According to the Crime Survey for England and Wales (CSEW), the number of domestic abuse (DA) related crimes in England and Wales rose 6% in the year ending March 2021 to 845,734. From these, a total of 42,270 crimes were in Wales. To tackle this, the Welsh government has been acting on many fronts, including in the healthcare settings. Currently, five out of seven local Health Boards commission the IRIS programme; the same initiative is also funded by the Office for the Police and Crime Commissioner (OPPC) in a sixth area.
IRIS is an evidence-based, specialist domestic abuse (DA) training, support and referral programme for General Practices. Once funded by local commissioners, the initiative works as a collaboration between primary care and third-sector organisations specialising in DA. Core areas of the programme include ongoing training, education and consultancy for the clinical team and administrative staff, and a simple direct referral pathway for patients with experience of DA to a named worker, the Advocate Educator (AE), based in a specialist domestic violence service.
Several studies demonstrate that IRIS improves the General Practice response to DA and the safety, quality of life and well-being of survivors of DA. Over the last seven years, it has been progressively implemented across Wales and it is now only a step away from being available to the whole population.
More than 1,000 referrals in Cwm Taf: IRIS, a model that works
Back in 2015, Cardiff & the Vale was the first are to run the IRIS programme, delivered in partnership with Cardiff Women’s Aid and BAWSO, and funded by the South Wales Police and Crime Commissioners. A few months later, the programme was also extended to Cwm Taf, where it has been delivered by Safer Merthyr Tydfil and RCT Domestic Abuse Service. In this second area, the programme has just reached the milestone of 1,000 referrals – meaning that over 1,000 patients were identified as survivors of DA during their consultations with clinicians and referred to specialist support through the IRIS pathway.
Emma Williams, Development Manager at RCT, remembers the beginning of this journey: “Safer Merthyr Tydfil and Women’s aid RCT were jointly commissioned by the South Wales Police and Crime Commissioner and Cwm Taf University Health Board to deliver the IRIS programme to 46 GP practices, based in Merthyr and Rhondda Cynon Taf”.
“The IRIS project has been running successfully in the area for seven years. Over this time the project has seen many changes, including the merger of several GP practices, a change in commissioner and the merger of local health boards. Since April 2018, the IRIS project has been solely funded by the local Health Board. In early 2019, the health board boundaries changed, and the newly formed Cwm Taf Morgannwg University Health Board (CTMUHB) was established. This led to the expansion of the IRIS project into Bridgend, an area that had previously not had access to the IRIS provision. As a result, an additional AE was recruited increasing the number of AEs in the team from two to three.”
Over the years, the relationship between the health board and the IRIS project has grown with the support of Mark Gall, Deputy Manager for primary care at CTMUHB, Jacqueline Gantley, Clinical Lead for Cwm Taf Morgannwg, and Laura Wass, Clinical Lead for Bridgend. With their close involvement, the IRIS team in Cwm Taf and Bridgend have been able to demonstrate meaningful reports that reflect shared goals and demonstrate the ongoing need for the project within the areas.
According to Mark Gall, currently, all GP Practices across CTMUHB have undergone initial training for clinical and non-clinical staff to raise responsiveness and identify the signs of domestic abuse. “With the support of our IRIS colleagues, and in line with the evidence-based programme, a cycle of refresher training to highlight awareness is ongoing. We are dedicated to improving referral rates and look forward to continuing our work with the IRIS programme to progress early intervention and avoid unnecessary suffering within our communities. Our GP practices offer a safe haven for victims and patients must be made aware of the strict non-judgmental and confidential role our clinicians and reception staff can offer, as part of the referral process, to provide the support that many of our most vulnerable patients require at their most desperate time of need.”.
Data collected in these areas show the effectiveness of IRIS: in the year prior to the implementation of the IRIS project, local domestic abuse services had only received 4 referrals from primary health care. “As a team, we are pleased to announce that, since the implementation of the project, there have now been in excess of 1000 referrals, indicating that primary care workers are now able to recognise, identify and refer those affected by domestic abuse to appropriate support”, says Emma.
Cwm Taf: what clinicians say, what the numbers show
“I think this type of training is so important as we often see people years later with the lasting effects of trauma, so the more information to act early is crucial” – GP
“We have been much more aware at a practice level and since commencing the training. I have referred to IRIS and thought about DV in every consultation. Well presented, clear and informative.” – GP
On average, the area receives 20 referrals a month. Last year, patient feedback revealed that from all patients supported through IRIS:
- 100% were pleased to be asked by their GP/nurse or HV if they felt unsafe in their relationship.
- 100% were pleased to be referred to a specialist domestic abuse support worker.
- 100% felt the support provided by the specialist worker was helpful.
- 80% felt safer as a result of the support offered.
Identifying the signs of DVA: the positive impact of IRIS among clinicians in Swansea Bay and Gwent
In 2020 and 2021, IRIS was expanded to two more areas: Swansea Bay and Gwent started delivering the programme in partnership with Calan DVS and Llamau, respectively. Swansea Bay was recently relaunched, after expanding the programme to a greater number of local general practices from April 2021 onwards.
Julia Ward, the AE working in Swansea Bay, shares the impact of IRIS: “From my previous role working as Team Leader with CALAN DVS, I can confirm we had very low referrals being received from any clinicians across Neath. The total received in the year 2019/20 was 3. Following IRIS being rolled out in the Neath area, I can confirm the referral rate has increased dramatically and we have received 39 referrals from clinicians to date. These are 39 individuals who may never have been asked about the domestic abuse they have been experiencing if the clinicians had not been trained.”
