BRIEFING PAPER Number 9233, 20 May 2021 The role of healthcare By Melissa Macdonald

services in addressing domestic abuse

Contents: 1. Introduction 2. Why is domestic abuse a healthcare issue? 3. Role of the NHS and Public Health England 4. Guidance for healthcare professionals 5. Healthcare initiatives

www.parliament.uk/commons-library | intranet.parliament.uk/commons-library | [email protected] | @commonslibrary 2 The role of healthcare services in addressing domestic abuse

Contents

Summary 3 1. Introduction 5 2. Why is domestic abuse a healthcare issue? 8 2.1 Use of healthcare services by victims and survivors of domestic abuse 10 2.2 Reaching ‘hidden victims’ 23 2.3 Use of healthcare services by perpetrators of domestic abuse 25 3. Role of the NHS and Public Health England 32 3.1 NHS: Strategic direction 33 3.2 Role of the NHS as an employer 34 3.3 Commissioning of services 34 Sexual Assault Referral Centres (SARCs) 36 3.4 Role of Public Health England 38 4. Guidance for healthcare professionals 40 4.1 NICE guidance 40 4.2 Department of Health guidance 43 4.3 Identifying and responding to domestic abuse 43 Training for staff 43 Routine and targeted enquiry 45 Steps following a disclosure of domestic abuse 46 Recording information 48 Impact of the Covid-19 pandemic 50 5. Healthcare initiatives 53 5.1 Pathfinder Project 53 5.2 Health-based Independent Domestic Violence Advisers 53 5.3 Identification and Referral to Improve Safety (IRIS) 56 5.4 Initiatives in mental health services 57 5.5 Pharmacy schemes 58

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3 Commons Library Briefing, 20 May 2021

Summary

It has been estimated that nearly half a million victims and survivors of domestic abuse seek assistance from medical professionals every year. Guidance for health professionals says that “domestic violence and abuse is so prevalent in our society that NHS and other provider staff will be in contact with adult and child victims (and perpetrators) across the full range of health services.” The Domestic Abuse Act 2021 received Royal Assent on 29 April 2021. The Act’s provisions will be brought into force in due course in line with the commencement schedule. The Domestic Abuse Commissioner, Nicole Jacobs, has said that health must be central to strategic thinking. The Commissioner notes that health settings are trusted environments which can reach people “from every background and walk of life subjected to domestic abuse”. And it is therefore “critical” to ensure awareness about domestic abuse is embedded in the practices of all health settings. A domestic abuse strategy is due to be published by the Government in 2021, alongside a new Violence against Women and Girls Strategy 2021-2024. Use of healthcare services by victims and survivors The NHS is directly involved in treating victims and survivors of domestic abuse in several ways. This could include the provision of mental health services, through its role as lead commissioner of Sexual Assault Referral Centres, or by treating physical injuries. Research has found that around 30% of domestic abuse begins during pregnancy. The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists have said it is a “maternal health issue”, with maternity care professionals such as midwives and health visitors “particularly well placed to identify and respond to abuse”. In some instances, the involvement of healthcare services will be limited to identifying the signs of abuse and directing victims to relevant specialised support. The introduction of health-based Independent Domestic Violence Advisers (IDVAs) following the Pathfinder Project means support services are increasingly provided in a healthcare setting, such as a hospital. Reaching ‘hidden victims’ SafeLives, a domestic abuse charity, says health settings “encourage higher rates of disclosure, including from groups who face additional barriers to getting support such as BAME, disabled, older and LGBT+ communities”. For example, health services can identify older victims of domestic abuse as they are more likely to use NHS services. ONS data for March 2019 to March 2020 shows disabled people to be almost three times more likely to have experienced domestic abuse than non-disabled people. Disabled victims of abuse experience barriers in accessing support and it’s been suggested that health professionals could help people disclose domestic abuse by ensuring they see patients alone at some point, without carers present. Use of healthcare services by perpetrators The Domestic Abuse Act 2021 includes provisions to widen the scope of Domestic Abuse Protection Orders so perpetrators can be compelled to be assessed for a perpetrator intervention programme, attend a mental health assessment or an assessment for a drugs or alcohol programme. 4 The role of healthcare services in addressing domestic abuse

The Draft Domestic Abuse Statutory Guidance Framework reports that up to 60% of men in perpetrator programmes have problems with alcohol and/or drugs. However, there is not a simple causal relationship between substance misuse and domestic abuse. Against Violence and Abuse (AVA) and Alcohol Concern say in their joint report (2016) that it is critical for alcohol treatment services to screen for domestic abuse and vice versa, otherwise “neither issue can be wholly addressed”. In written evidence to the Public Bill Committee on the Domestic Abuse Bill 2019-21, the Inter-Collegiate and Agency Domestic Violence Abuse Forum recommended an increase in funded quality-assured programmes for health professionals to refer perpetrators into. The Drive Partnership, which works with perpetrators of domestic abuse, published a ‘call to action’ in 2020 which identified “an urgent need for a domestic abuse perpetrator strategy for England and Wales underpinned by core statutory support”. The Domestic Abuse Act 2021 requires the Government to publish a strategy for the prosecution and management of offenders, including reducing the risk they commit further offences involving domestic abuse. The Home Office has indicated this ‘perpetrator strategy’ will be published as part of the “holistic” domestic abuse strategy. Guidance for healthcare professionals The Department of Health published Responding to domestic abuse: A resource for health professionals, in March 2017 which draws on recommendations made in the NICE guideline: Domestic violence and abuse: multi agency working. The resource is for all NHS staff and those providing NHS funded services. It aims to “help practitioners identify potential victims, initiate sensitive routine enquiry and respond to disclosures of abuse”. Research published in the British Journal of Nursing in July 2020 identified potential barriers preventing health professionals from screening women for domestic abuse and concluded “lack of training and education” were the most prevalent. It’s been suggested that clinicians are unwilling to engage in conversations about domestic abuse if they feel a responsibility to “fix” it and require clear referral pathways to specialist support. Written evidence on the Domestic Abuse Bill 2019-20, from the Inter- Collegiate and Agency Domestic Violence Abuse Forum asserted that further training for healthcare professionals is required alongside funding for referral routes. Further information is also available in: Domestic abuse and Covid-19: A year into the pandemic, Commons Library Insight, 11 May 2021 Support for victims of domestic abuse, Commons Library Constituency Casework, 26 April 2021 Domestic Abuse Bill 2019-21: Progress of the Bill, Commons Library Briefing, CBP 8959, 10 April 2021 Support for domestic abuse victims, Commons Library Briefing, CBP 9124, 8 February 2021 Domestic violence in England and Wales, Commons Library Briefing, SN06337, 21 November 2018 5 Commons Library Briefing, 20 May 2021

1. Introduction

The Home Office estimated the total economic and social cost of domestic abuse was over £66 billion in England and Wales for the year ending 31 March 2017. This was higher than the estimated cost of any other single type of crime.1 Of this, £2.3 billion was borne by the health service.2 Department of Health guidance for health professionals responding to domestic abuse states: “domestic violence and abuse is so prevalent in our society that NHS and other provider staff will be in contact with adult and child victims (and perpetrators) across the full range of health services.”3 Specialised victim support services are mainly provided by third sector organisations, such as Refuge, which runs the National Domestic Abuse Helpline. In some instances, the involvement of healthcare services will be limited to identifying the signs of abuse and directing victims to relevant specialised support. Healthcare services have an active role in supporting victims, mainly through the treatment of physical and mental harm caused by domestic abuse. The introduction of health-based Independent Domestic Violence Advisers (IDVAs) following the Pathfinder Project also means victim support services are increasingly provided in a healthcare setting. Pathfinder’s whole health model “aims to raise the ambition for the health sector to combat domestic abuse across all settings, from GP surgeries to mental health Trusts to acute hospital Trusts”.4 Women and girls In 2010, a Government taskforce, chaired by Professor Sir George Alberti, investigated the health aspects of violence against women and children and the role of the NHS. The taskforce’s report concluded that “the NHS has a vital role to play in dealing with violence and abuse and its consequences, both short and long-term” and that the NHS has a “clear duty” to help.5 The Government’s ‘Ending Violence against Women and Girls Strategy 2016- 2020’ (VAWG) emphasised that “abused women use health care services more than non-abused women and they identify health care workers as the professionals they would be most likely to speak to about their experience.”6

1 Home Office, Violence Against Women and Girls (VAWG) strategy 2021-2024: call for evidence, Last updated 8 January 2021 2 Home Office, The economic and social costs of domestic abuse, Research Report 107, January 2019, p6 3 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p7 4 Pathfinder, Pathfinder Toolkit, June 2020, p3 5 The report of the Taskforce on the Health Aspects of Violence Against Women and Children, Responding to violence against women and children – the role of the NHS, March 2010, p58 6 HM Government, Ending Violence against Women and Girls Strategy 2016- 2020, March 2016, p21 6 The role of healthcare services in addressing domestic abuse

The VAWG strategy highlights the opportunity for healthcare services to intervene early and direct victims towards appropriate statutory and non-statutory services. It states: GPs, midwives, health visitors, mental health, drug and alcohol services, sexual health and Accident and Emergency staff are all well placed to identify abuse.7 New strategies A new ‘Violence against Women and Girls Strategy 2021-2024’ is due to be published by the Government in 2021, alongside a separate domestic abuse strategy. In response to a Parliamentary Question, Victoria Atkins, Parliamentary Under-Secretary of State at the Home Office, said: “the two strategies will be complementary and work together to drive down VAWG crimes and their impact on society and will put victims and survivors at the heart of our response”.8 Galop, a LGBT+ anti-violence charity, emphasise that whilst domestic abuse disproportionately affects women, “it is nevertheless important to raise awareness and increase understanding that this is by no means the only circumstance in which it exists.”9 Men are also victims of domestic abuse.10 Domestic abuse is also prevalent in same-sex relationships11 and the new statutory definition encompasses abuse from family members as well as partner abuse.12 The Domestic Abuse Act 2021 received Royal Assent on 29 April 2021. The Act’s provisions will be brought into force in due course in line with the commencement schedule. The impact assessment said the legislation aims to “underpin a lasting culture change” leading to “improved support for all victims of domestic abuse and the children who are affected by it” and a “reduction in prevalence, offending and reoffending”. The Domestic Abuse Commissioner, Nicole Jacobs, has been tasked with helping to improve the quantity and quality of domestic abuse support services. The Act introduces a requirement for local authorities to appoint Domestic Abuse Local Partnership Boards to provide advice on local authority support services. The boards must include at least one representative from local healthcare services.13 The Domestic Abuse Commissioner, has said that health must be central to strategic thinking.14 The Commissioner also said she is a “strong proponent” of Pathfinder’s whole health model.15

7 Ibid. 8 PQ138009, Violence: Females, Answered on 21 January 2021 9 Galop, Recognise & Respond: Strengthening advocacy for LGBT+ survivors of domestic abuse, October 2019, p12 10 Office for National Statistics, Domestic abuse prevalence and victim characteristics - Appendix tables, Year ending March 2020, Table 1, 25 November 2020 11 Galop, Recognise & Respond: Strengthening advocacy for LGBT+ survivors of domestic abuse, October 2019 12 Domestic Abuse Act 2021 13 Domestic Abuse Act 2021, Part 4, Local Authority Support 14 Pathfinder, Pathfinder Toolkit, June 2020, p3 15 Pathfinder, Pathfinder Toolkit, June 2020, p3 7 Commons Library Briefing, 20 May 2021

Box 1: What is domestic abuse? The Domestic Abuse Act 2021 has introduced a statutory definition of domestic abuse for the first time. Behaviour is defined as domestic abuse if both people involved are aged 16 or over and are personally connected to each other, and the behaviour is abusive. • The definition encompasses individuals who have been in a relationship or are relatives. • Abuse is defined as physical or sexual abuse, violence or threatening behaviour, controlling or coercive behaviour, economic abuse or psychological, emotional or other abuse. • Children are also defined as victims of domestic abuse if they “see, hear or experience the effects of abuse” and are either a relative of the adult subject to, or perpetrating, the abuse, or if one of the adults holds parental responsibility for the child. Abuse directed towards a child is defined as child abuse. How prevalent is domestic abuse? The Crime Survey for England and Wales (CSEW) gathers data on domestic abuse (which includes non- sexual abuse, such as physical force and emotional or financial abuse, sexual assault, and stalking).16 • The CSEW for the year ending March 2020 found 5.5% of adults aged 16 to 74 had experienced domestic abuse in the last year (7.3% for women and 3.6% for men).17 20.8% of respondents reported they had experienced domestic abuse since the age of 16 (27.6% for women and 13.8% for men).18 • The survey also includes information on partner abuse and family abuse (subcategories of domestic abuse). Partner abuse was more common than family abuse, with 17.2% of respondents indicating they had experienced partner abuse since the age of 16, whilst 8% reported family abuse.19

