REACH is a domestic abuse service based in the A&E department of St Thomas' Hospital. This is in line with the NICE public health guidance on domestic violence and abuse (PH50) which recommends offering specialist advice, advocacy and support in settings where people may be identified or may disclose that domestic violence and abuse is occurring (recommendation 12).
This example was a finalist in the NICE 2015 Shared Learning Awards.
Aims and objectives
The aim of the service is to provide advice, advocacy and support to:
1. People who present themselves at the A&E department at St Thomas's Hospital as victims of domestic/family abuse
2. Staff and Students within the Trust who are victims or survivors of domestic violence and abuse.
This is in line with the NICE Domestic Violence and Abuse guidance which recommends offering advice, advocacy and support in settings where people may be identified or may disclose that domestic violence and abuse is occurring (recommendation 12) and ensuring that staff have the opportunity to address issues relating to their own personal experiences (recommendation 5).
The service is based at the A&E department of St Thomas' Hospital, although they accept referrals from any part of the hospital, including both inpatient and outpatient services. Where a patient attends the A&E, and where it is suspected that the injury they are presenting with has been sustained as a result of domestic violence incident, A&E staff will ask the patient if they are experiencing domestic violence. If a disclosure is made the patient is then referred (with their consent) directly to REACH. In addition to women and men in heterosexual relationships, the service supports people in same sex and transgendered relationships. The NICE guidance highlights that these are groups of people that may find it difficult to access services (recommendation 9).
REACH provides domestic violence awareness training to staff throughout the Trust, including during Nursing and Midwifery Induction. This means that, as recommended in the NICE guidance, frontline staff are trained to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences (recommendation 6).
Reasons for implementing your project
The REACH service manager previously worked for Mozaic, a domestic violence service within the maternity department of Guy's and St Thomas' NHS Foundation Trust.
As part of her role she trained staff within Guy's and St Thomas', including nursing staff in the A&E department. The A&E department was a setting where victims of domestic violence and abuse could be identified, and the nursing staff asked why they didn't have a dedicated domestic abuse service. The possibility of providing a service which covered both the maternity and A&E departments was considered. Mozaic, an independent service, had concerns about basing themselves within the A&E department and this option was dismissed.
However, both the management and staff at Guy's and St Thomas recognised that there was a need for a service who could support both male and female patients within the A&E department. It was recognised that within the department the identification of victims of violence and abuse and their referral for advice, advocacy and support was variable. It depended on a variety of factors such as which members of staff were on duty and how busy the A&E department was. It was recognised that a dedicated service would help to ensure that victims of domestic abuse and violence were identified and offered help.
The service was initially a partnership project between Guy's and St Thomas' NHS Foundation Trust and Victim Support Lambeth, a local branch of a national charity. Funding of £210,000 was received from Trust for London and the Henry Smith Charity to establish the service. It began accepting cases in August 2007, with an official launch on 14th February 2008.
How did you implement the project
The following barriers have arisen:
- Staffing difficulties: Staffing difficulties arose at various points in the project's history. For example, there have been difficulties in recruiting staff who can cope with the additional challenges of working within an A&E department. These challenges have been overcome by improving recruitment skills and processes so that the appropriate candidates are attracted and recruited.
- A 'culture clash' between the NHS and voluntary sector: The initial partnership between the Trust and Victim Support encountered some difficulties. These difficulties were tackled using effective communication and innovative thinking. For example, Victim Support initially wanted REACH staff to work office hours, but this didn't fit in with the needs of the A&E department. The solution was for the service to be available 8am to 6pm, which meant that the staff handover period was covered. This is important for service continuity and to support A&E staff, who may want to discuss referrals or their emotions where a person declines a referral.
- A lack of fit between the aims of clinicians to treat injuries as efficiently as possible and REACH's aim to support victims to make decisions that take more time and input: Such concerns have been allayed because REACH can save time for A&E staff. Where domestic violence or abuse is identified (and the victim consents to a referral) REACH can step in to provide support to the victim and to address any safety issues involved. This frees up A&E staff to move on to treat other patients.
