1. health and fitness

Appendix 4.3
MEETING:
DATE:
TITLE:
LEAD DIRECTOR/
MANAGER:
AUTHOR:
CONTACT DETAILS:
Haringey Clinical Commissioning Group
Governing Body Meeting
Thursday, 28 November 2013
Domestic and Gender Based Violence in Haringey
Jeanelle de Gruchy, Director of Public Health
Althea Cribb, Strategic Domestic and Gender Based Violence
Lead
althea.cribb@haringey.gov.uk, 020 8489 1501
SUMMARY:
The purpose of this item is to provide the CCG Governing Body with data on the
prevalence of domestic and gender based violence in Haringey, information about the
importance of health service responses, and an update on the work in progress to address
the partnership’s response to the issue.
Domestic and gender based violence is a significant issue in Haringey, and requires
responses from all organisations involved in the partnership. Health services have been
highlighted as having a specific, and essential, role in this partnership response.
The presentation provides the prevalence of domestic and gender based violence in
Haringey. This paper supports that data with contextual information on the importance of
health services’ response, and goes on to outline what actions are currently in progress to
address domestic and gender based violence.
The shared definition of domestic and gender based violence is:
Any incident or pattern of incidents of controlling, coercive or 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. This can encompass, but is not limited
to, the following types of abuse: psychological, physical, sexual, financial, emotional.
Controlling behaviour is: a range of acts designed to make a person subordinate and/or
dependent by isolating them from sources of support, exploiting their resources and
capacities for personal gain, depriving them of the means needed for independence,
resistance and escape and regulating their everyday behaviour.
Coercive behaviour is: an act or a pattern of acts of assault, threats, humiliation and
intimidation or other abuse that is used to harm, punish, or frighten their victim.
This Government definition, which is not a legal definition, includes so called 'honour’ based
violence, female genital mutilation (FGM) and forced marriage, and is clear that victims are
not confined to one gender or ethnic group.
SUPPORTING PAPERS:
Please see the presentation and the report below.
RECOMMENDED ACTION:
The Governing Body is asked to:
 COMMENT on the actions agreed at the health meeting, outlined in the report below.
 COMMIT TO SUPPORTING the DGBV partnership in the implementation of these
actions, and in ensuring health services delivery quality services to those affected by
DGBV (adult victims and perpetrators, and children and young people).
Objective(s) / Plans supported by this paper: Work to address DGBV impacts on the
following Health and Wellbeing Strategy outcomes:
 Outcome 1 – Every child has the best start in life
Through ensuring that all areas of work and responses to domestic and gender based
violence recognise and address the needs of children and young people. This includes:
children and young people living in a home with a perpetrator; children and young
people perpetrating abuse/violence against parents and/or family; young people
perpetrating / experiencing domestic and sexual violence who are involved in gangs.
 Outcome 3 – Improved mental health and wellbeing
The experience of domestic and gender based violence from a partner/ex-partner/family
member has been shown to have significant impacts on the mental health, safety and
wellbeing of victims, and the partnership is working to ensure they are identified and
offered help as early as possible.
Audit Trail: Data in the presentation has been gathered by Haringey Council’s Public
Health Team and Strategy and Business Intelligence Unit.
Patient & Public Involvement (PPI): None for this report.
Equality Analysis: Domestic and gender based violence fall within the UN definition of
violence against women and girls; that is: Any act of gender-based violence that is directed
at a woman because she is a woman or acts of violence which are suffered
disproportionately by women.
The greatest risk factor for experiencing domestic and gender based violence is being
female. However, men and boys also experience it and responses must address this.
Responses must also be sensitive to the additional needs victims/survivors have due to
their particular circumstances that can impact on help-seeking, e.g. sexual orientation,
ethnicity, disability, religion/faith.
Research shows that there are no causal links between socio-economic position,
employment status or poverty and the experience of domestic and gender based violence.
There are no additional risk factors relating to ethnicity or religion.
Risks: Failure to address domestic and gender based violence, at its most extreme, leads
to the death of women, men and children and young people.
Resource Implications: There are no financial implications arising directly from this report.
Most of the actions identified link in with existing work plans and can be met from existing
resources. If new activity is identified then a business case will need to be made.
Domestic and Gender Based Violence in Haringey and the Health Service Response
1.
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HEALTH RESPONSE
Haringey has a high prevalence of domestic violence – up to 8,900 victims every year
A significant amount of it goes unreported – or is reported but not recorded
Health services have an essential role to play in supporting those affected
Health services already respond to domestic and gender based violence; just not
necessarily very effectively / efficiently
The long term health impacts are costly: victims have been shown to attend health
settings more frequently, and therefore cost health services more than non-victims1
Health has almost unique levels of public trust for public sector, and so victims are more
likely to disclose in these settings
Health are universal services – and so attendance is stigma free
There is sometimes unmonitored access to people in health services, leading to greater
opportunities to ask about domestic violence
Health practitioners see people in states of undress (and so are likely to see what would
otherwise be hidden)
It is good clinical practice to address the whole of someone’s need, not just the
presenting one
CAADA2 data: services supporting victims based in hospitals see a different profile of
victims than other community based services:
o more complex needs (mental health, drug/alcohol use, no recourse to public funds)
o younger
o earlier in their experience of DGBV, having made no previous attempts to leave and
often still with perpetrator
Data from Multi-Agency Risk Assessment Conferences3 shows the disparity between
high risk victims actual use of healthcare, and the extent to which they are identified in
these settings:
All health
Primary care
Acute
Mental
health
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1
All national MARAC3
referrals – one year
4.4%
2.2%
1.5%
0.8%
IDVA4 clients attending health service in one
year (not same sample)
N/K
45%
21%
31% had issues with mental health; though not
necessary attending a service
Health services have a duty to response proactively and effectively to domestic and
gender based violence, as they have a unique opportunity to intervene earlier, thereby
reducing harm, reducing costs, improving the wellbeing of victims and children, and
ultimately savings lives.