16 ONS, Partner abuse in detail, England and Wales: year ending March 2018, 25 November 2020 17 ONS, Domestic abuse prevalence and victim characteristics - Appendix tables, Year ending March 2020, Table 1, 25 November 2020 18 Ibid. 19 Ibid. 8 The role of healthcare services in addressing domestic abuse

2. Why is domestic abuse a healthcare issue?

SafeLives, a domestic abuse charity, has set out a series of statistics regarding the health impacts of domestic abuse: • 80% of women in a violent relationship seek help from health services, usually GPs, at least once and this may be their first or only contact with professionals • 30% of domestic abuse starts and/or escalates during pregnancy • One in four women in contact with mental health services are likely to be experiencing domestic abuse20 Department of Health guidance says the NHS spends more time dealing with the impact of violence against women and children than “almost any other agency”.21 In written evidence to the Public Bill Committee for the Domestic Abuse Bill 2019-21, the Inter-Collegiate and Agency Domestic Violence Abuse Forum (a group of domestic abuse organisations) set out “the vital role of the healthcare system in responding to domestic abuse”: Every year nearly half a million survivors of domestic abuse seek assistance from medical professionals. Given that just one in five survivors call the Police, it is vital that survivors can access a non- criminal or justice-based route to effective support. Seeing a health professional can often be the only time that a survivor is able to disclose abuse without the perpetrator present. […] Domestic abuse cannot be effectively addressed unless the vital role of healthcare professionals is appropriately considered.22 The SafeLives November 2016 report, ‘A Cry for Health: Why we must invest in domestic abuse services in hospitals’, recommended that “national leaders should prioritise domestic abuse as a health issue.”23 The report went on to state: There is the opportunity for NHS England and the Department of Health to play a greater role in showing leadership in tackling what has traditionally been seen as a criminal justice issue. The cost of domestic abuse to health services needs to be taken seriously by all parts of the NHS to ensure that victims aren’t passing through a ‘revolving door’ – returning time and time again without the cause being identified and addressed.24

20 SafeLives, Health Pathfinder, 2020 21 Department of Health, Responding to domestic abuse: A resource for health professionals, 8 March 2017 22 Written evidence submitted by the INCADVA (Inter-Collegiate and Agency Domestic Violence Abuse) Forum (DAB57), Domestic Abuse Bill, June 2020 23 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p22 24 Ibid. 9 Commons Library Briefing, 20 May 2021

Types of healthcare support The NHS might be directly involved in treating victims of domestic abuse in several ways. This could include the provision of mental health services, through its role as lead commissioner of Sexual Assault Referral Centres, or by treating physical injuries arising from abuse. Data on healthcare service involvement in treating victims of domestic abuse is limited. The Office for National Statistics (ONS) has published a detailed breakdown of partner abuse findings from the Crime Survey for England and Wales for March 2017 to March 2018, which includes information on the use of healthcare services. One quarter of partner abuse victims (25.5%) reported they sustained some sort of physical injury in the year ending March 2018.25 Around one third (33.1%) of victims reported they received medical attention because of physical injury or other effects. The majority (83.1%) said they received medical attention from a GP, whilst 36.4% went to a specialist mental health or psychiatric service and 12.2% went to A&E.26 In some instances, healthcare service involvement will be limited to identifying the signs of abuse and directing victims to relevant specialised support. The proportion of referrals to IDVA services made by health services increased from 4.8% in 2016 to 9.2% in 2020.27 This compares to 28.4% of referrals to IDVA services made by the police in 2020.28 However, specialised victim support services are increasingly provided in healthcare settings, such as a hospital. Healthcare services also play an active role in supporting victims through the treatment of physical and mental harms caused by domestic abuse. Healthcare services and the Istanbul Convention The UK signed the ‘Council of Europe Convention on preventing and combating violence against women and domestic violence’, known as the Istanbul Convention, in 2012 and has been taking steps to ratify it, including the introduction of the Domestic Abuse Act 2021.29 Aspects of the Istanbul Convention directly relate to the role of healthcare services in addressing violence against women. For example, Article 20 sets out that “parties shall take the necessary legislative or other measures to ensure that victims have access to health care and social services and that services are adequately resourced and

25 ONS, Partner abuse in detail, England and Wales: year ending March 2018, 25 November 2020 26 Ibid. 27 ONS, Domestic abuse victim services, England and Wales: November 2020, 25 November 2020 28 Ibid. 29 HL Deb, LGBT Community: Domestic Abuse, 24 November 2020, c131 10 The role of healthcare services in addressing domestic abuse

professionals are trained to assist victims and refer them to the appropriate services.”30 The Convention recognises the difference between general and specialist support services. Whilst healthcare is classified as a general service, the accompanying guidance notes that “there can be specific violence against women provision within general services offered by public authorities such as […] health services”.31 The guidance emphasises that public authorities have a responsibility to identify victims of domestic abuse and refer them to support.“32 The Council of Europe encourages signatories to map support services for victims and has developed a tool to aid this process. In England, the Domestic Abuse Commissioner is tasked with mapping specialised domestic abuse support service provision, including in health settings.33 Baroness Williams of Trafford responded to a Parliamentary Question on 25 November 2020 setting out the timetable for mapping services and the Commissioner’s role: […] A key part of the Domestic Abuse Commissioner’s role will be to monitor and oversee domestic abuse services nationally, and to support this she will undertake an in-depth exploration of the current community-based support landscape. While the initial scoping work is expected to be completed this financial year, the work on mapping the provision of community-based services across the country is expected to conclude by the end of 2021. The Government will then work with the Commissioner to understand the needs identified and develop options on how best to address them.34 During the passage of the Domestic Abuse Act 2021, Baroness Williams said the Government committed to consulting on the provision of community-based domestic abuse services in its planned consultation on a new victims’ law.35

2.1 Use of healthcare services by victims and survivors of domestic abuse As set out by SafeLives, domestic abuse has severe and detrimental health implications which can be short-lived or long-lasting: The physical and often more obvious implications can be short- lived, or long-lasting. These can include: broken bones, sprains, cuts, bruises, digestive issues, eating problems, pain of the back, neck, abdomen, stomach or genital area, headaches, fainting,

30 Council of Europe, Council of Europe Convention on preventing and combating violence against women and domestic violence, Council of Europe Treaty Series – No.210, Istanbul, 11.V.2011 31 Council of Europe, Mapping support services for victims of violence against women in line with the Istanbul Convention standards: Methodology and tools, November 2018, p6 32 Ibid. 33 Pathfinder, Pathfinder Toolkit, June 2020, p3 34 Council of Europe, Council of Europe Convention on preventing and combating violence against women and domestic violence, Council of Europe Treaty Series – No.210, Istanbul, 11.V.2011 35 Commons Library, Domestic Abuse Bill 2019-21: Progress of the Bill, 10 April 2021 11 Commons Library Briefing, 20 May 2021

seizures, hypertension, urinary tract or vaginal infections, sexually transmitted diseases and sexual dysfunction.36 Research has consistently found that the more severe the abuse, the greater its impact on physical and mental health. Negative health consequences can persist long after abuse has stopped.37 It is established that healthcare professionals are often the first point of contact for victims of domestic abuse.38 Victims and survivors say healthcare providers are the professionals they would trust most with disclosure of abuse.39 Secondary care Figures obtained by NationalWorld from NHS Digital found 1,980 women in England had been admitted to hospital following abuse by a partner between 2015 and 2020.40 This is likely to be a significant underestimate as the figures only capture the cause of injury first recorded by staff.41 In response to the figures, a spokesperson for Women’s Aid said: Domestic abuse is largely a hidden crime and very few survivors report domestic abuse to the police. For many women, a visit to the hospital or the GP can be the only time they are alone and safe to disclose their experiences without risk from the abuser. All health professionals need to have specialist training on domestic abuse and other forms of violence against women and girls, to ensure they respond safely and effectively.42 Nicole Jacobs, the Domestic Abuse Commissioner, also emphasised that hospital admission can be a “crucial moment” for victims to find help, if specialist support is provided to them.43 The figures above relate to women. Data from the Crime Survey for England and Wales found that whilst both men and women were more likely to experience non-physical than physical partner abuse, a higher proportion of male victims of partner abuse (45.7%) reported experiencing physical force “once or more” than female victims (28%).44 Research indicates a link between experiencing domestic abuse and incidents of people seeking treatment for self-harm.45

36 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p35 37 WHO, Understanding and addressing violence against women, 2012 38 HM Government, Ending Violence against Women and Girls Strategy 2016- 2020, March 2016, p21 39 Ibid. 40 NHS Digital, Admissions and finished consultant episodes for maltreatment and sexual assault, 3 February 2021 41 NHS Digital, National Clinical Coding Standards ICD-10 5th Edition, April 2021, p187 42 NationalWorld, Domestic violence: hundreds of women end up in hospital from domestic abuse every year, new NHS figures reveal, 6 April 2021 43 Ibid. 44 ONS, Partner abuse in detail, England and Wales: year ending March 2018, 25 November 2020 45 Dalton TR, Knipe D, Feder G, et al., Prevalence and correlates of domestic violence among people seeking treatment for self-harm: data from a regional self-harm register, Emergency Medicine Journal, 2019 12 The role of healthcare services in addressing domestic abuse

Data collected by SafeLives indicates there is an opportunity for healthcare providers to intervene earlier to provide support, particularly in hospital. In 2019/20, 19.4% of victims seeking help from IDVA services had attended A&E because of the abuse in the last 12 months.46 The SafeLives report ‘Getting it Right First Time’ (2015) also states that “victims often seek help a number of times before they achieve safety.”47 The report notes that nearly a quarter (23%) of victims at high risk of harm and one in ten victims at medium-risk attended A&E because of acute physical injuries.48 The report also highlights that “in the most extreme cases, victims reported they attended A&E 15 times.”49 Non-fatal strangulation The Domestic Abuse Act 2021 includes provisions to make non-fatal strangulation a specific criminal offence, punishable by up to five years in prison. It typically involves an abuser strangling or intentionally affecting someone’s breathing in an attempt to control or intimidate them.50 The Home Office notes that the practice often leaves no visible injury, making prosecution harder.51 During debate on the Domestic Abuse Bill, Baroness Finn outlined the importance of healthcare professionals recognising the signs of non- fatal strangulation: Unfortunately, current understanding of symptoms and consequences will likely lead to cases being missed and narrow or absent diagnoses offered. If those in the health service seeing patients with the relevant physical and psychological conditions are conscious of the links to non-fatal strangulation, the problem can be picked up earlier and the victims supported.52 Acquired brain injury Victims of domestic abuse commonly suffer blows to the head and strangulation, leaving lasting psychological and physical trauma. The symptoms are often ‘unseen’ and unrecognised by services, including health services. Brain injuries can result in a range of symptoms, including psychological, cognitive, behavioural and emotional deficits, which could have a lasting effect on daily functioning. For example, symptoms include poor memory, lack of concentration, slowness to process information or

46 Office for National Statistics, Appendix tables: Domestic abuse victim services 2020, Table 14, 25 November 2020 47 SafeLives, Getting it Right First Time, November 2015, p16 48 Ibid., p17 49 Ibid. 50 GOV.UK, New laws to protect victims added to Domestic Abuse Bill, 1 March 2021 51 Ibid. 52 HL Deb, Domestic Abuse Bill, 3 February 2021, c2262 13 Commons Library Briefing, 20 May 2021

make decisions, poor impulse control, emotional dysregulation, anxiety and depression.53 The Disabilities Trust report, ‘Making the Link: Female Offending and Brain Injury’ (2019), found nearly-two thirds of female offenders (64%) at HMP Drake Hall reported “a history indicative of a brain injury”. Of those, 62% had sustained their injury through domestic violence. Research on the link between domestic abuse and acquired brain injury is in the early stages. Emerging studies indicate there might be a significant population of victims and survivors who have a brain injury which is not adequately recognised, assessed or considered in their support. The Disabilities Trust published a subsequent report in June 2020, ‘Brain injury and Domestic Abuse: An Invisible Impact’. The report notes it is critical for services to screen, recognise and support victims and survivors of domestic abuse with a brain injury, “in order to provide personalised holistic support”.54 Early recognition can help the person understand their symptoms and how functioning is affected. This should lead to the use of strategies to alleviate the effects and help services and professionals improve their understanding of the person and the challenges they face, allowing for reasonable adjustments to be made when engaging with services.55 The Disabilities Trust report makes a series of recommendations relating to healthcare services: • A clear need to develop appropriate pathways of support for women, whilst also introducing brain injury screening to empower staff to identify and ensure women’s needs are met. • These pathways are currently not in existence and would need to be created, both nationally and locally. They could include referrals to specialist brain injury services through general practice for those with more severe symptoms. • There is a critical need for further research on the prevalence, impact and causality of brain injuries caused by domestic abuse, alongside the development of an appropriate, sensitive and trauma informed brain injury screening method. • We also recommend brain injury awareness training for all professionals who engage with domestic abuse survivors as a priority for the survivors, themselves, their services and wider national policy. • Standard approaches for mental health interventions often do not have the same impact for those with a brain injury. To create more effective interventions for those with a brain injury, practitioners need to recognise and understand

