On the right Path

March 11 2021 saw the launch of the independent evaluation report of the Pathfinder project, conducted by Cardiff University. The project was the first systems-change initiative to bring together national good practice around responding to domestic abuse across the health economy. In this blog, evaluator and presenter Dr Kelly Buckley discusses the event.

Kelly Buckley | Cardiff University | DECIPHer
Dr Kelly Buckley

Even before we began the evaluation of Pathfinder, we were excited to release it into the world. We knew that the project had the potential to change the health system’s response to victim-survivors of domestic abuse, and that our evaluation report would hold some key learning that would help policy makers, commissioners and professionals from health and domestic abuse specialist services to do this. Having worked in and with the domestic abuse field for ten years, I know how much professionals and commissioners value robust research to evidence the value of their work, particularly interventions based in health settings where data is needed to encourage everyone to see domestic abuse as a public health issue, and invest in tackling it as part of the core business of the NHS. We were careful in writing our report to make sure we appropriately represented all the professionals, but more importantly all the victim-survivors who kindly shared their experiences with us as part of the research.

When Professor G.J. Melendez-Torres, Bethan Pell and I were invited to present our final report findings at an online launch on the 11th March 2021, it wasn’t quite how we had envisaged doing it: our grand plans for an in-person launch (and let’s face it, we’re all missing the free tea, coffee, cakes and chat you get at such events!) had like so many events moved to the virtual world. Still, we all got our glad-rags on, did our hair, and got our backgrounds ‘zoom-launch ready’ to showcase our report to the ‘room’ of participants who were eager to hear what we had found.

The crux is to improve the awareness, knowledge and skills of health professionals and the systems within which they, in order to increase their ability to routinely and sensitively enquire about domestic violence and abuse’

The event was coordinated by the Pathfinder Consortium of domestic abuse organisations who coordinated the intervention: Standing Together hosted the event, and Donna Covey from AVA expertly and enthusiastically chaired. Nicole Jacobs, the Domestic Violence Commissioner for England and Wales, spoke ahead of us to outline the aim and scope of Health Pathfinder, and the key role transforming the health response to domestic abuse plays in identifying and supporting victim-survivors. She spoke passionately about the project’s potential to engender a whole health system response to domestic abuse and the benefit it would be to victim-survivors if domestic abuse was considered the core business of the NHS. Nicole provided the perfect introduction to help contextualise our findings and outline why the health service is so important in identifying and supporting victim-survivors, and how we owe all victim-survivors an appropriate health response.

G.J., Bethan, Kelly and Donna Covey present

To combat the dreaded ‘zoom fatigue’, our event was only 90 mins long, and also included a presentation from a related project by Sandi Dheesa looking at the issues around flagging domestic abuse on health records. We also wanted a decent chunk of time for a panel Q&A at the end, so we faced the challenge of presenting the main messages from what is a mammoth report in less than 20 minutes. G.J., who led the evaluation, began by outlining the key questions of our evaluation: what is Health Pathfinder, what did it achieve, how did it work, what was it like to implement and how do we move forward?

As a jumping off point for our evaluation, we developed a logic model, which helped us map the multiple components of what was a complex intervention, and how those components work together. The audience learned what Pathfinder was: participating sites looked very different in nature and scope because they were able to shape implementation to their own needs depending where they were on their journey of tackling domestic abuse. Sites were from across the health system, including acute, mental health, primary care and dentistry.

We found that Pathfinder increased rates of referral to Multi Agency Risk Assessment Conferences (MARACs), suggesting that it also generated system-level improvement in identification of high risk cases.’

The crux of the Health Pathfinder intervention is to improve the awareness, knowledge and skills of health professionals and the systems within which these professionals work, in order to increase professionals’ ability to routinely and sensitively enquire about domestic violence and abuse, in order to increase the confidence of victim-survivors to disclose, and to receive a professional response that in turn leads to a timely referral to specialist services. Elements of Pathfinder implemented by sites included training professionals, co-locating domestic violence and abuse services in clinical settings, implementing new governance structures, establishing and supporting domestic violence and abuse coordinators, undertaking needs assessments, enhancing data collection strategies, and reviewing clinical policies relating to domestic violence and abuse.

G.J. presented highlights from the chapter in our report that outlines what Pathfinder achieved, mainly that it contributed to the timely identification of victim-survivors before they experienced high levels of risk. We also found that Pathfinder increased rates of referral to Multi Agency Risk Assessment Conferences (MARACs), suggesting that it also generated system-level improvement in identification of high risk cases.

Bethan then presented our findings about how Pathfinder was understood to work and create changes. We found that the intervention worked by creating five key ‘change mechanisms’: the foundational mechanism was to generate awareness of domestic abuse within health settings for professionals and victim-survivors; the second was to generate expertise among health professionals to identify and enquire safely; the third was to generate relationships between multi-agency professionals to create spaces to share expertise, support one another and work together; the fourth was to create a supportive group of professionals that empower health professionals with the confidence to put their new found expertise into practice; and the final mechanism was to generate data and evidence to demonstrate the value of the intervention and highlight areas for improvement.

Victim-survivors stressed the value of competent and sensitive responses from health professionals to help them to safety: indeed, they told us how it can be life-saving in more than one sense of the word when a health professional asks and acts.’

I then presented our findings about what it was like to implement the intervention from the perspectives of the professionals involved.  We identified several factors that professionals identified as affecting the way in which they implemented Pathfinder, these were: whether they had a history of implementing domestic abuse interventions previously; the presence of preconceptions and stigma about domestic abuse at individual and organisational levels; how these two factors played a role in whether Pathfinder was seen as relevant; and practical and structural factors that affected how the Pathfinder roles were able to embed into the health department.

After we presented the highlights from our report, the audience asked us some really important questions. We were pleased to be able to sense the enthusiasm excitement of participants ‘in the room’ through the chat function and the Q&A box, and the discussion was really engaging. We were asked our thoughts about how we move forward with this project, in a field so constrained by limited funding and commissioning cycles. The continued funding of interventions such as Pathfinder is crucial: our evaluation showed that the appetite was there to continue and build on the practices started by Pathfinder.

We were also asked to say more about what victim-survivors shared with us, who stressed the value of competent and sensitive responses from health professionals to help them to safety: indeed, they told us how it can be life-saving in more than one sense of the word when a health professional asks and acts. It is vital that commissioners finance the roles and initiatives that were a part of Pathfinder to create the changes that enable the health service to respond adequately to victim-survivors.

The full report can be read here.

The Pathfinder project was delivered in eight sites across England by a consortium of expert partners (Standing Together Against Domestic Abuse, AVA, SafeLives, IRISi, Imkaan). More about Pathfinder can be found here.

Dr Kelly Buckley, a Research Associate at DECIPHer, is a sociologist, with interests in gender, the media and gender-based violence.

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