In Gwent, IRIS has been commissioned for year-two funding across Blaenau Gwent, Newport, Caerphilly and Torfaen. According to the Head of Service Delivery and Quality Assurance at Llamau, Kirstie Addleton, bringing IRIS to Gwent has made an important difference to the support offered for victims of DVA in that area.
“We have been fortunate in Gwent that the buy-in to IRIS has come directly through local Neighbourhood Care Networks (NCNs). They have also acknowledged the need to work more holistically and proactively with the increased demand and made it a regional priority to address the impact of domestic abuse in their communities. COVID has created a platform of highlighted awareness of the issue, and the NCN areas made a commitment to work in partnership with IRISi and Llamau to address this”.
Gwent: what clinicians say, what the numbers show
“Having the opportunity to undertake this training has given me and my colleagues the opportunity to explore the implications that domestic abuse and violence has on our patients every day. A subject that is not always addressed in the correct manner, but vitally important to understand. Having access to our AE will enhance our response to domestic abuse and we will be able to work together to ensure our patients have the best support at the right time. Highly recommend the training to all” – GP
“Why isn’t this training part of the core foundation of medical school, to me, it’s just as important as everything else” – GP
“I don’t know if I would have still been here in 6 months’ time if I didn’t have support from you. I felt broken. I am not saying that I am fully recovered now from what I have been through, that will take years to go if it ever does go. But having the support has made me realise I have got a lot to live for. My kids, my family and my friends. Thank you” – Service User
“Being referred to this service has given me back my life. A million thank you’s wouldn’t be enough. This should be taught everywhere, that it’s ok to talk about domestic abuse and it’s nothing to be ashamed or embarrassed by any more” – Service User
The IRIS programme in Gwent trained a total of 523 healthcare professionals and received 527 referrals between 1st of July 2021 and 30th November 2022.
Patient feedback revealed that:
- 90% report attending GP less since engaging with IRIS
- 100% report being happy with the provision.
- 80% report feeling safer.
- 80% report feeling better able to cope.
- 80% report feeling more optimistic about the future.
Healthcare staff feedback revealed that:
- 100% reported that the training has been excellent
- 100% would recommend the training to colleagues
- 99% reported a better understanding of DVA post training
- 100% reported feeling more confident to deal with patients that disclose DVA
- 99% reported a better understanding of the link between DVA and child protection
- 95% reported a better understanding on where to refer all victims of DVA
- 99% reported a better understanding on where to refer male perpetrators
- 100% reported a better understanding of health conditions associated with DVA
IRIS in Denbighshire and Carmarthenshire: one step away from being available to the whole Welsh population
More recently, in January and June 2022, IRIS was also expanded to Denbighshire and Carmarthenshire respectively.
Rhiannon Edwards, who was the local Domestic Abuse and Sexual Violence Advisor when IRIS was first launched in Denbighshire, explained why it was so important to bring a DA training programme to clinicians working in the area: “We have wanted to bring this programme to North Wales for at least the last 5 years. We expect to see greater engagement between GP practices and specialist services, smoother and more efficient referral pathways, better trained and better-informed GPs and practice staff, but above all, we want to see victims of domestic abuse accessing the most appropriate support at the earliest time possible”.
According to Rhian Lewis, Service Manager at DASU, the partner organisation operating in Denbighshire, it became urgent to bring this new approach to tackle DA in the area due to the pandemic: “DASU has seen an increase of 40% in referrals (including high-risk referrals) since COVID. We have seen an increase in the length of support needed and an increase in the complexity of the needs of our clients. Referrals from primary care have always been quite low to our services and this will give us an opportunity to intervene earlier as well as supplying a wraparound suite of services for our clients in Denbighshire”.
In June, IRIS was implemented in Carmarthenshire also in partnership with Calan DVS. For Rachel Munkley, Lead Nurse at Bwrdd Iechyd Prifysgol Hywel Dda University Health Board (HDUHB), there were two main enablers of the commissioning process in the area: “We were able to demonstrate the value of the IRIS intervention to Primary Care and the commitment of the Corporate Safeguarding team in HDUHB to raise awareness of the need for improved recognition of violence against women. The process involved securing the commitment of all the three primary care clusters within the Health Board to contribute to the funding costs”.
Moyra Parfitt, Operations Manager at Calan Domestic Violence Services, the local partner organisation delivering IRIS in Carmarthenshire, explains that the area has 33 general practices aimed to be trained by the programme. “In 2021, nearly 2,880 people in Carmarthenshire were reported as being a victim of DA. Calan DVS believe the actual figure is far higher. The IRIS Programme has been training and supporting GPs to improve the primary care response to DA, thus encouraging more victims to come forward to receive the necessary support they deserve within the county”.
Working in this area, Dr Katie Silver, Clinical Lead, and Demi Ward, AE, both believe that implementing IRIS will be essential to improve the support for DA victims. “Having a training programme and a link directly to the Advocate Educator who can support people directly will provide support for people as needed”, says Dr Silver. “I first heard about IRIS when I was booked in to attend the training in 2019. Since then, it has become my passion to improve the healthcare response to Domestic Violence and Abuse, ensuring that clinicians recognise DVA as a health issue”, explains Demi.
For Lucy Downes, IRIS Network Director at IRISi, the strategic growth of the programme in Wales shows why DA should also be prioritised in healthcare settings. “We are delighted to see the IRIS Programme go from strength to strength in Wales. Since it launched in 2015, thousands of healthcare professionals have improved their response to patients experiencing domestic abuse and tens of thousands of women will have had access to advocacy and support. The commitment and passion of our partner organisations and allies in Wales have helped to spread the IRIS Programme to nearly all areas of Wales. We look forward to continuing to work with our stakeholders towards pan-Wales IRIS coverage, enabling every primary care clinician and every patient to have access to this programme”.