53 The Disabilities Trust, Making the Link: Female Offending and Brain Injury, February 2019 54 The Disabilities Trust, Brain injury and Domestic Abuse: An Invisible Impact, June 2020, p11 55 Ibid. 14 The role of healthcare services in addressing domestic abuse

the signs of a brain injury and its effects on behaviour, and both psychologically and physiologically. • Services also need to ensure they provide gender and trauma informed approaches, with practitioners able to dedicate time to foster a relationship, build rapport and enhance the possibility of disclosure and agreement for screening.56 Amendments to the Domestic Abuse Act 2021 were tabled to introduce screening for acquired brain injury for female victims and survivors of domestic abuse. The Government rejected them. Lord Parkinson of Whitley Bay explained the Government’s position: It is for the NHS to provide the most appropriate care and treatment, based on an individual’s medical history and clinical need. […] domestic abuse can manifest itself in many ways, not just through physical injuries but mental harm through coercive control and financial abuse. We do not think that such victims should be screened for brain injury, or that this would be an effective use of NHS resources. In addition, we would not want to deter women from coming forward to receive support if they are concerned about the possible outcomes of a brain screening.57 Lord Parkinson also outlined changes NHS England and NHS Improvement are making in relation to brain injuries: NHS England and NHS Improvement are continuing to work with the Disabilities Trust on a training package for healthcare practitioners to increase effectiveness when supporting people with impaired neurological functioning, either as a result of domestic abuse or due to other reasons. This training is also designed to provide practical steps for those working with patients, and self-help tools for the individuals themselves to reduce and overcome the impact of any brain injury.58 Perinatal healthcare: Midwives and health visitors Research has found that around 30% of domestic abuse begins during pregnancy.59 It has been estimated that between 40-60% of women experiencing domestic abuse are abused during pregnancy.60 The Royal College of Midwives and the Royal College of Obstetricians and Gynaecologists issued a joint policy statement on domestic abuse in November 2020. It describes domestic abuse as a “maternal health issue” and states that maternity care professionals “are particularly well placed to identify and respond to abuse”.61 The statement explains some of the health implications of domestic abuse during pregnancy: Domestic abuse doubles the risk of preterm birth and low weight, and more than 40% of survivors experience mental health issues including anxiety, depression and emotional detachment which

56 The Disabilities Trust, Brain injury and Domestic Abuse: An Invisible Impact, June 2020 57 HL Deb, Domestic Abuse Bill, c122, 15 March 2021 58 Ibid. 59 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p36 60 Ibid. 61 The Royal College of Midwives, Royal College of Midwives and Royal College of Obstetricians and Gynaecologists joint policy statement on domestic abuse, November 2020 15 Commons Library Briefing, 20 May 2021

can affect the way a mother bonds with her child. This has potentially far-reaching intergenerational effects.62 Since 2000, the Department of Health has recommended maternity services routinely ask patients whether they are experiencing domestic abuse.63 Further information about routine enquiry can be found in Section 4.3. The NICE guideline, ‘Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors’, provides a list of recommended actions which can be applied to pregnant women who experience domestic abuse. These include: “providing for flexibility in the length and frequency of antenatal appointments, over and above those outlined in national guidance to allow more time for women to discuss the domestic abuse they are experiencing.”64 The guidance recommends that women should be offered “a named midwife, who should take responsibility for and provide the majority of her antenatal care.”65 Continuity of carer The ‘Better Births’ report, published following the National Maternity Review (2016), highlighted the benefits offered by continuous care from one individual. This helps in building “a relationship of mutual trust” and helps midwives provide support and identify problems.66 The report recommended that every woman should have a midwife who is based in the community who can provide continuity throughout the pregnancy, birth and postnatal period.67 During a Westminster Hall debate on healthcare support services from conception to age two (2020), Cherilyn Mackrory, Co-Chair of the APPG on Baby Loss, emphasised the importance of continuity of carer and suggested the approach should be replicated for health visitors: Continuity of carer is relationship-based care that saves babies’ lives. Baby loss is reduced by 16%, and women are 19% less likely to lose their baby before 24 weeks. It also reduces pre-term birth. […] I would like continuity of carer to be promoted to all families and replicated in the health visitor sector, because it is so important. Parents’ responses shape their experiences; if they have a trusted carer they can go to if they are in crisis or struggling, whether it is with domestic violence or coercion in a relationship—or post-natal depression, which many of us have felt—an awful lot of that stress will be expelled.68

62 Ibid. 63 Ibid, p33 64 NICE, Pregnancy and complex social factors: a model for service provision for pregnant women with complex social factors, Clinical guideline (CG110), Guidance, 22 September 2020 65 Ibid. 66 National Maternity Review, Better Births: Improving outcomes of maternity services in England, 22 February 2016, p32 67 Ibid., p9 68 WH Deb, Healthcare Support Services: Conception to Age Two, 15 December 2020 16 The role of healthcare services in addressing domestic abuse

The role of health visitors in relation to domestic abuse was raised in the same debate. It was noted that 82% of health visitors had reported an increase in domestic abuse since the onset of the pandemic according to a December 2020 survey.69 MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK) publish reports investigating maternal deaths. The latest report, covering 2016 to 2018, was published in January 2021. It found 566 women died during or up to a year after pregnancy in the UK and Ireland, of which 61 were known to have experienced domestic abuse (11%).70 The report states that around a third of the women’s records (30%) did not include information on whether they were subject to domestic abuse. The report notes this as an improvement on 53% in the report for 2015 to 2017, but that a substantial number of women were not asked about domestic abuse, despite guidance to do so throughout pregnancy. 71 General practice settings The CSEW 2018 survey found that when victims sought medical assistance in relation to domestic abuse 83% said they went to a GP.72 SafeLives Insights data shows that on average, a person will experience abuse for three years before getting effective help and will visit their GP on average 4.3 times.73 GPs are identified as well-placed to initiate discussions about domestic abuse. Aside from having the most contact with victims of domestic abuse, general practice also benefits from being connected to multiple community and secondary care services. Historically, GPs have had a more holistic and relationship-based approach to healthcare than other professions.74 GPs are not required to routinely screen for domestic abuse, but instead are encouraged to undertake ‘targeted enquiry’. This involves GPs using their judgement to determine whether a patient should be asked about domestic abuse, such as if signs are present. Further information about routine and targeted enquiry can be found in section 4.3. Pathfinder guidance for GPs highlights a strong link between being a victim of domestic abuse and certain physical and mental health issues, and advises that patients exhibiting such symptoms “should always be asked about abuse”:

69 Ibid. 70 MBRRACE-UK, Saving Lives, Improving Mothers' Care 2020: Lessons to inform maternity care from the UK and Ireland Confidential Enquiries in Maternal Death and Morbidity 2016-18, January 2021 71 Ibid., p13 72 Office for National Statistics, Partner abuse in detail, England and Wales: year ending March 2018, 25 November 2020 73 Pathfinder, Guidance for General Practitioners responding to domestic abuse, 2020 74 Dowrick, A., Feder, G., & Kelly, M., Boundary-Work and the Distribution of Care for Survivors of Domestic Violence and Abuse in Primary Care Settings: Perspectives From U.K. Clinicians. Qualitative Health Research. 22 March 2021 17 Commons Library Briefing, 20 May 2021

Some physical and mental health issues, such as anxiety, depression, chronic pain, difficulty sleeping, facial or dental injuries, chronic fatigue and pregnancy and miscarriage have a strong link to being a victim/survivor of domestic abuse. Patients who present with such symptoms should always be asked about abuse. In addition, in heterosexual relationships abusive perpetrators often exert control over a woman’s reproduction; GPs should be alert to indicators such as urinary tract infections, unprotected sex, lesion of nipple, STIs, pregnancy and requests for a termination.75 The World Health Organization has set out that women with a history of abuse are more likely than other women to report a range of chronic health problems such as headaches, chronic pelvic pain, back pain, abdominal pain, irritable bowel syndrome, and gastrointestinal disorders.76 Dental practices NHS England Chief Dental Officer Sara Hurley has published guidance for dentists on how dental teams can help survivors and victims. As dental professionals are likely to observe and identify injuries to the head, face, mouth and teeth, they are well placed to identify risks and should keep accurate records of this. The guidance notes the general signs of domestic abuse which might be observed by dental teams, such as a patient always being accompanied by a partner or family member “who frequently speaks for the patient or cancels appointments,” the patient displaying high levels of anxiety, delays in seeking treatment and symptoms not fitting with the explanation provided.77 Sara Hurley has said: “combating domestic abuse is not just a medical mission, it’s a moral mission too and dentists are determined to play their part”.78 Mental health services Mental health services play an important role in responding to domestic abuse. During the passage of the Domestic Abuse Act 2021, Baroness Williams of Trafford said “you cannot decouple domestic abuse from mental health trauma” and added: Surely the two go hand in hand, not only for the woman—it is usually a women—who is suffering abuse at the hands of an abusive partner but also, usually, for her children, who feel those effects and the trauma for a very long time, if not the rest of their lives.79 Research shows clear links between domestic abuse and mental health, in both directions: being exposed to domestic abuse can lead to mental health problems such as depression and PTSD and people with severe

75 Pathfinder, Guidance for General Practitioners responding to domestic abuse, 2020 76 WHO, Understanding and addressing violence against women, 2012 77 NHS, Your NHS dentistry and oral health update, 12 February 2021 78 NHS, NHS urges sex crime and abuse victims to seek help, 20 March 2021 79 HL Deb, Domestic Abuse, 11 November 2020, c1030 18 The role of healthcare services in addressing domestic abuse

mental health problems face significantly increased risk of experiencing domestic abuse and sexual violence.80 Research in 2018 estimated that around one in four women and one in 10 men in contact with mental health services were experiencing, or had recently experienced, domestic abuse.81 The same research cited surveys estimating 69% of women and 49% of men in contact with mental health services for severe mental illness had experienced domestic and/or sexual abuse.82 NICE guidance recommends routine enquiry into domestic abuse in mental health settings. Since 2003 it has been Department of Health policy that all adult service users should be asked about experiences of violence and abuse in mental health assessments. However, there is evidence that routine enquiry is not being carried out systematically, meaning that abuse can often go undetected by mental health services.83 It has been estimated that just 10-30% of cases are identified this way.84 The Women’s Mental Health Taskforce, set up by the Department of Health and Social Care, says mental health practitioners and services do not appear to always understand the dynamics of abuse and its impacts on mental health.85 Its report, published in 2018, said mental health services needed to be “gender and trauma-informed”: For women who had experienced violence and abuse, to be physically restrained or put under one to one observation, often by male staff, could be profoundly distressing, triggering and humiliating. This impacted not only on their recovery but their long-term mental health, as well as their willingness to seek help again in future, having sometimes eroded their trust in the services designed to support them.86 The report highlighted that some women described feeling unsafe in in- patient services, specifically in relation to the risk of sexual assault or harassment, from both members of staff and patients.87 The Women’s Mental Health Taskforce noted evidence to support this feeling – citing 457 incidents of sexual assault or sexual harassment in mental health services between April and June 2017.88 The Taskforce said CQC recommendations around sexual safety on mental health wards must be applied in full.89

80 DHSC, The Women’s Mental Health Taskforce: final report, 19 December 2018, p23 81 King’s College London, LARA-VP: A resource to help mental health professionals identify and respond to Domestic Violence and Abuse (DVA), 2018 82 Ibid. 83 DHSC, The Women’s Mental Health Taskforce: final report, 19 December 2018, p25 84 King’s College London, Promoting Recovery in Mental Health: Evaluation Report, August 2016 85 DHSC, The Women’s Mental Health Taskforce: final report, 19 December 2018, p24 86 Ibid. 87 Ibid. 88 Ibid. 89 Ibid. 19 Commons Library Briefing, 20 May 2021

