Never a week goes by without claims of another ‘crisis’ engulfing the NHS: insufficient resources, dispirited staff, poor safety, waiting times, inadequate social care and more.
To mark the 70th birthday of the NHS, our colleagues at the London School of Hygiene & Tropical Medicine (LSHTM) are hosting a Question Time event with an expert panel from nursing, medicine, health policy and research to focus on the challenges and prospects for the future.
If you register to attend this free debate you can submit questions for the panel and contribute to the discussion on the day if you wish to.
Panellists for this event are –
Dame Donna Kinnair, Director of Nursing Policy & Practice, Royal College of Nursing
Nigel Edwards, Chief Executive, Nuffield Trust
Jane Dacre, President, Royal College of Physicians, London
Martin McKee, Professor of European Public Health, LSHTM
It will be chaired by Sir Nick Black, Professor of Health Services Research, LSHTM
New CLAHRC research has highlighted a lack of guidance for health and social professionals who encounter children exposed to domestic violence.
Around one in five children in the UK have been exposed to domestic violence or abuse between their parents or caregivers. Children can be directly impacted – leading to emotional and behavioural problems and risks of physical injury and death when children are caught up in the violence between adults. Even when not directly involved, children’s exposure continues through witnessing and being aware of the violence – and through its health, social and financial consequences. Health and social care workers are often the first professionals to have contact with a child experiencing these situations.
In a collaboration with CLAHRC East of England and international colleagues from the McMaster and Western Universities in Canada we examined the evidence on child, parent and professional views on acceptable approaches to identifying and responding to children exposed to domestic violence.
The resulting research paper, published in BMJ Open, highlighted conflicting views of children and mothers on the one hand and professionals on the other when it came an ideal response. Children and mothers wanted professionals to talk to children directly and engage them in safety planning. Professionals preferred to engage with children via the parent and they often did not perceive children exposed to domestic violence as patients or clients in their own right.
Guidelines for health professionals who encounter women who have experienced domestic violence provide various questions and prompts they can use in discussions, and a set of principles to follow. There are no equivalent recommendations on how to identify and respond to children exposed to domestic violence and limited evidence on which to base future guidance. Our analysis also revealed that professionals were not happy with the existing safety guidelines for children and mothers exposed to domestic violence and wanted changes.
The research was funded by the Public Health Agency of Canada through funding to the VEGA (Violence, Evidence, Guidance and Action) project. The VEGA Project is part of the Canadian Government’s Public Health Response to Family Violence. This research will inform the development of public health guidance, protocols, curricula and tools for health and social service providers. The research was supported by the NIHR CLAHRC North Thames and NIHR CLAHRC East of England.
Around one in five children in the UK have been exposed to domestic violence or abuse between their parents or caregivers. When adults are involved in an abusive relationship, their children bear the consequences.
The effects of domestic violence on a child can range from emotional and behavioural problems to physical injury and death when children are caught up in the violence between adults.
Even when not directly involved, children’s exposure continues through witnessing and being aware of the violence – and through its health, social and financial consequences.
Health and social care workers are often the first professionals to have contact with a child experiencing these situations. This could be when the abused parent seeks help, or when children undergo health checks. It can happen during assessments for emotional or behavioural problems, or when social services, a child’s school or the police become involved.
The World Health Organisation (WHO) recommends that health professionals who see women with clinical signs of domestic violence should ask them about safety in their relationship and at home. They advise that responses to disclosure should follow what is known as the “LIVES” principles: Listen, Inquire about needs and concerns, Validate, Enhance safety, and provide Support.
But there are no equivalent recommendations for children, and there is no agreed approach regarding how best to identify and respond to children who are exposed to domestic violence. So far, there has also been only limited evidence on which to base future guidance.
Now researchers at universities in the UK (Bristol, Queen Mary and Cambridge) and Canada (McMaster and Western) have combined existing evidence on the best ways to identify and respond to children experiencing domestic violence. This synthesis, the first of its kind, integrates findings from 11 studies with 42 children, 220 parents, and 251 health care and social services professionals.
We found that study participants’ opinions were strikingly consistent, and matched the LIVES principles. Children, parents (mostly mothers) and professionals agreed that identification of the problem should happen in the context of a good patient-professional relationship, and in a safe and supportive environment.
Health care professionals should enquire about the child’s safety when they see clinical signs of domestic violence and abuse in children. The ideal initial response should include emotional support, discussion about domestic violence and advice on local specialist services.
We also discovered that a professional’s ability to identify and respond to children’s exposure to domestic violence was heavily influenced by constraints within the health and social service system. Lack of time, funding cuts and poor inter-agency collaboration all have an impact. Professionals needed more training and resources to be able to respond to these children and their families in an appropriate and safe way.
However, there was a difference of opinion when it came to engaging directly with children and managing their safety.
A direct approach?
Children and mothers wanted professionals to talk to children directly and engage them in safety planning. Professionals, on the other hand, preferred to engage with children via the parent – and did not perceive children exposed to domestic violence as patients or clients in their own right. Also, professionals were not happy with existing safety guidelines and practices for children and mothers exposed to domestic violence. These elements are certainly subjects for future research and training.
Given the scale of the problem, and the long-term emotional, behavioural and physical impacts on children, we hope that the results of this study can form the basis of new, internationally agreed guidelines.
Our research findings have already been used to inform point-of-care responses to adults and children in Canada’s VEGA (Violence, Evidence, Guidance, Action) Project. That program is already developing the “Recognising and Responding Safely to Family Violence” Handbook for health and social care professionals.
And we hope our evidence will inspire development of professional training and resources elsewhere – so that front line practitioners feel better equipped to appropriately and safely respond directly to the needs of children. Too many children’s lives and futures could depend upon it.