Wisner et al, 1999
Coordinated Action Against Domestic Abuse, www.caada.org.uk
3
Information sharing monthly meetings between key partner agencies for the purpose of safety planning for
victims and their children
4
Independent Domestic Violence Advocacy Services – working with high risk victims referred via the MARAC
2
2. WORK IN PROGRESS
The second ‘Haringey Stat’ meeting, led by the Local Authority Chief Executive, focused on
domestic and gender based violence.
One of the outcomes was the recognition of the crucial role of the health service response,
and how this response was either unclear, or lacking, in many areas. A follow up meeting
has been held focusing on health, which was able to gather more data – local or from
literature reviews – as well as to understand more about the current response and where
development is needed.
The meeting established that there are many well developed responses to DGBV in health
settings in Haringey; but that these are not consistent, and that data is not collected to
demonstrate the process, or the effectiveness of the response.
The most developed response is in maternity and health visiting services; the least
developed are in Accident and Emergency Departments and General Practice. The data
shows the high number of victims who attend these services – demonstrating that this is
about improving the quality of the services already delivered to them, rather than creating
new services.
Further development is needed in all areas to:
 Ensure pathways are in place for appropriate response and referral following disclosure
 Systematise the response through training, policies and procedures
 Gather data on disclosures and outcomes
 Implement models of best practice where possible, i.e. IRIS
The data list is below.
Data Sought
Accident & Emergency
Departments
(Whittington Health;
North Middlesex
Hospital)
Literature review
Local data gathered
A&E data from two
London hospital-based
studies
From North Middlesex
Hospital
Maternity Services
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Any other hospital data
Data from research study
with fracture clinics
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Mental Health
Data in development
Whittington A&E–
audit planned
 North Middlesex A&E
– audit request
submitted
Data requested from
Whittington but unable to
provide due to change in
IT systems
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National research: people
who have experienced
abuse and violence, and
their experience of
common mental disorder
Admissions data for
Haringey women
attending any hospital
for assault
North Middlesex child
safeguarding referrals
for domestic violence
Women referred to
Whittington Female
Genital Mutilation
specialist service
Whittington: data can be
provided but wasn’t ready
in time for workshop
Sexual Health services
Health visiting
Whittington data on
domestic violence
prevalence in their
caseload where there are
safeguarding concerns
Multi-Agency Risk
Assessment
Conference
Number of referrals from
health agencies
Children’s Social Care
Referrals where domestic
violence is the presenting
factor
3. ACTION REQUIRED
The following table outlines the actions agreed at the meeting:
Actions / Points for consideration
Owner
Explore training on offer and required (North Middlesex, Whittington Health,
Barnet, Enfield & Haringey Mental Health Trust as priorities): with regard to
Public Health prevention budget which may be available to support training;
and look at NICE guidance recommendations on training required for health
professionals
Jeanelle de Gruchy, Director of
Public Health
Chief Executives: BEHMHT;
North Middlesex; Whittington
Policies and procedures to be developed, alongside training – working
towards responses being systemic
Jeanelle de Gruchy, Director of
Public Health
Chief Executives: BEHMHT;
North Middlesex; Whittington
Continue to progress IRIS for primary care
(Identification and Referral for Improved Safety, a targeted enquiry model to
improve early identification and appropriate referral for domestic violence
victims in General Practice)
Karen Baggaley, Haringey CCG
with Nicole Klynman, Public
Health
Look at this ‘targeted enquiry’ model, with referral pathway for victims (like
IRIS), for other health settings
Karen Baggaley, Haringey CCG
with Nicole Klynman, Public
Health
Explore with North Middlesex, Whittington Health and BEH Mental Health
Trust how they can ‘flag’ or code electronic files when DV is disclosed –
particularly as BEH Mental Health Trust (some teams), maternity services in
North Middlesex and Whittington Health, and Whittington Health Visiting
carry out routine enquiry
North Middlesex are addressing their response to (and recording of)
Female Genital Mutilation cases, looking at how Whittington Health already
do this; we also need to look at the wider inter-agency working in relation to
actual FGM and girls at risk
Consider where support services for victims are based; whether there may
be scope in future for service to be based in health organisations
Continue to develop the ‘minimum standard’, including ensuring that it
aligns with the NICE guidance that will be published in February 2014, and
work with health providers to achieve it
North Middlesex are looking at midwifery practice in relation to ensuring that
women are seen on their own on at least one visit, so that they can be
asked about domestic violence
Althea Cribb, Strategic DGBV
Lead
Chantel Palmer, Named Nurse
Child Protection, North
Middlesex
Althea Cribb, Strategic DGBV
Lead
Althea Cribb, Strategic DGBV
Lead
Chantel Palmer, Named Nurse
Child Protection, North
Middlesex