Findings
The authors compared experiences of patients affected by DVA with the perspectives of general practice healthcare professionals across four key themes: 1) coping with and responding to DVA during the pandemic; 2) availability of general practice; 3) consultations with general practice; and 4) the general practice response to DVA.
Coping with and responding to DVA during the pandemic
To provide vital context for patient and general practice healthcare professional interactions, this study shared perspectives from each group on how they experienced the pandemic in general. Interviews with patients affected by DVA helped to explain the health and social circumstances of patients when interacting with general practice. This study compared this with perspectives of healthcare professionals responding to DVA during the pandemic.
a) Adult patients. Adults affected by DVA provided a window into their life during the pandemic and in lockdowns, which for some patients had been traumatic. Those still in abusive relationships experienced worsening abuse.
One patient discussed the impact of the pandemic on his mental health:
‘[I] had to endure what I’ve endured before I’ve managed to escape and have the support which I needed, and then this has all come about now … It’s just almost like a double whammy for me, of the horrors I had to deal with last year, and to make that big step to do it, I have now, and there’s something else now to worry about.’
(Patient 6, male adult)
While a female patient experienced worsening coercive control and severe restrictions on her independence:
‘I felt like I couldn’t do anything because I had to be around him all the time.’
(Patient 9, female adult)
For others, the pandemic presented additional stressors, including financial and housing worries.
b) Child and adolescent patients. Children and adolescents affected by DVA shared information on their social circumstances during the pandemic, with direct relevance to their health and wellbeing.
Children affected by DVA discussed school closures during lockdown, with some feeling that they ‘didn’t mind it’ and one child feeling relieved to be at home:
‘Because I don’t like [the virus].’
(Patient 18, male child)
However, an adult participant, whose family were affected by DVA, was concerned about his 12-year-old son’s wellbeing at home:
‘He’s done nothing since February — well, since COVID, since leaving school in March, he would have been on that computer over 14 hours every day.’
(Patient 7, male adult)
An adolescent shared their worry regarding a shortage of services for mental health or relationship advice when they had been affected by DVA:
‘There’s a lot for little children, but not quite a lot for teenagers who are neither adults or eligible to be children any more. So, pretty hard for us … You’ve got that gap between 16 to 18 where nobody can really help you out with relationships or with your feelings.’
(Patient 21, male child)
c) Healthcare professionals. While trying to support patients affected by DVA, healthcare professionals also needed to rapidly adjust to new ways of working, including uncertainty regarding their future working practices:
‘Yes, a very different way of working at the minute, but it seems to be getting back to some type of normality in my other surgeries, but then it’s ongoing, we’re not sure how with the second lockdown or what is going on, forward. So, it’s kind of just being flexible and going with the flow.’
(Drug support worker)
Although there was a strong motivation to keep DVA in mind, there were competing pressures:
‘We’re trying desperately to deal with the physical, the COVID that’s going on, the massive mental health that’s going on. We’ve just got to keep remembering and trying not to switch off.’
(GP 1)
Availability of general practice
Patients reported barriers in accessing general practice during the pandemic: from a perception of general practice ‘being shut’, a fear of contracting the COVID-19 virus when entering the practice, to difficulties in arranging appointments. This occurred at the same time as a national general practice shift to remote consultations, aimed at minimising COVID-19 infection risk.
One patient described occasions of wanting to contact his GP. However, he was stopped by a perception of the practice being closed:
‘A couple of times I felt like I would have liked to have gone and seen them again, but with it being shut, I think I just left it … It’s basically, with the virus going on, I thought “Well, I’ll just get on with it a bit.” ’
(Patient 8, male adult)
Some patients discussed challenges in arranging a general practice appointment during the pandemic, for example, when wishing to discuss their medication:
‘It was just very difficult to get an appointment with the doctor, for them to review me, to continue. And I felt like I needed to almost go up on the medication. And I got to the point where I was like, “Do you know what? It’s causing me more stress trying to get hold of the medication.” ’
(Patient 15, female adult)
While healthcare professionals acknowledged difficulties in access for those affected by DVA was ‘scary’, they were being overwhelmed with the widening remit of general practice in response to the pandemic. As one nurse articulated:
‘That’s the scary thing is, it’s the most vulnerable time and probably the least … they have got the least accessibility to the practice and the GPs.’
(Practice nurse 3)
Consultations with general practice
The authors compared patient experiences of consultations in general practice with those of healthcare professionals, including perspectives on face-to-face versus remote consulting. While there was limited discussion with children about their experiences with general practice, healthcare professionals raised concerns about the visibility of children affected by DVA in remote consultations.