Child and Adolescent Mental Health Services (CAMHS) Domestic abuse is linked with negative mental health outcomes for children.90 The SafeLives ‘Children’s Insights’ data (2019/20) found concerns for the child’s mental health in 27% of domestic abuse cases. Nearly half (48%) of the children involved had anxiety.91 The Victims’ Commissioner has also referred to a “post code lottery” for CAMHS and noted stakeholder concerns regarding access.92 The Commissioner’s report, Sowing the Seeds: Children’s experience of domestic abuse and criminality (2020), said: Thresholds for accessing CAMHS services are reported as being extremely high in some areas and this can lead to children not being able to get the support they need or abused parents getting into debt to fund counselling services for their children. […] Stakeholders expressed concern that such high thresholds imply that statutory services are engaged in crisis management rather than supporting children and young people through more consistent lower level abuse. Services are more likely to be involved if there is physical harm, not taking into account the impacts and long-term effects of psychological abuse and coercive control.93 Action for Children’s ‘Patchy, piecemeal and precarious: Support for children affected by domestic abuse’ report (2019) also suggests there is a gap in service provision for children, with a need for support services less intensive than CAMHS but more tailored than universal child protection services. The report notes that “therapeutic one-to-one counselling can help children to develop their coping skills so that they can better understand and manage their feelings” but provision of services is inconsistent across the country.94 Further information on CAMHS can be found in the Library’s briefing ‘Children and young people’s mental health’. Speech and language therapy Experiencing or witnessing domestic abuse can impact on the development of speech, hearing, and communication skills.95 During a debate on the Domestic Abuse Bill 2019-21, Baroness Finlay of Llandaff made the following points on the role of speech and language therapists: The young child who experiences or witnesses abuse is more likely to have delayed speech and hearing development. This affects global cognitive development, especially in reading and writing, expressive language skills and social interaction skills. These children then fall further behind in many domains and may have

90 Royal College of Psychiatrists, Domestic violence and abuse – the impact on children and adolescents, November 2020 91 SafeLives, Children’s Insights dataset 2019-20, p4 92 Victims’ Commissioner, Sowing the Seeds: Children’s experience of domestic abuse and criminality, April 2020, p34 93 Ibid. 94 Ibid. 95 Joint Committee on the Draft Domestic Abuse Bill, Written evidence submitted by the Royal College of Speech and Language Therapists, May 2020 20 The role of healthcare services in addressing domestic abuse

flashbacks resulting in emotional shutdown and aberrant behaviours. […] The cycle continues. Speech and language therapists working with children and young people in care or in custody report a very high incidence of these children having been abused or witnessed abuse. The key point is that recognition of abuse and subsequent remedial action must happen early, which is why speech and language therapists should be viewed as key members of statutory domestic abuse services.96 Written evidence submitted by the Royal College of Speech and Language Therapists to the Joint Committee on the Draft Domestic Abuse Bill echoes this view.97 Further information can be found in its factsheet ‘Safeguarding children with communication needs’. In response to a Parliamentary Question on the role of speech and language therapists in supporting adults and children who have experienced domestic abuse, Safeguarding Minister, Victoria Atkins said: The Domestic Abuse Commissioner is responsible for assessing, monitoring and publishing information about the provision of services for victims and survivors. This will include speech, language and communication therapy, amongst other services.98 Non-statutory mental health support SafeLives has highlighted that whilst most people accessing mental health support use NHS services, a significant proportion utilise non- statutory support, such as private therapists and counsellors, and voluntary services (such as mental health charities).99 The SafeLives report ‘Mental health and domestic abuse’ emphasises the importance of best practice extending to non-statutory mental health support: […] it is important that private therapists/counsellors and voluntary services consider how the recommendations relate to their service provision. Mental health professional regulatory bodies and associations should ensure their guidelines for members reflect these good practices.100 Sexual health services Patients experiencing domestic abuse commonly attend sexual health services. NICE recommends these services regularly enquire about abuse to identify people affected. Research has indicated that women affected by domestic abuse are three times more likely to have gynaecological and sexual health problems.101 This can include STIs, pain during intercourse, chronic pelvic pain, vaginal bleeding and recurrent urinary tract infections.102

96 HL Deb, Domestic Abuse Bill, 27 January 2021, c1633 97 Joint Committee on the Draft Domestic Abuse Bill, Written evidence submitted by the Royal College of Speech and Language Therapists, May 2020 98 PQ64813, Domestic Abuse: Speech and Language Disorders, Answered on 8 July 2020 99 SafeLives, Safe and Well: Mental health and domestic abuse, May 2019, p47 100 Ibid. 101 IRISi, IRIS ADViSE [accessed on 14 May 2021] 102 WHO, Understanding and addressing violence against women, 2012 21 Commons Library Briefing, 20 May 2021

Even without sexual abuse, women who experience partner violence appear to have an increased risk of gynaecological problems, although the WHO note the reasons for this are not well understood.103 Sexual health professionals are likely to come into regular contact with victims and survivors of domestic abuse and therefore have a key role to play in responding. However, research has indicated that most sexual health practitioners have not had much training in identifying and responding to domestic abuse.104 It has been suggested that sexual health services could play an important role in reaching victims who might not access other healthcare services. Professor Sam Rowlands, of Bournemouth University and Dr Susan Walker of Anglia Ruskin University, have said: Sexual health clinicians are already trusted by their patients with highly confidential, potentially stigmatising information and are particularly adept at working in diverse populations and with vulnerable groups, who may not access other health care services. Sexual health services are therefore in a strong position to support early recognition of undisclosed or unidentified DVA [domestic violence and abuse] and offer an appropriate response. This can improve and save lives. The anonymity offered by sexual health services can support those affected by DVA who do not want to disclose to services where they are known.105 Many victims of domestic abuse will experience sexual abuse and rape. NHS England is the lead commissioner of Sexual Assault Referral Centres (SARCs). Further information on SARCs can be found in section 3.3. Reproductive coercion The concept of reproductive coercion was first described in 2010 and is defined as behaviours that interfere with reproductive autonomy.106 The British Medical Journal article ‘1 in 4 women at sexual health clinics report coercion over their reproductive lives’ sets out the following: Examples of contraceptive sabotage include a male partner lying about having had ‘the snip’ (vasectomy); refusal to permit the use of contraceptives; forceful removal of contraceptive devices; failure to practise withdrawal during sex; piercing condoms or other barrier methods; and throwing away/hiding contraceptive pills. And it includes ‘stealthing,’ whereby a condom is covertly removed during sex, and at the other end of the spectrum, spiking food and drink with agents known to induce abortion. The negative consequences are many: undermining responsibility for contraceptive use; unintended or unwanted pregnancy; a higher risk of abortion; higher rates of testing for sexually transmitted infections and pregnancy and requests for emergency contraception.107

103 Ibid. 104 IRISi, IRIS ADViSE [accessed on 14 May 2021] 105 IRIS ADViSE, The IRIS ADViSE Programme: Assessing for Domestic Violence and Abuse in Sexual Health Environments, 2019, p4 106 Rowlands S, Walker S, Reproductive control by others: means, perpetrators and effects, BMJ Sexual & Reproductive Health, 2019, 45:61-67 107 Ibid. 22 The role of healthcare services in addressing domestic abuse

Reproductive coercion also occurs between same sex couples and can be perpetrated by women towards men, but to date research has focused on male perpetrators and female victims. The British Medical Journal article suggests that healthcare professionals have a “key role in picking up and preventing this form of abusive behaviour”.108 Research has found that unintended pregnancy happens more frequently in abusive relationships.109 Women experiencing violence from intimate partners are twice as likely to have a male partner who refuses to use contraception and to have unintended pregnancies.110 It has been noted that reproductive coercion might cause non- adherence to contraceptives and that healthcare professionals should be alert to “frequent requests for emergency contraception, frequent attendances for pregnancy testing or STI testing, and requests for more than one abortion”.111 Research has shown it is important that women who attend health services with an escort, should also be seen alone at some point, so an issue can be raised.112 Substance misuse treatment services for victims and survivors Collective Voice, an alliance of drug and alcohol treatment and recovery charities, has set out how victims of domestic abuse might misuse substances to cope with the trauma, and how the perpetrator might use their dependency to exert control.113 The Domestic Abuse Statutory Guidance Framework addresses this issue: For some, substance abuse may progress to addiction. Perpetrators can also exploit and sustain addictions to keep a victim controlled and dependent on them, as well as manipulate the threat of exposing this to professionals (given the possible subsequent impacts should the victim have children). Research has shown that first responders can find it difficult to correctly identify perpetrators of abuse due to a tendency to see the perpetrator as the individual who is abusing alcohol or drugs. Alcohol use by women in particular has in other studies been found to be a response to experience of abuse from partners.114 The importance of considering domestic abuse when providing treatment services is emphasised. The Framework outlines how a perpetrator might control or withhold substances, force them to use

108 British Medical Journal, 1 in 4 women at sexual health clinics report coercion over their reproductive lives, January 2019 109 Rowlands S, Walker S, Reproductive control by others: means, perpetrators and effects, BMJ Sexual & Reproductive Health, 2019, 45:61-67 110 Ibid. 111 Ibid. 112 Ibid. 113 Collective Voice, Tackling domestic abuse and substance misuse, 10 May 2018 114 Home Office, Domestic Abuse: Draft Statutory Guidance Framework, July 2020, p29 23 Commons Library Briefing, 20 May 2021

substances against their will, and they might sabotage victims’ treatment for substance use.115 Trauma-informed approach In a joint report (2016), Against Violence and Abuse (AVA) and Alcohol Concern emphasised the need for a trauma-informed approach if alcohol treatment is to be successful. They said: As women’s problematic alcohol use may stem from experiences of trauma (most often abuse), it is vital that services are aware of the impact of trauma on people’s emotional and psychological well-being. Furthermore, treatment plans should take into consideration the fact that many victims will be using alcohol to manage symptoms of trauma such as flashbacks and general anxiety. If alcohol use is reduced before other coping strategies have been identified, this could result in the alcohol treatment being unsuccessful.116 Collective Voice echo the importance of trauma-informed services and the need for women-only services: Women-only services will play a role here; substance misuse services are predominantly male, reflecting patterns of substance misuse, and so can be an intimidating or even an unsafe place for women with experience of abuse perpetrated by men. Services need to be trauma-informed, so that issues underlying the substance misuse can be addressed, without re-traumatising vulnerable people.117 The Stella Project, an initiative investigating the interconnected issues of domestic abuse, substance use and mental ill health have produced a toolkit for supporting victims and survivors.

2.2 Reaching ‘hidden victims’ SafeLives state that health settings “encourage higher rates of disclosure, including from groups who face additional barriers to getting support such as BAME, disabled, older and LGBT+ communities”.118 The SafeLives ‘A Cry for Health’ report (2016) observed that health services are able to identify older victims of domestic abuse as they are more likely to use NHS services.119 Age UK has also highlighted that an older person’s experience might only first come to light during hospital admission.120 Research on the role of hospital-based Independent Domestic Violence Advisors (IDVAs) found that they helped twice as many victims and survivors from high-income households than community IDVAs.

