Guidelines for Implementation
Directorate of Healthcare Policy and Strategy
Scottish Government
July 2009
CONTENTS
- Purpose of paper
- Background
- Implementing the CEL on gender-based violence
A.Establishing an infrastructure
B.Developing an action plan
- Routine enquiry
ii.Dissemination of revised guidance on abuse
iii.Employee policy
iv.Multi-agency collaboration
- Role of the National Gender-Based Violence Team
- Monitoring and evaluation of the CEL
- Conclusion
Appendix 1Implementation schedule
Appendix 2Action plan template
Appendix 3Self-assessment baseline data pro-forma for Routine Enquiry
Appendix 4What needs to be in placebefore introducing Routine Enquiry?
Appendix 5 National GBV Team contact details
1. This paper provides further planning guidance to territorial Health Boards in relation to the requirements of the Chief Executive’s Letter (CEL) on Gender-Based Violence( It includes information on constructing an action plan for its implementation and on the baseline data needed to establishindividual Board targets. The role of the national team, which has been established to support and guide this process, is also outlined.
2. A 3-year programme of work to improve the identification and management of gender-based violence across NHS Scotland commenced in October 2008 with the issue of CEL_41 to Health Boards. This letter outlined the areas of development required to fulfil the aim of adopting ‘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’. Understanding this work will assist Boards meet their legislative obligations to promote gender equality as detailed in the Equality Act 2006.
3. The objectives of the programme are:
- To improve the healthcare identification of abuse
- To increase the institutional capacity of Health Boards to respond to abuse
- To develop indicators and establish healthcare outcome measures
- To develop comprehensive standards of care in relation to the different forms of gender-based violence
- To ensure that gender-based violence is integrated into the relevant strategic and planning frameworks
- To ensure the NHS contributes effectively to multi-agency efforts to address abuse
4. To progress these objectives, and to make the programme manageable, 4 key deliverables have been agreed:
- Implementation of routine enquiry of abuse within the priority settings of mental health, maternity, addictions, sexual & reproductive health, A&E, and primary care.
- Dissemination of revised guidance on abuse for staff.
- Production of an employee policy on gender-based violence.
- Multi-agency collaboration on gender-based violence particularly in relation to child protection and homelessness.
5. Each Health Board is expected to produce an action plan detailing how it will meet these deliverables by the end of September 2009. The key elements to be included in the plan are outlined below.
A. ESTABLISHING AN INFRASTRUCTURE
6. Each Board has been asked to identify an executive lead responsible for ensuring that the work of the GBV programme is undertaken. An operational lead is also recommended to guide and implement the programme.
7. In most Health Board areas an overarching steering group has been established with a remit to co-ordinate, oversee and report on the progress of work. The particular circumstances of each board will determine the viability or utility of adopting this approach, however, and you may therefore identify an alternative structure that is more appropriate for your needs. In relation to the specific priority services within which routine enquiry is being introduced, it may be helpful to have a sub-group that can plan this work in more detail and report back to the wider group.
8. Whatever structure is decided, there needs to be a system in place to ensure that information can be provided for the ongoing monitoring and evaluation process. Having a clear, accessible process for guiding and monitoring the work will be of paramount importance, and will allow the national team to engage most effectively with Boards to support its implementation. Identifying key people with whom the Regional Advisors and the Performance & Information Manager can link will therefore be essential in maximising the team’s contribution to local developments.
B. DEVELOPING AN ACTION PLAN
9. The action plan should cover the work planned within each Board to implement the requirements of the CEL. As the programme develops it is anticipated that there will be opportunities for collaborating on new initiatives both within and across Boards e.g. within the research programme. The action plan should therefore be viewed as a live document which each Board will review on a 6monthly basis with its Regional Advisor and against which it can benchmark activity and progress.
10. A schedule outlining the timescales for the work of the programme is provided to help Boards plan their activity (Appendix 1).
11. The action plan should incorporate key information on:
- What actions are planned
- Where and when these will be implemented
- How this will be done
- Who has lead responsibility
- How you will know the actions have been achieved
12. You do not have to put a huge level of detail into the action plan. It is important, however, that it addresses these areas and presents a clear picture of how your Board will implement the CEL. Each plan should indicate where and when an equality impact assessment will be undertaken to ensure that the differential needs of service users and staff are identified and addressed.
13. Below are some of the key points that need to be considered in planning and executing the programme at a local level for each of the 4 deliverables. It would be helpful for the action plan to reflect how this planning will be undertaken as well as noting expected outcomes.
