IRISi: Changing how healthcare responds to domestic violence and abuse

Using a social franchising model, the IRISi team enhanced the experience of each and every victim of domestic abuse who receives medical care.

One in four women and one in six men will experience domestic violence and abuse (DVA) during their lifetime, and healthcare professionals are often the ‘first point of contact’ victims and survivors. The initial action a survivor receives, and the subsequent follow-up in the wider system, can profoundly affect their ability to re-establish their life, health, and well-being but practitioners often lack the awareness, skills, or time to recognise and respond appropriately to DVA.

IRISi is a social enterprise established in 2017 to improve the healthcare response to gender-based violence. IRIS (Identification and Referral to Improve Safety) – its flagship intervention – teaches general practice teams how to identify patients experiencing the health impacts of current or past domestic violence abuse, enquire sensitively, document this in their medical records, and refer them to an advocate-educator for specialist support.

Between 2017 and 2021, the IRISi team was one of four health innovators in the Exploring Social Franchising Programme – an initiative delivered by The Health Foundation and Spring Impact to explore how social franchising principles can support scaling up within the NHS.

When IRISi started operations, the IRIS programme had already scaled organically and had seen much success in the process, being adopted by around 33 sites. However, a lack of planning or a strategy behind the scaling approach and limited systems and documentation to support the programme’s effective implementation led to inconsistencies in how the different implementers delivered the programme, depriving many victims and survivors of the care and support they needed when disclosing the abuse they had experienced.

“We were experiencing problems. Our partners didn’t know how much flexibility they had to tailor things to local circumstances. As a result, some areas started to deliver our programme in a way that wasn’t true to our model, which brought poorer outcomes for the local stakeholders and us”, mentions Lucy Downes, Network Director at IRISi.

There is when the expertise and support from Spring Impact came in.

“
Before the programme, we discussed the fidelity of local implementation and measured our progress through the amount of training delivered. Now we have learnt to focus on the impact of the problem
”

Increasing reach but not overlooking quality and impact

Supported by Spring Impact, the IRISi team developed a social franchise model for replicating the IRIS intervention. The first steps were focused on defining their intervention’s core – establishing sustainable behaviour change – particularly which key aspects make it work and how they see themselves in the future.

“Once our long-term plan and strategies were set up, we focused on piloting social franchising and expanding our team to include critical specific expertise that we didn’t have before around data monitoring and evaluation, as well as communications and marketing, which was beneficial”, remarks Lucy.

Selecting the right partners

Following the social franchising model, IRISi adopted two approaches to identifying and developing implementer sites. The first was a “commissioner-led” approach in which commissioners agree on funding, and then a local provider is recruited as the IRIS partner organisation. The second is a “partner-led” approach, in which IRISi identifies a suitable IRIS partner organisation first and then works collaboratively with them to secure funding.

In its initial growth phase, the IRIS team worked with any partner that approached them. However, throughout the programme, the team developed a robust recruitment process, including identifying essential criteria all partners must satisfy, such as being a specialist DVA organisation. By ensuring they are working with implementers with the right motivation and skills, the IRISi team can use their resources best and help potential partners identify what is needed for success.

Systemising and documenting the intervention

During prior scaling efforts, the IRIS team lacked the skills and time to sit down and fully document their intervention, contributing to issues with the fidelity of implementation.

Spring Impact supported IRISi to systemise all their documents and processes to deliver the programme as they wanted. The team codified the intervention and developed the systems needed for partner recruitment and quality assurance. This was a learning experience for the IRIS team but was essential in enabling them to empower local partners better to deliver the model independently.

Using this approach, following comprehensive training and initial support, partners were able to deliver the model independently, achieving the expected quality standards and retaining an ongoing relationship with IRISi. Moreover, from the beginning of the intervention, the IRISi team informally compared compliance with the model between the franchisees and non-franchisees sites and viewed that fidelity in the franchise sites was much higher.

“The training from Spring Impact gave us a solid foundation to tell the sites consistently how the programme needed to be run, which aspects can be adapted to local circumstances and which ones couldn’t be changed. The support was always thoughtful, with hand on support at the beginning and a gradual step back to enable us to do the reviewing and refining we were working on”, emphasises Lucy.

“
The training from Spring Impact gave us a solid foundation to tell the sites consistently how the programme needed to be run, which aspects can be adapted to local circumstances and which ones couldn’t be changed
”

The results

Currently, IRIS counts 39 sites across the UK, and 4 more are in the pipeline. However, from an IRISi perspective, their most significant achievement is to improve practitioners’ response to domestic abuse and gender-based violence across all patients in the NHS, enhancing the experience of every person receiving medical care.

“Before the programme, we discussed the fidelity of local implementation and measured our progress through the amount of training delivered. Now we have learnt to focus on the impact of the problem and the difference in GP behaviour and referral numbers. This has changed the strategic focus of our decision-making, focusing on creating sustainable behaviour change rather than how to roll out more training”, notes their Director.

Next challenges

The pandemic lockdown brought much attention from the media to the problem as the UK faced a ramp-up in reporting domestic abuse cases. This context allowed for decentralising the conversation about domestic violence. Virtuality-led institutions from different parts of the country were able to participate for the first time and to connect with organisations and government bodies working nationally. IRISi was one of those organisations that had a seat at the table for the first time.

The raised public profile of domestic abuse as a national health problem represents both an opportunity and a challenge for IRISi, which must be capitalised on since its model is a standard bearer in this field. “We created some specific DVA and covid-19 resources for all general practices within the NHS, not only for those participating in our intervention. Our DA and Covid-19 guidance was available across the country and addresses concerns about domestic abuse during lockdown restrictions with all patients”, highlights Lucy.

As scaling requires continuous improvement, the IRISi team is already working on reviewing the resources and processes developed with Spring Impact to refresh some of them, revising their KPIs to make their metrics more concise, assuring their partners meet the criteria to deliver the IRIS model, and spreading the quality standards for the programme to all sites, not only the social franchises.

“Overall, working with Spring Impact was an invaluable support and a growing process that enabled us to develop as an organisation”.