115 Ibid., p28 116 AVA & Alcohol Concern, Learning lessons from Domestic Homicide Reviews, June 2016, p38 117 Collective Voice, Tackling domestic abuse and substance misuse, 10 May 2018 118 SafeLives, SafeLives’ 2019 survey of domestic abuse practitioners in England and Wales, 2019, p15 119 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p41 120 Age UK, Older people and domestic abuse during the coronavirus crisis, 11 May 2020 24 The role of healthcare services in addressing domestic abuse

SafeLives suggests this is evidence of reaching demographics that are likely to be “hidden from statutory services”.121 Data indicates around half of male victims and survivors (49%) fail to tell anyone they are experiencing domestic abuse and are two and a half times less likely to tell anyone than female victims (19%).122 ManKind, a charity supporting male victims of domestic abuse, also report that 11% of male victims (7.2% women) have considered taking their life due to domestic abuse.123 Health services could therefore play an important role in identifying and supporting male victims of domestic abuse. Galop, an LGBT+ anti-violence charity, note that lesbian women report similar rates of domestic abuse to that of heterosexual women. It also notes that data indicates gay and bisexual men might be twice as likely to experience domestic abuse compared to heterosexual men and “prevalence rates of domestic abuse may be higher for transgender people than any other section of the population”.124 Research has suggested that up to 80% of trans people have experienced domestic abuse and SafeLives say “professionals are concerned that trans women are being let down when they seek support”.125 Despite the prevalence of domestic abuse, Galop observes that LGBT+ victims and survivors are disproportionally underrepresented among those accessing voluntary and statutory services.126 A study by Safelives in 2018 found LGBT+ survivors of abuse were twice as likely to have self-harmed and almost twice as likely to have attempted suicide.127 SafeLives also noted a higher rate of disability among the LGBT+ population.128 The prevalence of health issues suggests healthcare professionals could play an important role in identifying signs of domestic abuse amongst LGBT+ victims and survivors. ONS data for the March 2019 to March 2020 shows disabled people to be almost three times more likely to have experienced domestic abuse than non-disabled people. Rates of abuse were particularly high among young disabled people and those with learning disabilities, mental health needs or social or behavioural impairments.129 SafeLives research found that disabled

121 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p42 122 ManKind, Statistics on male victims of domestic abuse, Accessed on 18 May 2021 123 Ibid. 124 Galop, Recognise & Respond: Strengthening advocacy for LGBT+ survivors of domestic abuse, October 2019, p7 125 SafeLives, Transgender Victims’ and Survivors’ Experiences of Domestic Abuse, 2021, p2 126 Ibid., p8 127 SafeLives, Free To Be Safe: LGBT+ people experiencing domestic abuse, September 2018 128 Ibid., p26 129 CommunityCare, Disabled people nearly three times as likely to experience domestic abuse as non-disabled, study finds, 25 February 2021 25 Commons Library Briefing, 20 May 2021

victims experience more severe and frequent abuse over longer periods of time than non-disabled victims.130 Disabled victims of abuse face barriers in accessing support. During evidence sessions on the Draft Domestic Abuse Bill, it was suggested that if health professionals always saw patients alone at some point, without carers present, this would provide an opportunity for disclosure, and “would make an enormous amount of difference”.131 In 2017, SafeLives said: “individuals who are black and minority ethnic who are experiencing domestic abuse have historically formed part of a hidden group”.132 It went on to outline how health professionals, particularly those in A&E, may be well placed to provide support: Professionals (including GPs) working in A&E may be the first to identify victims and perpetrators who present with health or mental health issues. They may also be in a good position to identify when a repeat incident has occurred. In situations where the victim is mistrustful of the police or other enforcement agencies, health professionals may well be seen as a more benign, supportive environment for someone to disclose and continue to receive help.133 Information on the prevalence of domestic abuse by ethnicity can be found in the Library’s paper ‘Race and ethnic disparities’.

2.3 Use of healthcare services by perpetrators of domestic abuse As SafeLives set out in 2018, while domestic abuse is most often experienced by women and perpetrated by men, it can happen to anyone, and can be perpetrated by anyone.134 AVA and Alcohol Concern’s 2016 report, ‘Learning lessons from Domestic Homicide Reviews’, noted that perpetrators of domestic abuse also need help. They write that perpetrators may be individuals with very complex needs, including their own histories of abuse or neglect.135 The report emphasises that this does not reduce responsibility for the abuse perpetrated, but indicates the need for perpetrators to be referred to an accredited perpetrator programme to “hold the individual accountable alongside supporting them to access support for their own experiences if needed”.136

130 Ibid. 131 Joint Committee on the Draft Domestic Abuse Bill, Other issues: Prevention and early intervention, June 2019 132 SafeLives, Guidance for Multi-agency forums: Cases involving victims who are black or minority ethnic, 2017 133 Ibid. 134 SafeLives, Free To Be Safe: LGBT+ people experiencing domestic abuse, September 2018, p8 135 AVA & Alcohol Concern, Learning lessons from Domestic Homicide Reviews, June 2016, p41 136 Ibid. 26 The role of healthcare services in addressing domestic abuse

As with victims of domestic abuse, GPs are most likely to be in contact with perpetrators of domestic abuse compared to other healthcare professionals.137 Research in UK general practices has found an association between domestic abuse perpetration and reporting symptoms of anxiety and depression.138 Interviews with men attending domestic abuse perpetrator programmes between 2004 and 2005 found they were most likely to contact health services as their first port of call for help-seeking.139 Of the 45 men interviewed, 32 said they had been to their GP prior to starting the perpetrator programme.140 It is noted that some might not have been explicit about their behaviour, instead reporting problems with anger, or “feeling low”.141 The NICE ‘Domestic violence and abuse’ quality standard (QS116) advises that people who disclose they are perpetrating domestic violence or abuse should be offered a referral to specialist services.142 NICE explains that specialist services might include initiatives and interventions to deal with their behaviour and any related issues. The interventions should “primarily aim to increase the safety of the person’s partner and children (if they have any)”.143 In written evidence to the Public Bill Committee on the Domestic Abuse Bill 2019-21, the Inter-Collegiate and Agency Domestic Violence Abuse Forum recommended an increase in funded quality-assured programmes for health professionals to refer perpetrators into that are based on research and evidence.144 Article 16 of the Istanbul Convention ‘Preventive intervention and treatment programmes’ sets out a requirement to put in place perpetrator services: Parties shall take the necessary legislative or other measures to set up or support programmes aimed at teaching perpetrators of domestic violence to adopt non-violent behaviour in interpersonal relationships with a view to preventing further violence and changing violent behavioural patterns.145

137 SafeLives, Health Pathfinder, 2020 138 Hester M, Ferrari G, Jones SK, et al, Occurrence and impact of negative behaviour, including domestic violence and abuse, in men attending UK primary care health clinics: a cross-sectional survey, BMJ Open, 2015 139 University of Bristol & the Home Office, Domestic Violence Perpetrators: Identifying Needs to Inform Early Intervention, April 2006, p14 140 Ibid., p11 141 Ibid. 142 NICE, Domestic violence and abuse: Quality standard (QS116), 29 February 2016 143 Ibid. 144 Written evidence submitted by the INCADVA (Inter-Collegiate and Agency Domestic Violence Abuse) Forum (DAB57), Domestic Abuse Bill, June 2020 145 Council of Europe, Council of Europe Convention on preventing and combating violence against women and domestic violence, Council of Europe Treaty Series – No.210, Istanbul, 11.V.2011 27 Commons Library Briefing, 20 May 2021

Perpetrator programmes Community based perpetrator programmes, as opposed to probation run programmes, are limited. Guidance published by Her Majesty’s Prison and Probation Service (HMPPS) in 2019 states that “international evidence to support the effectiveness of perpetrator programmes is inconsistent and inconclusive” which causes difficulties when trying to draw firm conclusions on what works and the merits of one intervention type over another146 The guidance recommends interventions should focus on risk factors for intimate partner violence147, including supporting participants to: • Challenge, change and manage any thoughts or beliefs that support intimate partner violence • Develop social skills for healthy intimate relationships like communication, negotiation and assertiveness • Develop problem solving skills • Explore the impact of alcohol or substance misuse, support appropriate management and refer to treatment when required • When appropriate, encourage participation in couples’ counselling that focusses on eliminating abusive behaviours and teaching negotiation, communication, and interpersonal problem solving.148 Home Office draft guidance (2021) emphasises the importance of quality assured programmes, delivered by appropriately trained professionals.149 Perpetrator intervention programmes can be accredited by the specialist domestic abuse organisations Respect and DAHA (Domestic Abuse Housing Alliance) alongside the Ministry of Justice Correctional Services Accreditation and Advice Panel.150 The Drive Partnership, which works with perpetrators of domestic abuse, published a ‘Call to Action’ in 2020. This identified “an urgent need for a domestic abuse perpetrator strategy for England and Wales underpinned by core statutory support”.151 The ‘Call to Action’ outlines that one in four perpetrators are repeat offenders with some having as many as six victims.152 The point is made that “domestic abuse can only end if we address those that are perpetrating abuse”: This means challenging the social norms that facilitate abuse, intervening with those on the cusp of offending, those already

146 HMPPS, Intimate Partner Violence – domestic abuse programmes, 15 May 2019 147 Intimate partner violence (IPV) is a type of domestic abuse, where abuse is perpetrated against a current or former partner. 148 Ibid. 149 Home Office, Domestic Abuse Protection Notices and Domestic Abuse Protection Orders: Draft statutory guidance for the police, January 2021 150 Ibid., p25 151 Drive Project, A Domestic Abuse Perpetrator Strategy for England and Wales: Call to Action, January 2020, p4 152 Ibid., p5 28 The role of healthcare services in addressing domestic abuse

causing serious harm, and all stages in between. We want to see systems that enable those who have been abusive or are at risk of being abusive to change their behaviour and systems that force them to do so if they are unwilling to change. We want to see a range of interventions for all types of perpetrators, including individuals with protected characteristics, and that address abuse in all its forms.153 As of January 2021, there were over 125 signatories to the Call to Action, including several domestic abuse charities such as Women’s Aid, SafeLives and Refuge.154 Section 75 of the Domestic Abuse Act 2021 requires the Government to publish a strategy for prosecution and management of offenders, including reducing the risk that such individuals commit further offences involving domestic abuse.155 The Home Office has indicated this ‘perpetrator strategy’ will be published as part of the “holistic” domestic abuse strategy.156 During a debate on the Domestic Abuse Bill 2019-21, Baroness Williams of Trafford said the Government recognised that more work is needed to improve the response to perpetrators,.157 She said: I can inform the Committee that, later this year, the Government will bring forward a new, ambitious strategy to tackle the abhorrent crime of domestic abuse. This strategy will be holistic in its approach to tackling domestic abuse and will outline our ambitions not only to prevent offending but to protect victims and ensure that they have the support they need. It is right that we have a strategy that takes a holistic approach to tackling domestic abuse.158 In the Queen’s Speech (2021) it was announced the new domestic abuse strategy will be accompanied by £25 million of investment “which will more than double the amount being spent on programmes to work with perpetrators”.159 The Domestic Abuse Act 2021 includes provisions to widen the scope of Domestic Abuse Protection Orders (DAPOs) so ‘positive’ requirements can be placed on perpetrators (rather than just prohibitions).160 This could include compelling the perpetrator to: • Attend an assessment for a perpetrator intervention programme • Attend a mental health assessment • Attend an assessment for a drugs or alcohol programme.161 Where a positive requirement is imposed, the DAPO must specify the person who is to be responsible for supervising compliance. They are

153 Ibid., p5 154 Drive, Call to action for a perpetrator strategy 155 Domestic Abuse Act 2021, Part 7, Prosecution and management of offenders 156 Home Office, Domestic Abuse Act: Factsheet, 29 April 2021 157 HL Deb, Domestic Abuse Bill, 10 February 2021, c391 158 Ibid. 159 Gov.uk, Queen’s Speech 2021: background briefing notes, 11 May 2021, p87 160 Home Office, Domestic Abuse Act 2021 commencement schedule, 13 May 2021 161 Home Office, Domestic Abuse Protection Notices and Domestic Abuse Protection Orders: Draft statutory guidance for the police, January 2021, p24 29 Commons Library Briefing, 20 May 2021

referred to as “the responsible person” and can be an individual or an organisation, such as a provider of a perpetrator intervention programme, or of a drug or alcohol treatment programme.162 The responsible person must inform the police of the perpetrator’s compliance or non-compliance with the requirements.163 Breaches amount to a criminal offence, punishable by up to five years’ imprisonment, unlimited fine or both.164 Whilst the Drive Partnership Call to Action welcomes the new pathways to interventions brought about by the DAPOs, it notes that “suitable and quality-assured interventions are far from universally available” and for some groups, such as LGBT+ perpetrators “there are almost no suitable interventions available”.165 The SafeLives report, ‘Free To Be Safe: LGBT+ people experiencing domestic abuse’, indicates that running perpetrator group programmes with both LGBT+ and non-LGBT+ participants “may be unsafe and create anxiety which is not conducive to facilitating change”.166 The report also notes that most perpetrator programmes have been designed for men in heterosexual relationships.167 Whilst some programmes work with women too, it has increasingly been recognised there may be a need for programmes tailored to female perpetrators. For example, the City of London’s ‘Violence against Women and Girls Strategy 2019-2023’ commits to “exploring the option of perpetrator programmes for women with external specialist agencies such as Respect”.168 Substance misuse services for perpetrators. The ‘Draft Domestic Abuse Statutory Guidance Framework’ says that factors such as alcohol and drugs misuse can increase the likelihood and severity of domestic abuse. It reports that up to 60% of men in perpetrator programmes have problems with alcohol and/or drugs. However, there is “not a simple causal relationship between substance misuse and domestic abuse.”169 The guidance explains that addressing a perpetrator’s drug or alcohol use alone is “unlikely to reduce or solve the problem of their abusive behaviour” and: It is important that any alcohol or drugs treatment programme for perpetrators, as well as addressing the causes of the substance

