Domestic abuse as a PUN and DEN for appraisal

Vasumathy Sivarajasingam is a GP in West London and an Honorary Clinical Research Fellow at Imperial College London. She is also the Northwest London Primary Care Clinical Lead (Ealing Borough) for Green Agenda, Adult Mental Health, and Patient Engagement. She is on X: @vasu2776563

Domestic abuse (DA), a pervasive but often hidden issue, affects millions of individuals worldwide. It manifests in diverse ways across different communities and leaves enduring physical and emotional scars on its victims.¹

Annual GP appraisals play a pivotal role in enhancing the quality of healthcare provided by GPs by driving learning via patient unmet needs and doctors educational needs  (PUNs and DENs).² These appraisals mandate that GPs undergo adult and child safeguarding training, emphasising their responsibility to protect vulnerable individuals from harm or abuse. Safeguarding training equips clinicians with the skills necessary to effectively communicate with vulnerable populations, including children. It also empowers them with the knowledge required to accurately document suspected cases of abuse and neglect. It should also clarify obligations to report to the appropriate authorities.

So, why not consider incorporating DA as PUNs and DENs into your next appraisal submission?

DA often involves dynamics of power and control within the same family or household. Many victims endure this abuse silently and secretly. Those experiencing DA often feel stigmatised, diminished, or ignored, shattering their overall well-being. The impact on children and young people can be profound, affecting their health, well-being, and development into adulthood. Children tend to emulate behaviours and attitudes from their parents or caregivers, and when raised in an abusive environment, they may internalise and normalise abusive behaviours, possibly perpetuating abuse in their own adult relationships. This perpetuation of abuse across generations underscores the critical importance of addressing DA as a safeguarding concern.³

The Domestic Abuse Act and its Relevance to GPs

The UK government introduced the Domestic Abuse Act of 2021 with a vision to create a safer society with zero tolerance for DA. This legislation provides a statutory definition of DA, including forms such as coercive, threatening, and emotional abuse. It also recognises children under the age of 18 who see, hear, or experience the effects of abuse as victims in their own right. The Act aims to raise awareness about DA, offer protection and support for victims, hold perpetrators accountable, and improve the responsiveness of the justice system.⁴

GPs bear a key responsibility in recognising and addressing DA, whether it involves victims/survivors or perpetrators. Their role extends to raising awareness, early intervention, and prevention, along with addressing the exposure of children to such abuse. As trusted gatekeepers of healthcare, GPs are uniquely positioned to assist DA victims – GPs frequently encounter health concerns and injuries stemming from abuse in their daily work. Often, GPs serve as the first or sole point of contact for victims seeking help. While GPs are not specialists in DA, nor are they expected to provide specialised services, they play an indispensable part in the initial stages of addressing this complex issue and referring victims to support services or specialists.¹

Challenges and Considerations

Addressing patients experiencing abuse presents numerous challenges for clinicians and affected individuals alike. DA requires collaboration within a multi-disciplinary team.⁵

Given its complexity, widespread prevalence, and diagnostic challenges, it is essential that GPs remain vigilant and look beyond the surface during patient consultations. Every encounter, whether in the clinic, during home visits, or through remote consultations, should be an opportunity to address the issue. However, it is crucial to exercise caution when discussing DA during remote consultations or home visits, as perpetrators may be in proximity.

Recognising risk indicators (e.g., pregnancy, new mothers, mental illness, disability, etc.) and health markers of DA (e.g., substance abuse, chronic pain, mental health issues, STIs, high-frequency attendance, etc.) is is critical to raising awareness in case finding.⁶ The ‘SPECSS+’ framework, which stands for Separation, Pregnancy, Escalation, Cultural factors, Stalking/Strangulation, Sexual assault, serves as a valuable tool in general practice, reminding clinicians of immediate risk factors that signal high-risk individuals, beyond the evident physical violence.⁷ Adopting an open, non-judgmental approach, asking sensitive questions safely and compassionately, and validating victims’ experiences can facilitate disclosures by clarifying concerns and their underlying reasons.⁷

Response and Confidentiality

Following a disclosure, clinicians are responsible for assessing immediate safety concerns for the victim, their children, and dependents. They must initiate safeguarding procedures as required, arrange referrals to designated personnel for initial assessments, and guide victims toward the appropriate local DA specialist support. Signs of immediate risk, such as home safety, threats to children, and life-threatening situations, should be thoroughly explored. In cases where a victim is unwilling to engage with services or reluctant to disclose abuse, clinicians can provide information on DA support services, offer a basic safety plan, and reassure them that they can return at a later time when they feel ready. DA services can assist in assessing risks to victims and provide advocacy in areas like housing, social care support, and the criminal justice system.

Respecting patient confidentiality is crucial for patient confidence and safety. Patients should be made aware that their conversations are confidential, but it is important to note that confidentiality has limits, especially when children or vulnerable adults are involved. If a decision is made to share information without consent or if consent is refused, it should be thoroughly documented with detailed reasons. Seeking expert advice, such as from the local Caldicott guardian, is advisable in such situations.⁷ Accurate recording with the appropriate coding, ‘history of DA,’ is paramount. The consultation should be hidden from online access to prevent any unauthorised viewing by perpetrators and redacting it from the patient’s record helps safeguard the content during record access. A flowchart from ‘Responding to DA: guidance for general practices‘ offers valuable guidance on addressing DA within general practice.⁸

In conclusion, as part of ongoing learning and professional development, take a moment to reflect on these insights and consider how you might approach similar situations differently in the future. Click though the hyperlinks in this article, have look at similar articles in the BJGP/BJGPLife and other journals. Share what you learn with colleagues. Addressing DA is not only a professional obligation but also a moral duty in safeguarding vulnerable individuals.

Deputy Editor’s note: See also

• https://bjgplife.com/book-review-in-control-dangerous-relationships-and-how-they-end-in-murder/
• https://bjgplife.com/how-we-proactively-identify-and-support-our-victims-of-domestic-abuse-in-our-practice/
• https://bjgplife.com/episode-020-domestic-abuse-among-female-doctors/
• https://bjgplife.com/book-review-my-dark-vanessa/
• https://bjgplife.com/domestic-abuse-in-the-time-of-coronavirus/

References

1. https://bjgplife.com/improving-the-management-of-domestic-abuse-in-general-practice/ (accessed 18/9/23)
2. https://www.rcgp.org.uk/your-career/revalidation/supporting-information-guidance (accessed 18/9/23)
3. Sivarajasingam, V., Webber, I., Riboli-Sasco, E. et al. Investigating public awareness, prevailing attitudes and perceptions towards domestic violence and abuse in the United Kingdom: a qualitative study. BMC Public Health 22, 2042 (2022). https://doi.org/10.1186/s12889-022-14426-9
4. https://www.legislation.gov.uk/ukpga/2021/17/section/1/enacted (accessed 18/9/23)
5. https://www.medscape.co.uk/viewarticle/top-tips-identifying-domestic-abuse-2022a10015rf?icd=login_success_email_match_norm (accessed 18/9/23)
6. https://patient.info/doctor/domestic-violence-pro (accessed 18/9/23)
7. https://cwasu.org/wp-content/uploads/2016/07/if.pdf (accessed 18/9/23)
8. https://elearning.rcgp.org.uk/pluginfile.php/170658/mod_book/chapter/349/Guidance-on-recording-of-domestic-violence-June-2017.pdf (accessed 18/9/23)

Featured photo by Kat J on Unsplash