- Funding: Changes in funding has effected service provision, with staffing levels over the history of the service varying from one to three. When funding was cut by Victim Support in 2012, Guy's and St Thomas' NHS Foundation Trust took the decision to retain the service and provided additional monies. In 2013, a grant of £37,500 was awarded by the Better Community Business Network which will pay for one multi-lingual staff member for a minimum period of a year. An evaluation of four domestic violence advocacy schemes (Islands in the stream: An evaluation of four London independent domestic violence advocacy schemes) estimated that the cost of REACH per-victim survivor was £415.84. This was based on three staff members, although at present the service has two. The costs were lower than the two community services included in the report (£690.26 and £711.36 per victim-survivor).
The following results have been achieved:
- Fewer repeat incidents: Whilst 76% of all domestic violence incidents are repeat, according to the Home Office document 'Crime in England and Wales 2009/10', the REACH repeat victims figure stands at less than 5%. This means both an increase in safety and a decrease in demand for A&E.
- More incidents reported to the police: Almost 50% of clients report to the police with REACH support, compared with just 16% of unsupported victims, as reported in the Home Office document 'Crime in England & Wales 2008/9'.
- Improvement in immediate care and in long-term support for domestic violence victims: Pre-REACH, the senior A&E staff realised that 'there was no equality of service for domestic abuse victims', 'it depended on what staff were on duty' and whether 'that said member of staff had the time or expertise to deal with the domestic abuse incident'. Since REACH started, the staff know 'that all staff are trained and that REACH staff are on hand to provide specialist advice and support to staff, the victim and any children in the family'. REACH simplifies the referral pathway for victims of domestic abuse; its 'one stop shop' approach simply saves clinical time and moreover is extremely effective. REACH can provide ongoing support for domestic violence victims even after they have been discharged from A&E, which means increased safety and stability for victims and their children. If the patient is not local to GSTT, REACH staff, after dealing with the crisis, will transfer the patient's care to a relevant service in their area.
- Improvement in care for all other A&E patients: Their presence frees up the Nursing and Medical staff to concentrate on seeing and treating effectively all patients under their care. This also enhances the department's ability to achieve targets.
- Improvement in protection of children and vulnerable adults: Referral rates by A&E staff to the Child Protection and vulnerable adults' programmes have significantly increased since REACH came on board, as the training provided by REACH raised awareness of the needs of these victims. REACH are an additional safety net for children living in violent homes.
- Improvement in care for victims of all ages: The age range of referrals is from 13 to 89: REACH have thus evidenced the need for a domestic abuse service which patients of all ages can access and they are one of the few agencies that accepts such a diversity of referrals.
Key learning points
- Be part of the A&E team: REACH recognises the vital importance of being part of A&E team and working together to identify and help victims of domestic violence and abuse. This includes extending our hours during particularly busy periods, such as Bank Holiday weekends, World Cup (which saw a 100% increase in referrals) and New Years Day.
- Build relationships with new staff in A&E: Staff turnover within the A&E department can be high, but REACH sees all new nurses on a 1:1 basis and is part of the doctors' induction. Students will also spend time with us during their placement. This is a good opportunity to tell them about the service and give advice about how to ask question about domestic violence and abuse. This means that if a member of staff makes a referral or would like help and/or advice on situations that have arisen within the department they are familiar with the team.
- Make services accessible to staff and students: REACH is part of the Trust?s staff induction programme. REACH run an introductory session during the induction programme to let them know about the service and its aims to support both patients and staff.
- Support staff: REACH plays an important role in supporting staff who are victims or survivors of domestic violence or abuse. Where members of staff are victims, wherever possible and/or necessary action can be taken to maintain their safety in the work environment. In addition, REACH can sometimes play an important role in opening the lines of communication between a staff member and their manager. Helping staff to feel safe and supported has helped the Trust to retain staff.
- Work together with the police: The hospital has an in-house police officer who wears partial uniform. His presence and good working relationship with REACH has been an important factor in increasing the number of incidents being reported to the police.
The service is currently funded by Guy's and St Thomas' NHS Foundation Trust and a grant of £37,500 from the Better Community Business Network.