Lucy Clarke and Kim Jones
Betsi Cadwaladr University Health Board with Domestic Abuse Safety Unit (DASU) and the Elizabeth Casson Trust
Background:
The increased incidence of domestic abuse, following Coronavirus, jeopardizes service user’s physical and emotional wellbeing and affects daily social and cognitive function, affecting relationships, employment and daily living skills. Oliver et al., (2019) estimated the cost of domestic abuse to the economy as £34,015 per victim, per year.
The Occupational Therapy Department within the East area of BCUHB were successful in securing funding from the Elizabeth Casson Trust for a Band 5 Occupational Therapist, experienced in domestic abuse, to work within the local DASU. Our intention was to provide rehabilitation, through Occupational Therapy, to victims of domestic abuse, allowing them to re-engage in daily social, educational, occupational, behavioural and cognitive activities, helping to rebuild their identity and life.
Project Aims:
This project aimed to provide an Occupational Therapy service, co-located within DASU to:
- Provide early intervention and mental health rehabilitation ’upstream’, embedding self-management strategies to support wellbeing into daily routines, for people recovering from the trauma of domestic abuse.
- Use a person-centred approach to identify individually meaningful occupational goals for daily living following domestic abuse, overcoming barriers, and enabling development of occupational identity through meaningful activity and roles within home, family and community life.
- Harness a network of health, social care and third sector providers to deliver appropriate prudent support to individuals seen.
Challenges:
This new service took additional time to establish due to the ongoing ‘lock down’ for COVID-19. Service users had to prioritise home schooling, and had difficulty attending 1:1 appointments. Not all service users were able to use virtual support, dependent on their ability to have privacy and access to digital technology. Many community activities, supports and 3rd sector services remained closed or with limited virtual programmes. Consequently, no group work was offered and networking with partners was done in small groups and remotely.
In addition, it became apparent through the project, that prudence would be improved through employing additional Occupational Therapy Assistant Practitioners, to support practice of skills developed within therapy.
Key Outcomes:
- Approximately 500 people from partner organisations contacted, influenced or educated about Domestic Abuse, the Domestic Abuse Safety Unit and service, and the role of the Domestic Abuse Occupational Therapist.
- Feedback from multidisciplinary/ agency colleagues within and without DASU has evidenced the positive impact of the Domestic Abuse Occupational Therapist on moral, engagement and multi-agency working (Click here for more detail)
- Documents and processes for use within an Occupational Therapy pathway, from referral through to discharge have been created for this service, in readiness to adopt and spread the service across Wales.
- 30 people have been seen by the Occupational Therapist across the period of the project pilot. All of working age, and all female. (Click here for demographic information)
- 8 onward referrals made to manage significant risk.
- 20* people engaged with Occupational Therapy intervention. *(1 person declined to complete scores)
- 15 people made significant* improvement with their ability to perform their chosen occupations as measured with the Canadian Occupational Performance Measure (COPM) (Carswell, A. et al. 2004). See Chart 1.
*(A score of 2 or over is considered statistically significant as measured by the COPM).
Chart 1. Changes in ‘Performance’ scores for people following Occupational Therapy intervention on the COPM.
Occupational Therapy intervention resulted in progress with goals:
A thematic analysis of all personalised occupational goals, set by individuals, identified eight themes. Click here for more information.
It is interesting to note that 43% of the goals identified by service users pertained to managing symptoms and carrying out an important role such as being a worker, student, or parent.
Quotes from service users illustrated progress with being able to perform personalised goals against the eight themes:
Cope with symptoms
‘I don’t want to die any more, I want to live and know what it’s like to live free.’
‘I had a panic attack, before college but I’m here and I’m okay.’
‘My fibromyalgia is under control, due to the reduced stresses.’
‘I feel less of an emotional connection to my ex.’
Look after myself
‘I have washed my hair before you arrived.’
‘I have started eating healthier food choices that I prepare.’
‘I am engaging in outdoor fitness activities, to help with my weight loss.’
‘I had a bath for the first time in a long time.’
Find enjoyment
‘Spending time with my horse is more of a joy than a hindrance.’
‘I have started to watch music videos on the TV, and enjoy them.’
‘I went to my sisters and actually relaxed while sitting in her garden.’
See friends
‘I completed a 40 minutes Wii workout with my friend and had fun.’
‘I have made contact with my best friend of 20 years, as I am now free to do so.’
‘I have started meeting my friends during the day, to go shopping and have lunch.’
Hold and carry out an important role (worker, student, parent)
‘Work have seen a massive change in my productivity, quality and concentration.’
‘I am shocked and proud that I have lasted this long in work without the urge to avoid going.’
‘I just got 100% in both my exams.’
“Thank you for your support getting me in touch with mental health services” (for her son) …
Establish a routine
‘The dog and myself have a pleasant evening routine.’
From the case-record “Carol stated that due to the new skills, Goals, routine and anxiety management she is able to remove herself from negative thoughts and feelings.”
Have and look after my home
‘I can recognise things I love about my home.’
‘I went upstairs and cleaned my windows, for the first time in years.’
‘I am beginning to catch up with things I have been putting off, such as taking the dog for his booster.’
From case-record, ‘Sarah reported that she has developed a tick list for; bills to pay, emails to send, and people to speak to.’
Have confidence to get out
‘Guess what I did last week, took the dog for a 5-minute walk.’
‘I spent 20 minutes in a neighbour’s garden, talking to her.’
‘I went for a coffee on my own in the village at the weekend, it was lovely.’
The combined effect of managing every day activities improved overall satisfaction with performance and quality of life.
Occupational Therapy saved significant costs to the economy in line with Prudent Principles
On average, the person living with domestic abuse, experiences the cycle of violence 36 times while exiting and re-establishing the relationship seven times before the relationship is finally over. This is catastrophic to employment, housing needs, health service and the legal system.
Domestic abuse costs the economy approx. £34,015 per victim per year (Oliver et al., 2019).
The cost to the economy associated with health costs addressing emotional harms and lost output alone range between £3,610 and £308,510 per victim per annum, dependent on the severity of the abuse, extent of harms, and the level of earnings of the individual.
Consequently, providing upstream early intervention and therapy to support return to daily activities such as work, and improving emotional wellbeing and resilience will have a significant impact.
Total savings to the economy for the 15 people who made significant progress with daily living having completed OT intervention is £510,225 as calculated from this data, representing a significant return on investment for 1 band 5 Occupational Therapist!
If all currently undergoing Occupational Therapy have the predicted outcomes with the COPM then this equates to total savings to the economy of £510,225.
Case Study:
Mair (pseudonym) presented to DASU after ending an abusive relationship that she had tried and failed to leave, several times, over 7 years. Download the case study to see how Occupational Therapy intervention helped her to move on, and make this the last time. (References are here).
Next Steps:
We are exploring further funding streams to continue and expand the project across BCUHB, with the Occupational Therapy service providing clinical governance and acting in partnership with domestic abuse service providers, such as DASU. A service specification and training resource to support Occupational Therapists, who undertake such work, are in draft form.
Our Exemplar Experience:
It has been fascinating, all-consuming and a steep learning curve to deliver this project. The Bevan exemplar education programme has been supportive, helping me to keep on track and developed my skills, helping me to manage, supervise, support and lead the Occupational Therapist providing the service. I would recommend the programme to anyone developing a prudent innovation within the NHS.
Showcase:
Thank You Elizabeth Casson Trust
A full report was completed for the Elizabeth Casson Trust. This can be found here.
Lucy Clarke;: Lucy.Clarke2@wales.nhs.uk
Kim Jones: Kim.Jonesa5d87@wales.nhs.uk