14. An action plan template is provided which you can use if you find it helpful. (Appendix 2).
(i)Routine enquiry
- Of the 4 key deliverables in the CEL, the introduction of routine enquiry will necessitate the most careful planning. It is not a screening process in the traditional public health understanding of the term but is rather designed as a means of supporting diagnosis and assessment of service users’ needs to ensure most appropriate treatment and care.
16. Although it is crucial to gather data on the frequency of presentations of abuse, this is notthe only, or indeed primary, purpose of routine enquiry. Furthermore, such data cannot represent prevalence since a significant number ofwomen and men donot report abuse to official agencies.
17. The priority settings identified for routine enquiry of abuse have been selected because of the disproportionate numbers of patients presenting to these services who have experienced, or are experiencing, abuse and for whom this may be associated with their health problems. This isnot a universal programme for all service users, but will primarily focus on initial presentations within these services.
18. A phased introduction of routine enquiry should be undertaken to ensure it is manageable for staff and to allow its impact on services to be assessed. This approach will alsoassist in identifying what works most effectively within different areas and with different client populations. In rural & island areas, for example, the national team have had early discussions with Boards around the possibility of piloting different methods of introducing routine enquiry to address concerns around anonymity for service users.
19. Not all forms of abuse are included in routine enquiry. In relation to mental health and addictions, women and men will be asked about childhood sexual abuse given the evidence of its adverse impact on people using these services, and women will be additionally asked about domestic abuse. In the other priority settings of maternity, sexualhealth and community nursing, routine enquiry of domestic abuse will be introduced for female service users.
20. Selective enquiry of domestic abuse is advocated for men experiencing domestic abuse in both heterosexual and same sex relationships given the lack of evidence in relation to prevalence data, health impact and appropriate interventions concerning such abuse that would meet the criteria for routine enquiry. There is also insufficient evidence of the acceptability by men about being asked about abuse. It is important, however, that staff are aware of this issue and it will accordingly be included in the training provided. It is also anticipated that the practice of routine enquiry may serve to raise practitioners’ index of suspicion around the ways in which male survivors may present and increase their confidence in broaching this issue.
21. In A&E the planned initiative with the Violence Reduction Unit to ask all patients presenting with injuries about how and where these were sustained will include domestic abuse as well as other forms of violence. The national team will work with Boards to explore the capacity issues in relation to extending this further to include other presentations.
22. GPsare not expected to undertake routine enquiry, but it is anticipated that their involvement in addressing abuse will be encouraged at a local level, and that they will have access to the practice guides being developed by the national team.
23. The Royal College of General Practitioners has issued the following statement indicating its support for the national programme:
‘RCGP Scotland welcomes the move by the Scottish Government towards addressing issues around gender based violence, through appropriate training and empowerment of frontline healthcare staff.’
24. The national team and RCGP Scotland have agreed to work together to ensure that GPs are kept informed about developments in this area of work.
WHAT DO YOU NEED TO DO?
25. Detailed guidance on introducing routine enquiry, tailored to the needs of the specific priority settings, will be produced by the national team. At this stage, the action plan should outline where, when and how you propose to introduce routine enquiry. The following are key considerations for your planning:
- Identification of initial services where routine enquiry will be implemented
In keeping with the staged approach to implementation, identify the services within the priority settings where you wish to begin routine enquiry and how you envisage this being rolled out across other services. Community based services should be the initial focus for mental health, addictions, sexual health and community nursing.
- Assess current stage of readiness in selected services for routine enquiry
A self-assessment form is provided (Appendix 3) to assist you in recording the current approach to the identification and management of abuse within the initial services selected in the first stages of routine enquiry, and to identify the steps which may need to be undertaken to ensure it can be introduced appropriately across the service.
This information will providethe baseline data needed as part of the monitoring and evaluation process.
The information is also important to assist the planning of staff training for routine enquiry. The national team is developing training materials that are tailored to the needs of each priority setting, and is negotiating and co-ordinating the delivery of this training across Health Board areas. To do so effectively, the number of staff requiring training has to be identified as soon as possible.
The action plan should reflect when this process will be undertaken for the initial services and should indicate how it will be conducted with further services as routine enquiry is rolled out.
- Strengthen current practice
In some areas, e.g. maternity services, routine enquiry may already be established practice. In such cases, we would ask that Boards review current implementation to identify whether there are areas that require strengthening e.g. in relation to the recording and collation of data around abuse, and for this to be reflected in the plan.
