As outlined in Section 1, concerted efforts have been made to build the capability of universal services, however some stakeholders described their experiences of practical, financial and cultural barriers to universal services consistently and effectively identifying and responding to family violence.
Successful MARAM alignment requires a dedicated effort
A clear theme that emerged from our consultations was that a dedicated effort within each service is required to enable effective MARAM implementation, but that this is easier to achieve in some settings than in others. For example, as the Victorian Council for Social Service stated, a large hospital has a far greater capacity to engage than an early childhood centre due to its size, budget and workforce profile.
“Recently diagnosed with breast cancer I have been through the medical system a lot…and unfortunately the same response to my disclosure [of past abuse] every time…no response at all…or maybe a “Oh I’m sorry” and then lets pretend like she didn’t just say that… or I didn’t just hear that…sadly this has been the normal for me…and I imagine if it’s happening to me it’s most definitely happening to others and this does not encourage victim survivors to speak up.”
- Sharon, victim survivor
Two examples from our consultations stood out as being highly effective in their MARAM implementation: Goulburn Valley Health (see Box 1) and cohealth (see Box 2). Both services emphasised the importance of having a dedicated resource within their organisation to drive real change, with Goulburn Valley Health suggesting that family violence roles should be funded for every hospital across the state, and cohealth suggesting that there should be consultants out in the sector to actively support implementation. Indeed, Goulburn Valley Health is considering creating and internally funding a permanent family violence role to lead MARAM alignment work, but not all services have the capacity to do this. Similarly, Early Childhood Australia suggested a family support worker located at each centre or at least attached to a group of centres would greatly support MARAM implementation in the early childhood sector [relates to action 10].
One regional Principal Strategic Advisor noted that there appeared to be an assumption that she and her counterparts across the state could work directly with services to take them through their roles and responsibilities. While some of this work can occur, there can be hundreds of prescribed agencies within a region, and it would be impossible to provide the required level of support to every one of them. We suggest that as part of the planning for the next phase of implementation, consideration should be given to the types of support required to help prescribed workforces embed MARAM in practice; this may include access to dedicated support within organisations.
Box 1: Good practice example - Goulburn Valley Health
Goulburn Valley Health is one of the larger regional hospitals to be funded under the Strengthening Hospital Responses to Family Violence (SHRFV) initiative, with approximately 3,000 staff across multiple sites.
Goulburn Valley Health credits the success of their MARAM alignment to the SHRFV initiative, which included dedicated hospital-specific funding and resources, having a highly engaged and committed executive team (which is briefed on progress every month), and a dedicated trauma-informed services department (believed to be unique to this service), representing a clear location for the leadership of this work.
The team includes a project officer who has mapped all staff roles within the hospital according to MARAM responsibilities to identify gaps in family violence knowledge and skill. The service started aligning to MARAM in August 2020 – including alignment of policies, processes and procedures – and expects to be able to demonstrate MARAM alignment by June 2022.
The service also recognises that staff may have their own experiences of family violence and may need support. In response, they have ‘workplace support’ training aimed at managers and a ‘Family violence support for employees’ procedure. The service representatives we met with also acknowledged there was room for improvement in how they provided ongoing supervision and support to staff who were supporting patients experiencing family violence.
Source: Family Violence Reform Implementation Monitor, based on information provided by Goulburn Valley Health.
Box 2: Good practice example - cohealth
cohealth is a community health organisation delivering services across the northern and western suburbs of Melbourne, with approximately 1,300 staff across its locations.
cohealth has implemented MARAM throughout the service, including customised training (covering topics of relevance to the service such as family violence in the context of same-sex relationships, culturally diverse communities, refugee communities and male victims). It also runs monthly information sessions relating to MARAM, providing an opportunity for staff to ask questions and consult around particular case examples.
cohealth emphasised the importance of its executive being on board, tailored sector-appropriate resources and, importantly, the dedicated consultant it hired using its own funds to lead the change management process and provide workforce support.
Source: Family Violence Reform Implementation Monitor, based on information provided by cohealth.
Reform fatigue and time challenges for multiple workforces
Reform and training fatigue, particularly in the pressure of the ever-changing pandemic environment, was raised repeatedly during our consultations. For example, 84 per cent of hospitals and health services participating in the SAFE audit reported that staff turnover and education fatigue was a key challenge for the sustainability of family violence response achievements in their service.1 Lack of time was the most frequently cited barrier to accessing training and development, based on responses from selected universal services staff responding to the 2019–20 Census of Workforces that Intersect with Family Violence.2
Exacerbating this, in many cases, was a perceived lack of time to participate in training and engage in family violence information sharing, particularly for staff who are casual or all client-facing, including:
- nurses whose working hours are all clinical
- early childhood educators who have minimal time ‘off the floor’
- GPs who are generally operating within small businesses and can’t bill for the work
- rural and remote hospitals relying on locums and travel nurses.
“There is no doubt that frontline workers are missing signs of family violence. At least some of the reason for this is related to time limitations.”