162 Ibid. 163 Ibid. 164 Ibid. 165 Drive Project, A Domestic Abuse Perpetrator Strategy for England and Wales: Call to Action, January 2020, p7 166 SafeLives, Free To Be Safe: LGBT+ people experiencing domestic abuse, September 2018, p31 167 Ibid. 168 City of London, Violence against Women and Girls Strategy 2019-2023: A strategy for our whole community, p23 169 Home Office, Domestic Abuse Draft Statutory Guidance Framework, July 2020, p27 30 The role of healthcare services in addressing domestic abuse

abuse, also addresses the complex dynamics and power and control which underpin domestic abuse.170 It is recognised that the relationship between domestic abuse and substance misuse is complex.171 Alcohol Concern and AVA note in their joint report (2016) that a significant proportion of problem drinkers also have a mental health problem, and this combination “is associated with high levels of suicide, self-harm and violence to others”.172 During the House of Lords debate on the ‘Alcohol Harm Commission: Report 2020’, Lord Bethell, Parliamentary Under-Secretary of State at the Department of Health and Social Care, said the importance of joining up domestic abuse, mental health and substance misuse services will be “reflected upon”: We know there is frequent co-existence of domestic abuse, mental health problems and the misuse of drugs and alcohol. Research indicates that in 34% of incidents of domestic violence, the victim perceived the offender to be under the influence of alcohol. The Domestic Abuse Bill will see better protections for victims and more effective measures to go after the perpetrators. We will reflect the importance of joining up domestic abuse, mental health and substance misuse services in the supporting statutory guidance. One action of this important Bill is to establish in law the office of the domestic abuse commissioner, with strong powers to tackle domestic abuse.173 In the AVA’s ‘Learning lessons from Domestic Homicide Reviews’ (2016), alcohol use was found to be a common theme among the initial sample of 39 Domestic Homicide Review (DHR)174 reports examined. In 22 reports (56% of the 39), the perpetrator of the homicide was identified as experiencing alcohol problems.175 The report highlighted: • A referral to a specialist alcohol service was only made in 8 out of 22 DHRs (36%), where it was known the perpetrator had a problem with alcohol. • In six of the eight cases (75%) where the perpetrator was referred to specialist alcohol services, the perpetrator had a pattern of “non-engagement”.176 The report said that referring perpetrations into treatment services “all too often” did not happen and that non-specialist services tended to assume the provision of information about services is adequate. Instead,

170 Ibid., p28 171 Ibid 172 AVA & Alcohol Concern, Learning lessons from Domestic Homicide Reviews, June 2016, p44 173 HL Deb, Alcohol Harm Commission: Report 2020, 22 April 2021, c386GC 174 A Domestic Homicide Review is defined by the Home Office as “a multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal relationship, or a member of the same household as themselves.” 175 AVA & Alcohol Concern, Learning lessons from Domestic Homicide Reviews, June 2016, p11 176 Ibid., p12 31 Commons Library Briefing, 20 May 2021

there is a need for robust pathways between services with “more handholding and less signposting”.177 AVA and Alcohol Concern conclude “it is critical that alcohol services screen for domestic abuse and vice versa. Neither issue can be wholly addressed unless the accompanying abuse or alcohol misuse is taken into consideration”.178 There are indications that being a perpetrator of domestic abuse may contribute to a reluctance to address alcohol misuse. AVA and Alcohol Concern note that alcohol use is likely to be an integral part of abusive behaviour, such as using it as an excuse, and that this needs to be addressed on any behaviour change programme.179 It’s suggested that perpetrators may use alcohol as a means to cope with negative feelings which are tied up with the perpetration of abuse.180 AVA and Alcohol Concern say a perpetrator programme “should always accompany a treatment plan”.181 Following changes to DAPOs, which mean perpetrators can be required to attend an assessment for a drug or alcohol programme, concerns have been raised about how this will be implemented. Collective Voice noted in 2018 that “current drug rehabilitation requirements and alcohol treatment requirements are failing to work as planned due to the fragmentation of the system”. Changes to the commissioning process for substance misuse treatment services has also resulted in less specialist provision.182 Academic literature has highlighted that a zero-tolerance approach to domestic abuse and compliance with court orders would be at odds with models of treatment for alcohol and drug use that acknowledge relapse is common, and make efforts to avoid reducing individuals identities’ to their drug consumption.183

177 Ibid., p38 178 Ibid., p12 179 Ibid., p41 180 Ibid., p12 181 Ibid., p23 182 Collective Voice, Tackling domestic abuse and substance misuse, 10 May 2018 183 Gadd, D et al., The Dynamics of Domestic Abuse and Drug and Alcohol Dependency, The British Journal of Criminology, Volume 59, Issue 5, September 2019, pp1035–1053 32 The role of healthcare services in addressing domestic abuse

3. Role of the NHS and Public Health England

A Government taskforce, chaired by Professor Sir George Alberti, published a report in March 2010 which investigated the role of the NHS in responding to violence against women and children. The taskforce made 23 recommendations, many of which applied specifically to NHS practices. This included: All NHS staff should have – and apply – a clear understanding of the risk factors for violence and abuse, and the consequences for health and well-being of violence and abuse, when interacting with patients. […] Every NHS organisation should have a single designated person to advise on appropriate services, care pathways and referrals for all victims of violence and abuse, providing urgent advice in cases of immediate and significant risk.184 The report concluded that the NHS has a “vital role to play in dealing with violence and abuse and its consequences, both short and long- term” and has a “clear duty to help”.185 In response, the Department of Health published ‘Improving services for women and child victims of violence: the Department of Health Action Plan’ in November 2010. The action plan acknowledged the important role healthcare services play in responding to abuse: Health services are involved because of the significant impact of violence and abuse. Violence and abuse can lead to increased risk of poor mental health, injuries, chronic physical conditions, unwanted and complicated pregnancy, sexually transmitted infections and substance misuse, and the effects can last a lifetime and into subsequent generations. If we can intervene early, we have a chance to reduce the impact of the many health consequences. For many victims, the police are not always the first port of call. The victim may attend A&E, sexual health clinics or go to their GP. Health professionals are therefore in a position to identify violence that is occurring or has occurred; and to intervene and refer women and children to the appropriate services and support. For some extreme cases, there may only be one chance to save a life.186 The plan set out a series of actions to improve the NHS response in 2010/11, which included raising awareness amongst NHS staff, improving “the competencies and skills of NHS staff to equip them to

184 The report of the Taskforce on the Health Aspects of Violence Against Women and Children, Responding to violence against women and children – the role of the NHS, March 2010, p5 185 Ibid., p58 186 Department of Health, Improving services for women and child victims of violence: the Department of Health Action Plan, 25 November 2010, p5 33 Commons Library Briefing, 20 May 2021

appropriately identify, treat and refer” and improving the quality of specialist services such as Sexual Assault Referral Centres.187 The action plan highlighted challenges with providing services in different areas and where there are different levels of need. Rural areas were identified as posing challenging due to the higher costs in remote locations and greater sparsity. 188

3.1 NHS: Strategic direction During an evidence session on the Draft Domestic Abuse Bill, Jackie- Doyle-Price, then the Minister for Mental Health, Inequalities and Suicide Prevention, was asked why domestic abuse does not feature in the NHS Long-Term Plan published in 2019. Responding, the Minister said: Although it is not specifically referred to in the long-term plan, part of the expansion, for example in mental health services, will be very much tackling and supporting victims of all kinds of abuse. We know that, in terms of women who are presenting in a mental health setting, a very high proportion of those are people who have been through domestic violence or sexual violence. Although it is not a specific workstream per se, it is something that is picked up in the general ambition for improving a level of service. […] In respect of what the NHS can do in this space, it really is about behavioural and cultural change. We are very clear that, ultimately, it is probably the most important gateway for the state to be able to pick up victims—we get that completely. We need to encourage more services to be more alive to that. We are trying to spread out GPs specifically, because obviously that is the first place. […] In respect of A&E services, I am quite optimistic. We are rolling out liaison psychiatry teams to have a 24/7 presence in accident and emergency departments. I would expect those people to be able to pick up on signs of abuse.189 NHS England asserted it “actively engaged” in the consultation process on the Domestic Abuse Bill and will be producing a four-year action plan in response.190 This plan will include: Recommended training programme and awareness raising for all staff. One of the tenets of the action plan will be that any and all victims and survivors of domestic abuse and their children will not be unduly disadvantaged in accessing physical and mental health services when they are forced to move to new accommodation in a different area.191

187 Department of Health, Improving services for women and child victims of violence: the Department of Health Action Plan, 25 November 2010, p13 188 Ibid., p18 189 Joint Committee on the Draft Domestic Abuse Bill, Oral evidence: Draft Domestic Abuse Bill, HC 2075, 22 May 2019 190 NHS England, Workstreams: Domestic abuse and violence Bill, accessed 31 January 2021 191 Home Office, The Government response to the report from the Joint Committee on the Draft Domestic Abuse Bill, CP 137, July 2019, para 140 34 The role of healthcare services in addressing domestic abuse

In a letter in to domestic abuse organisations in July 2020, Health Minister Nadine Dorries also commented on the development of the NHS England and NHS Improvement action plan. The Minister said: NHSE&I is developing an action plan specifically on Domestic Violence and Abuse. This will both raise awareness amongst NHS staff, ensure that staff have the skill to identify and refer, and address the issue of NHS staff who are themselves victims, or perpetrators.192

3.2 Role of the NHS as an employer In November 2020, NHS England said it had been working with survivors of domestic abuse to create an “internal domestic abuse policy” for staff. It said the policy “clearly sets out the roles and responsibilities the organisation has to recognise and support victims and survivors of domestic abuse.”193 The Department for Business, Energy and Industrial Strategy (BEIS) published ‘Workplace support for victims of domestic abuse: Report from review’ in January 2021. The report noted NHS Safeguarding had published an internal staff domestic abuse policy and provided the following information: […] it considers how the organisation responds to self-disclosures of staff who may have perpetrated abuse. Due to staff working remotely, we also created specific line manager guidance on how to ask/signpost about domestic abuse safely in a virtual setting, which is linked to the staff domestic abuse policy.194

3.3 Commissioning of services The NHS is lead commissioner of Sexual Assault Referral Centres (SARCs) and while specialised domestic abuse support services are mainly provided by third sector organisations, healthcare bodies are often involved in the commissioning process. The Government’s ‘Violence Against Women and Girls Strategy 2016- 2020’ summarises how responsibility for service provision is devolved to local commissioners: We have devolved responsibility for local service provision to local commissioners, including PCCs, health and local authority commissioners. This shift recognises that local areas are best placed to assess local need, to design comprehensive and good quality interventions, and to be held to account through improved local democratic accountability.195 This can take place via Community Safety Partnerships (CSP), for example. CPSs are a statutory partnership of organisations who work to create strategies and interventions to reduce crime in their local area, including domestic abuse. CSPs are made up of representatives from the

192 Letter from Nadine Dorries, Minister of State for Patient Safety, Suicide Prevention and Mental Health, to Suzanne Jacob, Chief Executive of SafeLives, 2 July 2020 193 NHS England, Your silence is their greatest weapon: 16 days of action against domestic abuse, 25 November 2020 194 Department for Business. Energy and Industrial Strategy, Workplace support for victims of domestic abuse: Report from review, January 2021, p15 195 GOV.UK, Violence Against Women and Girls Strategy 2016-2020, p29 35 Commons Library Briefing, 20 May 2021

police, local authority, fire and rescue service, probation trust and the Clinical Commissioning Group.196 The Home Office ‘Domestic Abuse Commissioner factsheet’ outlines how services are commissioned by a range of bodies such as Police and Crime Commissioners, local authorities and the NHS, and notes that whilst this has provided flexibility, “it can mean the quantity and quality of services can vary nationally.197 The Domestic Abuse Act 2021 includes a provision requiring local authorities to appoint Domestic Abuse Local Partnership Boards to provide advice regarding local authority support services. The boards are to include at least one representative from local healthcare services.198 This requirement is not yet in force.199 During a debate on the Domestic Abuse Bill in the House of Lords, Baroness Williams of Trafford responded to calls for the statutory duty on tier 1 local authorities to provide support for victims to be extended to other bodies, including Clinical Commissioning Groups: Clearly, local authorities and clinical commissioning groups also have a role to play […] I welcome the domestic abuse commissioner’s commitment to leading a detailed mapping exercise into the current community-based support landscape […] The Government are committed to addressing the findings of this review and, should we find that there is a need for legislative changes, it is right and proper that we should consult on those so we can consider the views of the affected public authorities. […] there will be further opportunities to legislate in this area, including the upcoming victims’ law.200 There have long been calls for greater integration of domestic abuse support services. ‘Safety in Numbers’, a report evaluating IDVA services, published in 2009 made the following points: These findings point to the need for concerted efforts to be made to strengthen links with generic and specialist health services, especially since recent studies have shown that the delivery of integrated services to address domestic abuse in tandem with health related issues (mental health, substance misuse) facilitates improved outcomes for victims201 The NHS England ‘Strategic direction for sexual assault and abuse services’ for 2018-2023 emphasises the importance of joined-up commissioning of services and the challenges faced: The landscape for sexual assault and abuse services is wide and complex. It spans a number of different systems and government organisations, including health, care and justice, and requires them to work together. The commissioners of services are varied, and there is a wide range of providers, including some specialist and third sector organisations. This creates a significant challenge,