A ‘checklist’ of what needs to be in place to fulfil the requisite conditions for implementing routine enquiry sensitively and safely is provided (Appendix 4). This may help you to identify particular issues to be addressed where routine enquiry is already underway, or indeed in terms of identifying the work required for its introduction in other services.
- Timescales
As noted in the CEL, the phased, gradual approach to implementation is designed to make the programme manageable for Boards, and to ensure that enough time is accorded the planning of this work to safeguard the welfare of both staff and service users.
It is recognised, however, that some Boards have already developed initiatives across the priority settings and they may wish to accelerate the programme in these areas.
It would be helpful for the plan’s Year 2 activity to clearly identify the steps being proposed for the smooth introduction in Year 3 to A&E, community nursing & sexual health services.
ii) Dissemination of revised guidance on abuse
26. A range of practice guidesdefining the nature of the healthcare role in relation to the different forms of gender-based violence will be distributed to Boards later this summer. Additional materials will be developed as the programme progresses, and web space will be set up for staff to access otherliterature around abuse.
27. Staff need to be aware of, and have access to, these resources. Achieving such an objective can be challenging, particularly within larger Boards, and we are aware of the volume of information that staff are expected to absorb. Whilst Boardsare asked to be proactive in disseminating these materials, an incremental approach may be required. The action plan may therefore include reference to:
-How staff within the priority areas where routine enquiry is being introduced will access the new practice guides.
-Communication with other staff to alert them to the availability of the guides e.g. road shows, events, staff newsletters, wage slips, posters, protected learning time etc.
28. Resources of up to £10K p.a. are available to each board to promote these materials during the course of the programme.
iii) Employee policy
29. Given the number of staff employed in NHS Scotland there inevitably will be a significant number within the workforce who have current or previous experience of abuse. For some this may be causing distress or interfering with their ability to cope. Additionally, there will be employees who are perpetrators of abuse. Currently a number of Boards have a policy for employees experiencing domestic abuse, although it is uncertain to what extent staff are aware of these or have sought support via such policies.
30. As an employer, NHS Scotland is committed to promoting the welfare of its staff and the CEL accordingly has the development of an employee policy on gender-based violence as one of its key deliverables. Since there are 22 Health Boards in Scotland, however, it is a duplication of effort for all to develop individual policies. Staff Governance at the Scottish Government will therefore take responsibility for developing one policy for all staff in conjunction with the national team, the unions and the staff side. It is hoped that this will be completed by spring 2010, and local action plans should therefore indicate how this will be implemented at Board level.
iv) Multi-agency collaboration
31. The NHS has a pivotal role to play in identifying and responding to abuse. Nonetheless, it is more effective in discharging such a role when it works collaboratively with other agencies to provide a seamless and co-ordinated approach. Most Boards will have some degree of engagement with multi-agency partnerships or local training consortia. The degree and nature of this involvement will be shaped by local circumstances and resources. It is anticipated that action plans will therefore reflect the differing arrangements that exist.
32. Routine enquiry of domestic abuse is identified as Priority Area 1 in the National Domestic Abuse Delivery Plan for Children and Young People, reflectingthe interconnection between women and children’s safety. Ensuring clear linkage with the wider child protection arrangements around the issue of abuse is consequently important.
33. The newly formed Adult Protection Committees will also be considering the impact of abuse for vulnerable adults. Through its representation on these committees, the NHS can raise the profile of this issue. This should obviously be in cases where the criteria identified in the legislation are met since the existence of abuse per se is insufficient to meet the criteria for an adult in need of protection.
34. Similarly local action plans for health and homelessness should indicate where the issue of abuse is being addressed given its role in precipitating homelessness as a primary or secondary factor.
35. The national team comprises a Programme Manager, 3 Regional Advisors, a Performance & Information Manager, a Research Manager and administrative support. (See Appendix 5 for team contact details).
36. The Regional Advisors will support and guide Boardsto implement the CEL and as such will be their key contacts. They will seek to ensure a smooth flow of information within and across Boards, and will share developments and good practice across the country.
37. As noted in the CEL, training will be provided for staff undertaking routine enquiry. The Regional Advisors have established a number of sub-groupsto produce training materials designed to meet the specific needs of the different priority settings. This training will be planned and co-ordinated by a national group, and will link with the National Training Strategy on Violence against Women Team and local training consortia.
38. The Regional Advisors have a further role in monitoring the implementation of action plans, including mutually agreed targets and timescales. This should hopefully allow for early identification and resolution of any issues or difficulties that may arise. To support this process we would encourage Boards to link Regional Advisors into their local steering groups.