While some patients valued remote consultations when receiving focused long-term support from DVA specialist services, this was not reflected when disclosing to or receiving support from a GP. In a GP consultation, male and female patients overwhelmingly preferred face-to-face consultations to remote consultations. Reasons included being able to see the response of another person being facilitated when discussing personal DVA experiences:
‘Well, it is just being in the room with someone, isn’t it? And being able to open up to someone, and actually see who you are talking to, and see their responses when you are talking to them about problems.’
(Patient 9, female adult)
Others valued a face-to-face consultation for the opportunity to express non-verbal communication:
‘I prefer to see people face-to-face because I prefer to see their body language and for them to see my body language, because I talk a lot with my hands.’
(Patient 15, female adult)
Healthcare professionals agreed that remote consultations were limited by the loss of non-verbal communication, complicating DVA identification:
‘We got so much out of seeing our patients and physically seeing all the non-verbal cues. So, the advantage of having a [face- to-face appointment] is that I can talk to someone, and I know what they look like, and I know what they sound like, and I can tell when they’re not right.’
(GP 1)
However, one GP shared a specific case when a video consultation was helpful in achieving face-to-face by proxy:
‘She was one where I actually really saw the value of doing a video consultation … I spoke to her over the phone and she was kind of holding it together, and then when I spoke to her on video, it was just that, speaking to someone face-to-face where she broke down in tears … ’
(GP 3)
When discussing children with healthcare professionals, there was concern that an absence of face-to-face appointments had resulted in missed visual cues. Visual cues may be relied on to help identify DVA, especially if children may not communicate problems verbally:
‘We’re not seeing children, we’re not seeing whether they’re scruffy, unkempt, bruised, we’re not seeing women. All the cues that you would have got before, you’re not getting.’
(GP 1)
Healthcare professionals also noted that, in face-to-face appointments, they could ask a relative to ‘step out for a minute’, and remote consultations weakened opportunities to speak to children alone. They also found:
‘Lots of children tend to not want to speak [to me] over the telephone anyway and I end up speaking with their parents.’
(Urgent care practitioner)
Finally, one GP emphasised that face- to-face consultations had still taken place throughout lockdowns, although they acknowledged differences in communication across consultation models:
‘It is not that we have ever stopped seeing any patients, even at the height of the pandemic we were seeing patients, but yes, I guess the conversation and the relationship is slightly different when we are not face-to- face.’
(GP 6)
The general practice response to DVA
The authors compared what patients valued in the response from general practice with the strategies used by healthcare professionals to identify and respond to DVA. Patients appreciated a flexible, time- efficient response, as well as continuity of care and signposting to relevant resources. Healthcare professionals found a proactive, intuitive approach was important in consultations, as well as awareness of historical DVA in the medical record, multidisciplinary working, and connectivity between general practice and DVA services.
In receiving help, patients valued a prompt and flexible response from the practice. One patient shared how this response enabled them to speak freely, away from an abusive partner:
‘It was done over the telephone to the COVID situation. Originally, I contacted her, and my husband was in the room at the time, so I said about some issues that I was experiencing, and the things that I could say in front of him. Then she asked me to pop down to the surgery to get a couple of tests, and at that point I spoke to the receptionist who came out to me. I explained that I needed to hopefully speak to the doctor again. I said, “I want to talk without my husband being around.” She quickly said, “That is absolutely fine, go and sit in the car and we will contact the doctor to call you again.” Within about ten minutes my doctor called me back and I was able to have a confidential conversation without my husband being there.’
(Patient 10, female adult)
Continuity of care from the same GP was felt to be essential:
‘She’s been with me all throughout my journey of feeling anxious.’
(Patient 12, female adult).
In addition, patients appreciated relevant signposting and the availability of options when discussing DVA:
‘She listened to what I needed to say, and gave me all the options that would be available that I would consider … Yes, it was quite a nice conversation in the grand scheme of things.’
(Patient 10, female adult)
When trying to identify and respond to patients affected by DVA, healthcare professionals were proactive and used their instinct:
‘Something that makes you think, “Oh, that doesn’t sound right.” So, you’ve got to be much more switched on … I’ve spoken to one person and said, “Are you safe? Can you talk to me? Are you safe at home?” and that was … I don’t even remember now why I wondered about that, but it just felt something that I needed to check … A lot of it is instinct.’
(GP 1)
Alerts in the electronic medical record, including if a patient has experienced historical DVA, was another useful reminder for healthcare professionals to think about DVA in consultations. Sharing concerns about patients in multidisciplinary meetings, including with midwives, health visitors, and palliative care teams, was an additional mechanism in identifying and responding to DVA using a team approach.