196 NHS, NHS Data Model and Dictionary: Community Safety Partnership 197 Home Office, Domestic Abuse Commissioner factsheet, last updated 17 August 2020 198 Domestic Abuse Act 2021, Part 4, Local Authority Support 199 Home Office, Domestic Abuse Act 2021 commencement schedule, 13 May 2021 200 HL Deb, Domestic Abuse Bill, 1 February 2021, c2009 201 SafeLives, Safety in Numbers: A Multi-site Evaluation of IDVA Services, November 2009, p18 36 The role of healthcare services in addressing domestic abuse

and all the different bodies can find it difficult to work together effectively to meet the lifelong needs of victims and survivors. This can result in fragmentation in service delivery, frustration and poor outcomes for victims and survivors of sexual assault and abuse over their lifetime.202 In July 2020, the Health Minister Nadine Dorries detailed how, alongside the introduction of the new Domestic Abuse Commissioner, the Ministry of Justice is developing a cross-Government victim funding strategy which will provide an opportunity for improved integration.203 Sexual Assault Referral Centres (SARCs) NHS England commissions public health services as per the NHS public health functions agreements made under section 7A of the National Health Service Act 2006.204 One of these responsibilities is the co- commissioning of sexual assault referral centres (SARCs). NHS England took on the lead commissioning role for SARCs in April 2013, together with Police and Crime Commissioners. This is led by the NHS England regional Health and Justice teams. The Survivors Trust explains that SARCs are specialist medical and forensic services for anyone who has been raped or sexually assaulted. They provide services to victims and survivors regardless of whether they choose to report the offence to the police.205 There are a number of ways to access the service, including referral by the police, social services, GP or self-referral.206 The NHS website provides a search tool to locate the nearest rape and sexual assault referral centres.207 The delivery aim of SARCs is to provide:

• acute healthcare and support in age-appropriate settings • comprehensive forensic medical examinations • follow up services which address medical, psychological, social and ongoing needs

• direct access or referral to Independent Sexual Violence Advisors.208 The NHS England ‘Commissioning Framework for Adult and Paediatric Sexual Assault Referral Centres (SARC) Services’ states:

202 NHS England, Strategic direction for sexual assault and abuse services: Lifelong care for victims and survivors: 2018 – 2023, p20 203 Letter from Nadine Dorries, Minister of State for Patient Safety, Suicide Prevention and Mental Health, to Suzanne Jacob, Chief Executive of SafeLives, 2 July 2020 204 NHS England, Commissioning Framework for Adult and Paediatric Sexual Assault Referral Centres (SARC) Services, 10 August 2015 205 The Survivors Trust, Sexual Assault Referral Centres (SARC) 206 NHS England, Commissioning Framework for Adult and Paediatric Sexual Assault Referral Centres (SARC) Services, 10 August 2015, p59 207 NHS, Find rape and sexual assault referral centres 208 NHS England, Sexual assault and abuse 37 Commons Library Briefing, 20 May 2021

The SARC service must be available 24 hours a day, 7 days a week, including public holidays, to provide advice to police and clients, and deliver acute medical and forensic examination.209 There are 47 SARCs across England and NHS England has commissioned a range of providers to run the services, including Mountain Healthcare and G4S Health Services. SARCs must provide “Sexual Assault Referral Centres Indicators of Performance” at least quarterly, to “inform national commissioning assurance and any regional, sub regional assurance.”210 As the NHS England commissioning framework says the SARC may refer survivors of sexual assault to other services. For example, the framework notes crisis workers are to deliver “confidential, emotional and practical support to clients” and must offer a referral to a counsellor, based on need.211 The framework says the SARC may make referrals to local community mental health services or acute services as appropriate.212 The NHS Long Term Plan published in January 2019 committed to expanding provision to “ensure survivors of sexual assault are offered integrated therapeutic mental health support, both immediately after an incident and to provide continuity of care where needed”.213 NHS England has published the ‘Strategic direction for sexual assault and abuse services’ covering 2018 to 2023. The strategy includes six core priorities: 1. Strengthening the approach to prevention 2. Promoting safeguarding and the safety, protection and welfare of victims and survivors 3. Involving victims and survivors in the development and improvement of services 4. Introducing consistent quality standards 5. Driving collaboration and reducing fragmentation 6. Ensuring an appropriately trained workforce214 As part of the strategy, NHS England said that victims of sexual abuse will receive “a lifetime of mental health care” to help cope with trauma.215 In July 2020, Nadine Dorries, the Minister for Patient Safety, Suicide Prevention and Mental Health, referred to the development of trauma- informed commissioning and practice in a letter responding to domestic abuse organisations: NHS England’s five-year Strategic Direction for Sexual Assault and Abuse Services aims to ensure victims receive joined-up pathways of care over the course of their lifetime whenever they need it.

209 NHS England, Commissioning Framework for Adult and Paediatric Sexual Assault Referral Centres (SARC) Services, 10 August 2015, p14 210 Ibid., p13 211 Ibid., p17 212 Ibid. 213 NHS, NHS Long Term Plan, January 2019, p118 214 NHS England, Sexual assault and abuse 215 NHS England, Lifetime NHS mental health care for sexual assault victims, 4 June 2018 38 The role of healthcare services in addressing domestic abuse

The development of trauma-informed commissioning and practice across the pathway will enhance the healthcare response to victims and survivors, to help them recover, heal and rebuild.216 Government funding for SARCs increased from £27 million in 2017/18 to £35 million in 2019/20.217 On 20 March 2021, NHS England said the number of people receiving help from SARCs halved after the first lockdown compared with the previous year despite official figures showing increases in domestic abuse and sexual assault.218 In July 2019, around 2,500 patients accessed SARC services but that decreased to 1,250 in July 2020.219

3.4 Role of Public Health England Domestic abuse has been described by the World Health Organization as an “urgent public health priority”.220 Public Health England has been involved in several initiatives to tackle domestic abuse. In 2014, Public Health England said: Our main aim at Public Health England is to support and grow capacity within the public health system to prevent and respond to domestic violence. We want to draw attention to the remarkable work that is already being done by numerous domestic violence charities and organizations and support the system to get better at measuring and demonstrating their impact on lives and communities.221 Also in 2014, Public Health England (PHE) launched a ‘Violence Toolkit for Businesses’ alongside the Corporate Alliance Against Domestic Violence. Working with the University of the West of England, they developed a bystander intervention programme for students to address sexual coercion and domestic abuse. In an article for Women’s Aid in 2015, Dr Justin Varney from PHE said they had commissioned the charity, Against Violence and Abuse (AVA), to refresh their free e-learning modules to align with NICE guidelines on domestic violence and NHS professionals, and to provide free access to training up to level 2 .222 Public Health Outcomes Framework A Public Health Outcomes Framework was launched in 2013 which the then Department of Health described as introducing “the overarching vision for public health, the outcomes we want to achieve and the

216 Letter from Nadine Dorries, Minister of State for Patient Safety, Suicide Prevention and Mental Health, to Suzanne Jacob, Chief Executive of SafeLives, 2 July 2020 217 PQ77659, Health Services: Domestic Violence, Answered on 1 September 2020 218 NHS England, NHS urges sex crime and abuse victims to seek help, 20 March 2021 219 Ibid. 220 World Health Organisation, Bulletin of the World Health Organisation: Violence against women: an urgent public health priority, January 2011 221 Public Health England, Domestic violence: What action are you taking?, 25 November 2014 222 Women’s Aid, Domestic violence – a fundamental issue for sexual and reproductive health services, 3 December 2015 39 Commons Library Briefing, 20 May 2021

indicators that will help us understand how well we are improving and protecting health.”223 The SafeLives report ‘A Cry for Health: Why we must invest in domestic abuse services in hospitals’ (2016), included the following commentary on the link between public health and domestic abuse: Over the past three years, the Public Health Outcomes Framework (PHOF) 2013–2016 has contributed to developing practices to integrate domestic abuse with healthcare. This is a framework aimed at reforming the public health system as a whole, situating public health within local government. Identifying domestic abuse as a key determinant of health, the PHOF administers responsibility to local authorities and local healthcare entities (GPs, A&E departments and hospitals) to recognise domestic abuse as a major public health issue, and protect those who are vulnerable.224 The ‘Public Health Outcomes Framework 2019-2022’ includes domestic abuse as an indicator under the objective for “improvements against wider factors which affect health and wellbeing and health inequalities.”225 The Framework’s data dashboard includes a breakdown of domestic- abuse related incidents and crimes per 1,000 people.226 In 2019/20 there were 28 domestic abuse-related incidents and crimes per 1,000 people across England.227 The figure was highest in the North East (42.3) and lowest in the South East (22.3).228 The dashboard includes recent trends showing an increase in domestic-abuse related incidents and crimes across all regions except London, where there was no significant change.229 The extent to which the abolition of Public Health England and creation of the Office for Health Promotion in autumn 2021 will impact on public health responses to domestic abuse is currently unclear.

223 Department of Health, The Public Health Outcomes Framework for England, 2013- 2016, January 2012 224 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p37 225 Public Health England, Public Health Outcomes Framework 2019-2022: At a glance, Last updated 2 August 2019 226 Public Health England, Public Health Outcomes Framework, B. Wider determinants of health, B11 – Domestic abuse-related incidents and crimes, Accessed on 30 January 2021 227 Ibid. 228 Ibid. 229 Ibid. 40 The role of healthcare services in addressing domestic abuse

4. Guidance for healthcare professionals

Professional bodies have published domestic abuse guidance for healthcare staff, including the following: • Royal College of Nursing – Domestic abuse: Professional Resources • Royal College of General Practitioners – Domestic abuse • Royal College of Midwives – Domestic Abuse: Identifying, caring for and supporting women at risk of/victims of domestic abuse during Covid-19 • Royal College of Obstetricians & Gynaecologists – Gender-based domestic violence: How can I help my patients? • Royal College of Psychiatrists offer a module on ‘Domestic violence and abuse: Identifying and responding to victims and perpetrators’ • Royal College of Emergency Medicine – Management of domestic abuse • British Medical Association – Domestic Abuse 4.1 NICE guidance The National Institute for Health and Care Excellence (NICE) has a ‘Domestic violence and abuse overview’ which summarises all NICE guidance on this issue in an interactive flowchart. It includes guidance on various aspects of identifying, preventing and reducing domestic violence and abuse. This includes planning services, training and ensuring adults have the best experience of care.230 Domestic violence and abuse: multi-agency working NICE published the public health guideline (PH50) ‘Domestic violence and abuse: multi agency working’ on 26 February 2014. The guideline was produced by NICE following a request from the Department of Health in 2008 for guidance on “how to identify, prevent and reduce domestic violence and abuse”.231 NICE concluded there was insufficient evidence on which to base recommendations for primary prevention programmes, saying “most of the evidence about this relates to interventions in educational settings and these are outside the scope of this guidance unless they are delivered by a health or social care professional.” It added that that prevention was an important area for future research.232

230 NICE, NICE Pathways: Domestic violence and abuse overview, Accessed on 30 January 2021 231 NICE, Domestic violence and abuse: multi-agency working, Public health guideline (PH50), Introduction, 26 February 2014, p67 232 NICE, Domestic violence and abuse: multi-agency working, Public health guideline (PH50), Introduction, 26 February 2014 41 Commons Library Briefing, 20 May 2021

