A new paper by researchers from the University of Bristol and NIHR CLAHRC North Thames highlights the post-trial journey of an evidence-based domestic violence and abuse (DVA) intervention to the NHS front-line, and the human and contextual factors that influence how its effect is sustained over time.
IRIS (Identification and Referral to Improve Safety) is a general-practice-based DVA training, support and referral programme. The programme develops DVA awareness and skills among general practice staff and provides a referral pathway to a named DVA advocate (IRIS advocate educator) based in a third sector agency. IRIS advocate educators provide IRIS training and ongoing support, consultancy to practice staff, and advocacy to referred patients.
Following a successful randomised controlled trial, IRIS has been implemented in over 30 local authorities in the UK. The trial and local evaluations of implementation showed an increase in referrals from general practice to third sector DVA agencies, with variation in referral rates within and across practices.
In this new study, we aimed to understand the reason for the variability in referral rates by identifying factors that influenced the implementation of IRIS in the NHS. We used mixed methods (including a case study, survey and qualitative interviews) and Normalisation Process Theory (NPT) to evaluate what was happening on the ground.
NPT is a theoretical framework researchers use to unpick the human and contextual elements at work around a new set of practices, such as those within the IRIS programme. The theory helps us understand the path of a complex intervention requiring multi-agency cooperation.
What we found
We found that IRIS training in itself is not enough to change and maintain professionals’ behaviour and that ongoing support of trained staff at practice and commissioner levels is required to sustain the number of referrals.
We found that the IRIS advocate educator was the main driver of implementation, acting as a broker between the differing organisational cultures of general practice and the third sector. The continuity of the IRIS advocate educator and her ability to adapt IRIS to the overstretched general practice team helped to maintain the number of DVA referrals.
A major barrier to the sustainability of the number of referrals was the short‐term funding of IRIS, resulting in staff turnover in the third sector agencies, professional uncertainty and loss of trust in the programme across both sectors.
Interestingly, a consistently high number of DVA referrals did not ‘protect’ the third sector agencies from a period without funding in between short-term funding time-frames.
Our research highlighted the fact that differing cultures between NHS and third sector agencies require additional skills and resources to bridge the two in a multi-sector response to DVA. It also highlighted the need for extended funding periods for IRIS.
Our findings are relevant to the implementation and sustainability of any complex intervention which involves multi-agency work when providing whole-person care to patients with medico-social problems. As such, they will be of interest not only to those who support people who have suffered DVA, and those who commission the services that provide this vital support, but to the wider academic and health and social care communities.
Read the CLAHRCBITE, which summarises the study’s findings and highlights recommendations for commissioners and policy makers (downloadable pdf).
The study is one of three to evaluate post-trial implementation of the programme in the real-world NHS. The papers are:
- Implementation of the Identification and Referral to Improve Safety programme for patients with experience of domestic violence and abuse: A theory based mixed method process evaluation by Natalia Lewis et al. Published in Health and Social Care in the Community 2019.
- Cost-effectiveness of a domestic violence and abuse training and support programme in primary care in the real world: updated modelling based on an MRC phase IV observational pragmatic implementation study by Estela Capela Barbosa et al. Published in BMJ Open 2018.
- Improving the healthcare response to domestic violence and abuse in primary care: protocol for a mixed method evaluation of the implementation of a complex intervention by Alex Hardip Sohal et al. Published in BMC Public Health 2018.