A place of safety

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Issue: 21 July 2010
Author: Alison Moore

Women who suffer domestic violence often present to the NHS in need of time and privacy. Alison Moore reports

Domestic violence affects one in four women during their lifetimes. It costs public services £2.9 billion a year and accounts for £2.7billion in lost productivity, according to estimates by the Department of Trade and Industry.

Some women seek medical help from their GPs or A&E departments, often presenting with obvious injuries.

But some women will present in the NHS system some time after the incident  sometimes with vague symptoms which they can’t explain. Or they may seek appointments for what seem trivial reasons.

Some will be referred for physiotherapy. And in some cases the length and privacy of physiotherapy appointments  and the relationship they establish with the physio  will encourage them to speak of their experiences, sometimes for the first time.

But this can be a difficult time for physios.Lindsay Ashton, a senior physiotherapist at North Wales NHS trust, was shocked when one patient  a professional woman  disclosed she had suffered domestic violence. Although Lindsay Ashton was able to suggest where the woman could seek further help and offer to speak to her GP, the encounter had a tremendous impact on her and her colleagues.

The woman had told her story in an outpatients clinic, where she could be overheard by others in the department.

‘I didn’t feel anything in training had prepared me to deal with occasions when people have disclosed to me,’ she says. ‘I was taken aback by some of the things that she confided in me. She had been through many different practitioners but I think the way I asked one question was what prompted it.’

While Lindsay Ashton felt able to refer the woman to other sources of help, the woman decided not to go ahead, possibly because the domestic violence was some time in the past.

But as self referral becomes more usual physios may see women at an earlier stage.

In March the report from a Department of Health taskforce, Responding to Violence Against Women and Children  the role of the NHS¸called for all NHS staff to be trained to respond to this sort of disclosure (see panel).

Jane Newman, a clinical specialist physiotherapist in the pelvic floor and women’s health at the John Radcliffe hospital, Oxford, frequently treats woman who have developed problems following abuse.

She, and several of her colleagues, have had counselling training.

‘We spend time facilitating them, talking and saying what has happened to them which is important in pelvic pain,’ she says.

She works closely with a consultant gynaecologist and a counsellor to offer women whatever support they want, and often involves the woman’s GP who may know the background of the family.

Some women have dealt with the domestic violence and overcome it  and may not want any additional intervention, beyond the physical issues which have resulted in the visit to the physio, she points out. Others want counselling or referral onwards.

‘One has to make sure that they are happy and not go in with a heavy-handed or prescriptive approach,’ she says.

Treatment concerns

Women who have experienced violence may be reluctant to be examined, especially vaginally or anally.

 Louise Shea-Simonds, a women’s health specialist at Mid Essex hospital services trust, says all patients should be offered the chance to decline examinations .

She tries to teach women who are reluctant to be examined vaginally self-examination techniques. And she stresses that greater privacy would help women disclose what has happened to them.

But in some situations physios may have a duty to disclose what they have learned.

Louise Shea-Simonds had to contact child protection agencies after a patient revealed her children were still living with her violent partner. Ms Shea-Simonds explained what she needed to do and why, but the woman never returned for further appointments. She says that physios who are in this situation need feedback about what action has been taken.

Training to help patients experiencing domestic violence may be painful for some staff who have been exposed to it themselves. The NHS as an employer has to be aware that some members of staff have been, or will be, victims of domestic violence. Jane Newman says; ‘We have to be aware of this when people rotate into the area  it may uncover things that they have kept well hidden.’

The CSP is supporting Amnesty International’s campaign on Violence Against Women, and is developing a briefing paper on the issue.

Fiona Bowman is every inch the successful businesswoman.  But as a young woman she spent five days in hospital as the result of domestic abuse.

Recognise, react, refer

A manager at her work  realised what had happened, which enabled  Fiona Bowman to ‘escape’ the violence. She was offered a job in London and a chance to leave her previous life and abusive husband in Scotland. That was over 30 years ago. She has never looked back and is now an executive member of the UK Corporate Alliance Against Domestic Violence  which NHS Employers belongs to  and has spoken and written about her experience.

She urges employers to ‘recognise, react and refer’ when staff have been abused.

NHS staff can play an important role by passing on information enabling patients to seek support, she says. But they should not be surprised if  people do not take immediate action.

‘People are scared of other people intervening,’ she says. ‘I ended up in the Royal Infirmary in Edinburgh with serious head injuries. I kept telling the staff I had fallen down the stairs.

‘I know that the nurses were trying to help and convince me that I should disclose…if I had wanted to at that point, I could have. The sister on the ward took me around the ward and showed me other people who had been assaulted. I think she was trying to tell me that I was not the only person it had happened to. But I don’t think I was ready to seek help.’ fl

A place of safety 

What the NHS should do

• NHS staff should be made aware of violence and abuse of women and children, risk factors and what they can do to help
• Staff should have at least basic training and education on how to meet these needs; ’first contact’ staff may require more advanced education and training
• PCTs and NHS trusts should work with other agencies to ensure that victims can access appropriate services
• Every NHS organisation should have a single designated person to advise on appropriate services, care pathways and referrals
• NHS staff who are victims of domestic and sexual violence should be able to access support
• There should be consistency about the circumstances in which confidentiality can be broken.

 

Source: Responding to Violence Against Women and Children - the role of the NHS.Department of Health, March 2010.

Further information

Corporate Alliance Against Domestic Violence www.caadv.org.uk