1. Scottish Women’s Aid Annual Conference 5 February 2013 Domestic Abuse STOPS…… Breaking the barriers, ending domestic abuse, together

2. Hidden in plain sight ‘Supporting the NHS to identify and respond to domestic abuse’ Katie Cosgrove Gender-based Violence and Health Programme Manager Scottish Women’s Aid Conference 5 February 2013

3. Health consequences  Injuries, lacerations  Gastro-intestinal symptoms e.g. Stomach ulcers, IBS  Gynaecological, central nervous system, and stress-related problems 3 ( Coker et al, 2000; Drossman et al, 1995; Lesserman et al, 2007; Kernic et al, 2000; Talley et al, 1994; Wuest et al 2008; Gerber et al 2007;Campbell et al 2002 ; Letourneau et al, 1999; Mark et al, 2008; Shei, 1991; Dieneman et al 2000; Kernic et al 2000 ) Elevated rates of depression and anxiety Panic attacks Suicidal ideation Eating disorders Alcohol /drug problems

4. Domestic abuse and co-morbid health conditions Arthritis Asthma Headaches and migraines Back pain Chronic pain syndromes 4 Black & Breiding, 2008; Campbell et al, 2002; Coker et al, 2000; Constantino et al, 2000; Follingstad, 1991; Kendall-Tackett et al, 2003; Letourneau et al, 1999; Wagner et al, 1995 High blood cholesterol Heart attack and heart disease Stroke Depressed immune function

5. Domestic abuse - a public health priority  Profound & damaging physical, emotional and psychological consequences  Significant predictor of poor health & strong risk factor for poor health outcomes & compromised functioning.  Early intervention in crucial to protect victim and increase treatment effectiveness  Health services are uniquely placed to identify and respond.  Must be part of a partnership approach with other key agencies

6. Chief Executive’s Letter (CEL_41) ‘Our aim is to adopt a systems approach to ensure that the NHS in Scotland fully recognises and meets its responsibilities around gender- based violence as a service provider, employer and partner agency’

7. Systems approach Integrated into policy Building capacity Data Health Board Action Plans

8. Improving the NHS response to gender-based violence Routine enquiry of abuse Guidance for staff Employee Policy Multi- sectoral collaboration

9. Why routine enquiry?  supports diagnosis and assessment of service users ’needs to ensure most appropriate treatment and care.  increased detection allows earlier and more effective intervention and improved health outcomes  staff may be reluctant to ask because of lack of confidence, skill, or fear of making things worse  Women may not disclose without direct questioning because of the perceived stigma or fear of not being believed  women find it acceptable to be asked about domestic abuse.

10. Paula’s story “ Someone once told me that we never remember pain. Once it's gone it's gone. A nurse. She told me just before the doctor put my arm back in its socket. She was being nice. She'd seen me before. - I fell down the stairs again, I told her. - Sorry. No questions asked. What about the burn on my hand? The missing hair? The teeth? I waited to be asked. Ask me. Ask me. Ask me. I'd tell her. I'd tell them everything. Look at the burn. Ask me about it. Ask. No. She was nice, though. She was young. It was Friday night. Her boyfriend was waiting. The doctor never looked at me. He studied parts of me but he never saw all of me. He never looked at my eyes. Drink, he said to himself. I could see his nose moving, taking in the smell, deciding. “ (‘The Woman Who Walked into Doors’ Roddy Doyle)

11.  Given the questions about the provision of and quality of medical care, it would seem that an involvement in social care could be to the detriment of providing what is expected from general practitioners - technically competent medical care“  "The patient would attend for support and then not act on the advice given, then would continue to attend. Should I withdraw? I have been left worrying about so many issues and have gone round and round in circles. There is no way I am going to look for more work in this area. I'm sticking to hypertension - at least there is evidence based advice"

12. Routine enquiry Setting Health Boards  Maternity 14  Mental health 9  Substance misuse 8  Sexual Health 6  A&E 2  Community Nursing (HVs) 9

13. Mental health

14. Substance misuse

15. ‘ I’ve tried to ask most of mine [clients] since the introduction just to see, and I’ve been astounded by the results, sadly, unfortunately. I don’t think I’ve come across anybody yet who’s not fallen into a category [of experiencing abuse]’ ‘Initially we did think there would be huge knock on effects with other agencies, like psychology referrals would be sky high and obviously other agencies with huge spikes of activity but that doesn’t seem to be the case’ (MH Focus Group B)

16. But…. ‘They’ve all disclosed something and that’s causing problems in other ways because I have to find them a service because in mental health we don’t – it’s not necessarily ours you know? And we cannot access [specialist abuse support agency], so it’s quite difficult…..and it’s an issue for me ……I’m starting to retract. I cannot do it with everybody because we don’t have access to the resources that I think are required’ (MH focus group B)

17. Future direction  Ongoing implementation of RE  Focus on primary care  NHS commitments in the forthcoming National Violence against Women Strategy  Strategic integration in key policy areas  Strengthen focus within the wider public health approach to violence and abuse  Integration into pre and post graduate curricula

18. Good practice guides

19. Scottish Women’s Aid Annual Conference 5 February 2013 Domestic Abuse STOPS…… Breaking the barriers, ending domestic abuse, together