Part of the CLAHRC’s mission is to raise awareness of new research evidence, and get it to the front-line where it can used by NHS staff. We are working with our host Trust NHS Bart’s Health to translate the new knowledge we generate into everyday practice among NHS professionals.
Bart’s Education Academy has developed an eCPD app available to download for free for users of Android and iPhone smartphones. The eCPD app aims to reduce the time staff have to leave the frontline to attend training courses in person, and give them more flexible learning they can fit around their busy schedules. The app allows staff to log in and create personal and professional development plans (including mandatory training) and optional learning modules. Once completed a notification is sent to both the member of staff and their supervisor, to show they have carried out the necessary training and are credited with CPD points where appropriate.
The CLAHRC has provided learning modules focused on our research findings, and more of our work will appear on the App in the near future.
We are now rolling out some of our popular CLAHRC Academy courses so that they can be accessed via the App – our Academy Director Dr Nora Pashayan (below right) and Academy Teaching Fellow Dr Silvie Cooper (below left) recently met Director of Academic Health Sciences at Barts Health NHS Trust Professor Jo Martin to launch our Introduction to Evaluationcourse via the App.
The Barts Education Academy provides clinical placements for 2,500 medical undergraduate students and trains 1,040 junior doctors, over 800 children, adult nursing and midwifery students and 275 allied health professionals. The Education Academy offers resuscitation skills training, moving and handling, simulation and clinical skills training and a range of skills based short courses, as well as ensuring the trust achieves high levels of compliance for its statutory and mandatory training.
CLAHRC researcher Dr Jean Ledger is being honoured for an outstanding research paper on how health care organisations use management knowledge.
Dr Ledger is one of the authors of ‘The Silent Politics of Temporal Work: A Case Study of a Management Consultancy Project to Redesign Public Health Care’ which has won the 2017 Urwick Prize, awarded annually by the Worshipful Company of Management Consultants (WCoMC) for an outstanding recent piece of research relevant to management consultancy, published in the UK. The work addresses the tension generated between consultants and clients through their different perceptions of time.
Lead authors Professors Gerry McGivern, Sue Dopson and Ewan Ferlie attended an Education Supper hosted by WCoMC and were presented with the Cup in April by the Master David Johnson BA FCMA FIMC.
Professor McGivern will be delivering the Urwick Lecture on September 13 and the team will be publishing a book – with a launch scheduled for October.
The Prize is awarded annually to honour the life and work of Colonel Lyndall Urwick, who was a distinguished writer and thinker on the topic of management in the mid-20th century and the founder of Urwick Orr Management Consultants.
Details of the full paper are below
The Silent Politics of Temporal Work: A Case Study of a Management Consultancy Project to Redesign Public Health Care
Gerry McGivern, Sue Dopson, Ewan Ferlie, Michael Fischer, Louise Fitzgerald, Jean Ledger, and Chris Bennett
“Patient and Public Involvement (PPI) can often be something bolted on to research in a way that fits with the existing research plan. This makes research much easier to press ahead with, as the conflicting and changing opinions of the public do not need to change the planned course of progression. Unusual then, that PPI was considered to be an integral part of Power Up, and awarded time, resources, and influence. The young people who were involved have made great use of this newfound power. The Power Up app is fantastically tailored to the target audience because the target audience made it. The novel approach to PPI used in the project was important in hearing and using the young people’s views…I would urge future researchers to consider PPI as a vital part of research proceedings, as it has been in Power Up.” Project worker, Power Up
The Power Up study, supported by NIHR CLAHRC North Thames, has made the involvement of young people an integral part of the research process in work to develop an app to support shared decision-making in mental health. Power Up is a four-year research project to develop an app for young people to use from their first assessment with Child and Adolescent Mental Health Services (CAMHS) to empower them to be actively involved in decision-making.
Young people were active participants in taking the concept of a shared decision-making tool through design, prototype, and testing through three different types of involvement: governance of the project; needs and environment analysis; and detailed input for the development of the intervention.
PPI was embedded into the project model from the outset, to be iterative and cyclical informing the development and direction of the digital tool at each stage. Involving service users resulted in the identification and implementation of multiple changes to the app, both conceptual and tangible. Several challenges associated with PPI were also encountered, warranting future research and discussion.
One aspect of the GIRFT study uses statistical methods, including economic analysis, to examine ‘what works and at what cost?’
We are trying to assess whether the GIRFT programme has reduced variations in orthopaedic practice and costs, and improved patient outcomes. To do this, we are requesting confidential patient data for a group of patients who have undergone elective orthopaedic surgery between 1st April 2009 and 31st March 2018.
The data we would like to use include Hospital Episode Statistics (HES), a database containing details of all admissions to NHS hospitals in England, which is collected so that hospitals can be paid for the care they deliver. These data can also be processed and used for other purposes, such as research and planning health services. We would also like to use data from the National Joint Registry, which records details of joint replacement operations in order to monitor the results of surgery and protect patient safety.
Secure storage and processing of patient information
Researchers will not be able to identify patients, using the information that they are given by the organisations (National Joint Registry and NHS Digital). Personal identifiers of patients will only be securely transferred between these two organisations, so NHS Digital can link them together, to provide more accurate and complete information for researchers.
Both organisations will securely transfer pseudonymised data to researchers at UCL, so patient information can be processed without researchers being able to identify patients.
All pseudonymised patient information will be stored on a secure network that is password-protected, and can only be accessed by those with specialised training and access for the duration of the study.
If you would like further information about the use of your data in this research study, or would like to request that your confidential patient information is not included in this study, please contact us between 1st May – 1st June 2018 to discuss.