- Lily, victim survivor
The early childhood sector was repeatedly raised as a sector that faced significant MARAM implementation challenges due to a casualised workforce, workforce shortages and high turnover, meaning supporting staff to access training was difficult. We understand that this workforce was one of the few funded for backfill to allow staff to access training, but work is required to improve awareness of this option.
As phase 2 implementation continues, ways to incentivise these diverse and time-poor workforces to engage in training, build their family violence capability and see the inherent value in these activities need to be actively considered [relates to action 10].
The time challenges extend beyond training and capability building, though, with many stakeholders indicating that the time taken for information sharing under the Family Violence Information Sharing Scheme, which can be a key element in identifying family violence, was considerable. We understand that the five-year review of MARAM, which is scheduled to occur during 2022, will further investigate the administrative burden of the scheme on services.
Cultural challenges for the education sector
Early childhood services and schools have a very important role to play in identifying family violence because this sector regularly interacts with families, in some cases over many years. However, because of the close relationships that are formed with families, we understand that this can sometimes lead to a reluctance to raise concerns unless the child is very clearly affected by abuse. The reasons given include that they:
- don’t want to damage the relationship or create awkwardness
- are worried they’ll create problems for the family
- don’t know how to have the conversation.
“I definitely do think frontline workers are missing signs of family violence. I’m not sure if this is because they don’t receive enough training in the area of spotting signs … whether they’re too afraid … because if they do acknowledge they think something is wrong they’re then faced with the dilemma of how to deal with it … and maybe it’s all a bit too hard … or confronting.”
- Sharon, victim survivor
Addressing this reluctance will require a cultural shift, supported by practical guidance around how to have these conversations.
Transitions between kindergarten and primary school, and primary to secondary school, were raised as another area where there was a tendency for kindergarten and grade 6 teachers to avoid including any information about family violence in writing, meaning there is the potential for much of this information to be lost [relates to action 8]. Some schools proactively reach out to each child’s kindergarten or primary school, as appropriate, to gather contextual information about the child and their family situation, but this does not happen consistently. There is an opportunity to place more structure around these transitions to ensure information about family violence risk is consistently communicated to ensure ongoing support for the child and any adult victim survivors.
Funding was a common frustration
Certainty of funding was raised most strongly by the hospital and primary health sectors [relates to action 1].
Hospitals indicated that government investment in the SHRFV initiative, while announced for multiple years, had to be confirmed year to year, and that the uncertainty and late notice of funding allocations for the coming year posed a real implementation risk because staff will look for positions elsewhere. Indeed, some services had lost staff while waiting for confirmation of further funding, resulting in knowledge and expertise being lost and reform momentum being stalled.
While we understand that some uncertainty may be unavoidable, decisions about funding held in contingency (based on performance measures) should be communicated as early as possible – and certainly well in advance of the end of the financial year – to ensure critical staff who are leading this work and who are on contracts are not lost due to late funding confirmation.
Furthermore, to embed and achieve the intended outcomes of the reforms, a longer term commitment to staff capability development – likely beyond the remaining three years of funding – is required. Year-to-year funding is highly problematic, and ideally there should be a realistic assessment of time needed to embed family violence capabilities in practice, and dedicated resources should be confirmed for this whole period. This is particularly important now that the MARAM perpetrator practice guidance is (partly) available, as services will need to begin building capability around working with perpetrators when for many this is an entirely new area of practice.
GPs are another group where major funding issues have been raised. Anecdotally, while GPs are not prescribed under MARAM, most want to improve their ability to identify and respond to family violence to support better outcomes for their patients. However, a major barrier is that the primary health sector is largely made up of small businesses, with billing based on 15-minute Medicare items. There are currently no family violence–related Medicare items, meaning that any extra time a doctor spends collaborating with other services, exploring referral pathways and sharing information is done outside of the standard consultation time, and is therefore unpaid activity.
The draft National Plan to End Violence against Women and Children 2022–2032 states that ‘health service providers such as general practitioners … need to be supported through resources, time and education to identify and respond to family, domestic and sexual violence’ [relates to action 2]. The GP may be one of the few professionals in touch with all members of the family, and we suggest that the national plan may provide an opportunity for Victoria to advocate for creating Medicare items relating to family violence to better account for the time taken to consult effectively with victim survivors (including children) and perpetrators and to respond appropriately. The creation of such items would also help with monitoring the volume and frequency of family violence work for GPs.
Existing Medicare items for chronic disease management and mental health treatment could provide some guidance for creating any future family violence items, including tying access to higher fee items to the completion of training. For example, ‘all GPs are able to access the GP Mental Health Treatment items. However, GPs who have not completed Mental Health Skills Training as accredited by the General Practice Mental Health Standards Collaboration (GPMHSC) will not be able to access higher schedule fee items.’ Given the relatively high rates of disclosure to GPs, it is vital that they be supported to perform this identification and response role.
- The Royal Women’s Hospital and the University of Melbourne (2021): The System Audit Family Violence Evaluation (SAFE) Project, Final Report, p. 5.
- We only considered results for the following workforces: schools, maternal and child health, early childhood, public health services and community health services.