. The validity of the chosen research methods i.e. whether they measured what they were supposed to measure, was considered. Minimum Standards adopted by Manchester Health Trusts on Domestic Violence include a standard on creating a supportive environment for disclosure. Both the observation grid and interview schedule were developed against the requirements for this standard.