The NICE guidance is for health and social care commissioners, specialist domestic violence and abuse staff and others whose work may bring them into contact with people who experience or perpetrate domestic violence.233 The recommendations cover the “broad spectrum of domestic violence and abuse, including violence perpetrated on men, and those in same- sex relationships and on young people.”234 NICE made 17 recommendations in total: 1. Plan services based on an assessment of need and service mapping 2. Participate in a local strategic multi-agency partnership to prevent domestic violence and abuse 3. Develop an integrated commissioning strategy 4. Commission integrated care pathways 5. Create an environment for disclosing domestic violence and abuse 6. Ensure trained staff ask people about domestic violence and abuse 7. Adopt clear protocols and methods for information sharing 8. Tailor support to meet people's needs 9. Help people who find it difficult to access services 10. Identify and, where necessary, refer children and young people affected by domestic violence and abuse 11. Provide specialist domestic violence and abuse services for children and young people 12. Provide specialist advice, advocacy and support as part of a comprehensive referral pathway 13. Provide people who experience domestic violence and abuse and have a mental health condition with evidence- based treatment for that condition 14. Commission and evaluate tailored interventions for people who perpetrate domestic violence and abuse 15. Provide specific training for health and social care professionals in how to respond to domestic violence and abuse 16. GP practices and other agencies should include training on, and a referral pathway for, domestic violence and abuse 17. Pre-qualifying training and continuing professional development for health and social care professionals should include domestic violence and abuse

233 Ibid. 234 Ibid. 42 The role of healthcare services in addressing domestic abuse

NICE undertook a surveillance review in 2018 and decided not to update the guideline as no evidence was found which would impact the recommendations.235 NICE quality standard NICE published a ‘Domestic violence and abuse’ quality standard (QS116) on 29 February 2016. NICE quality standards are described as “a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care.”236 The quality standard lists the following quality statements: 1 Statement 1 People presenting to frontline staff with indicators of possible domestic violence or abuse are asked about their experiences in a private discussion. 2 Statement 2 People experiencing domestic violence and abuse receive a response from level 1 or 2 trained staff. 3 Statement 3 People experiencing domestic violence or abuse are offered referral to specialist support services. 4 Statement 4 People who disclose that they are perpetrating domestic violence or abuse are offered referral to specialist services. The SafeLives report ‘Safe and Well: Mental health and domestic abuse’ (2019) acknowledges the importance of the health response to domestic abuse is recognised in NICE guidelines but claims “implementation of these guidelines is inconsistent.”237 During an evidence session on the Draft Domestic Abuse Bill, then- Health Minister, Jackie Doyle-Price, confirmed that the NICE guidelines are “about generating awareness and good practice throughout the system” and are not mandatory.238 As such, the Minister said “it is not monitored so much” and “some practitioners will really take their responsibilities seriously in this matter, and some will not”.239 The surveillance review carried out by NICE in 2018 for the ‘Domestic violence and abuse: multi agency working’ guideline said that “no data are available on the uptake or implementation” of the guideline.240

235 NICE, 2018 surveillance of Domestic violence and abuse: multi-agency working (2014) NICE guideline PH50, Appendix A: Summary of evidence from surveillance, August 2018, p2 236 NICE, Domestic violence and abuse: Quality standard (QS116), Introduction, 29 February 2016 237 SafeLives, Safe and Well: Mental health and domestic abuse, May 2019, page 46 238 Joint Committee on the Draft Domestic Abuse Bill, Oral evidence: Draft Domestic Abuse Bill, HC 2075, 22 May 2019 239 Ibid. 240 NICE, 2018 surveillance of Domestic violence and abuse: multi-agency working (2014) NICE guideline PH50: Appendix A: Summary of evidence from surveillance, August 2018, p2 43 Commons Library Briefing, 20 May 2021

Budgetary constraints were acknowledged as impacting on how the recommendations are implemented.241 In response to a Parliamentary Question on domestic abuse health interventions and best practice Nadine Dorries said: […] Best practice is already shared in a number of ways, including through events, guidance and resources such as the National Institute for Health and Care Excellence quality standards. Accountability and regulatory structures are also in place to ensure commissioned health services meet high standards of quality and safety. In this case, the new Domestic Abuse Commissioner will help drive further consistency and better performance in the response to domestic abuse across all local areas and agencies.242

4.2 Department of Health guidance Department of Health published guidance ‘Responding to domestic abuse: A resource for health professionals’ in March 2017 which draws on recommendations made in the NICE guideline ‘Domestic violence and abuse: multi agency working’. The resource is “for all NHS staff and those providing services funded by the NHS” and aims to “help practitioners identify potential victims, initiate sensitive routine enquiry and respond to disclosures of abuse”.243 The guidance includes a section on health professionals’ responsibilities: You have a responsibility to: • know and recognise the risk factors, signs, presenting problems or conditions, including the patterns of coercive or controlling behaviour associated with domestic abuse • facilitate disclosure in private without any third parties present; to be attentive and approachable; and use selective, routine enquiry to question what you hear and decide if the presentation of the patient warrants concern. The Department of Health also published separate professional guidance for midwives, health visitors and school nurses on ‘Domestic Violence and Abuse’.

4.3 Identifying and responding to domestic abuse Training for staff NICE Quality Statement 2 ‘Response to domestic violence and abuse’ sets out that service providers should ensure frontline staff are trained to provide a level 1 or 2 response appropriate to their role.244

241 NICE, 2018 surveillance of Domestic violence and abuse: multi-agency working (2014) NICE guideline PH50: Appendix A: Summary of evidence from surveillance, August 2018, p2 242 PQ77657, Health Services: Domestic Violence, 21 July 2020 243 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p7 244 NICE, Domestic violence and abuse: Quality standard (QS116), Quality Statement 2: Response to domestic violence and abuse, 29 February 2016 44 The role of healthcare services in addressing domestic abuse

Level 1 training is intended to equip staff to respond to a disclosure of domestic abuse sensitively and safely, and direct people to specialist services.245 This level of domestic abuse training is often included as part of mandatory safeguarding training.246 Level 2 domestic abuse training is intended to train staff to ask about domestic violence and abuse in a way that makes it easier for people to disclose it. This involves an understanding of the epidemiology of domestic abuse, how it affects lives and the role of professionals in intervening safely.247 NICE states that level 2 training is typically for healthcare workers in contact with patients, such as nurses, GPs, mental health professionals, midwives, health visitors and alcohol and drug misuse workers, amongst others.248 The 2017 Department of Health guidance provides a summary of the different levels of training to respond to domestic abuse.249 When giving evidence to the Joint Committee on the Draft Domestic Abuse Bill, then-Health Minister, Jackie Doyle-Price, said “we expect all frontline practitioners to have achieved at least level 1” and the training consists of online modules which are “available to everyone”.250 In July 2020, Nadine Dorries, said mandatory safeguarding training is being reviewed in a letter to domestic abuse organisations: NHSE&I and Health Education England are reviewing mandatory safeguarding training for all health professionals to ensure that they are fully equipped with the key skills, knowledge and principles to protect all citizens.251 The Domestic Abuse Commissioner, Nicole Jacobs, has said “health must be central to our strategic thinking”: I aim to amplify and promote effective practice. And if and when there are opportunities in legislation and statutory guidance to make improvements, health must be central to our strategic thinking.252 Calls for additional training and support Research published in the British Journal of Nursing in July 2020 identified potential barriers preventing health professionals from screening women for domestic abuse and concluded “lack of training and education” were the most prevalent.253

245 Ibid. 246 PQ246549, Domestic Abuse, Answered on 1 May 2019 247 NICE, Domestic violence and abuse: Quality standard (QS116), Quality Statement 2: Response to domestic violence and abuse, 29 February 2016 248 Ibid. 249 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p30 250 Joint Committee on the Draft Domestic Abuse Bill, Oral evidence: Draft Domestic Abuse Bill, HC 2075, 22 May 2019 251 Letter from Nadine Dorries, Minister of State for Patient Safety, Suicide Prevention and Mental Health, to Suzanne Jacob, Chief Executive of SafeLives, 2 July 2020 252 Pathfinder, Pathfinder Toolkit, June 2020, p3 253 British Journal of Nursing, What barriers prevent health professionals screening women for domestic abuse? A literature review, Vol.29, No.13, 10 July 2020 45 Commons Library Briefing, 20 May 2021

A 2019 YouGov survey of healthcare professionals also found that half of healthcare professionals in GP surgeries and NHS hospitals did not feel they had received adequate training to identify a victim of domestic abuse.254 YouGov reported that private sector health professionals were 66% more likely than public sector professionals to think they do not need training.255 Research has established that clinicians are unwilling to engage in conversations about domestic abuse if they feel a responsibility to “fix” it and require clear referral pathways to specialist support.256 Encouraging disclosure of domestic abuse, as part of a trauma-informed approach to primary care, involves developing an environment where a person who has experienced trauma feels safe and can develop trust.257 This can have implications for staff wellbeing such as emotional burnout.258 It is suggested the emotional labour of patient care should be shared within teams and between services.259 Written evidence on the Domestic Abuse Bill 2019-20, from the Inter- Collegiate and Agency Domestic Violence Abuse Forum asserted that further training for healthcare professionals is required alongside funding for referral routes: Sustainable funding is required for high-quality, specialist training of all healthcare professionals, including online resources that can be easily accessed during the current crisis. Sustainable funding also needs to be provided to ensure referral routes are in place for patients. As outlined by Agenda in the Ask and Take Action Briefing Paper, there is a need for public authorities to ensure frontline staff in our public services are making trained enquiries into domestic abuse. Tiered and mandatory training around domestic abuse should be set up in all Health services. Training should include specialist content on how to identify, respond to and refer both survivors and perpetrators of domestic abuse in acute, mental health and primary care settings, as well as embed specialist workers within health settings. The training delivered should be led by specialists, trauma-informed and should take an intersectional approach.260 Routine and targeted enquiry Research has shown that spontaneous disclosure of domestic abuse is very rare; individuals need to be prompted to disclose information.261 Routine enquiry into domestic abuse is recommended in some health environments, including maternity services, sexual health services,

254 YouGov, Half of UK healthcare professionals ‘untrained’ to spot domestic abuse, 12 August 2019 255 Ibid. 256 Dowrick, A., Feder, G., & Kelly, M., Boundary-Work and the Distribution of Care for Survivors of Domestic Violence and Abuse in Primary Care Settings: Perspectives From U.K. Clinicians. Qualitative Health Research. 22 March 2021 257 The King’s Fund, Tackling poor health outcomes: the role of trauma-informed care, 14 November 2019 258 Ibid. 259 Ibid. 260 Written evidence submitted by the INCADVA (Inter-Collegiate and Agency Domestic Violence Abuse) Forum (DAB57), Domestic Abuse Bill, June 2020 261 BASHH, Responding to Domestic Abuse in Sexual Health Setting, February 2016, p6 46 The role of healthcare services in addressing domestic abuse

mental health services, and substance misuse services. This means all patients are asked about domestic abuse, regardless of any visible signs of abuse.262 Recommendation 6 of the NICE guideline says that health and social care service managers and professionals should: Ensure trained staff in antenatal, postnatal, reproductive care, sexual health, alcohol or drug misuse, mental health, children's and vulnerable adults' services ask service users whether they have experienced domestic violence and abuse. This should be a routine part of good clinical practice, even where there are no indicators of such violence and abuse.263 As set out in Pathfinder guidance to GPs, “there is insufficient evidence to recommend screening or routine enquiry in most healthcare settings”. GPs are recommended to practice targeted enquiry (also known as clinical enquiry) instead. Targeted enquiry involves practitioners applying “a low threshold for asking” whether a patient is experiencing domestic abuse and using information from the interaction with the patient to make an assessment.264 Steps following a disclosure of domestic abuse The 2017 Department of Health guidance sets out examples of how a health professional can support the patient in both the short-term and longer-term following a disclosure of domestic abuse, including undertaking a comprehensive physical and mental health assessment and referral to other health services.265 The Department of Health guidance states that “once domestic abuse is identified, an assessment should be undertaken to evaluate the risk of further harm to the person and to children in the household”.266 The assessment helps determine whether a referral to a multiagency risk assessment conference (MARAC) should be made. The guidance says the SafeLives ‘Domestic Abuse, Stalking and Honour Based Violence’ (DASH) risk assessment tool “is a reliable method for your initial risk assessment”. Pathfinder recommends professionals use this tool only if they have received specialist training in how to use it.267 Health service involvement in MARACs The 2017 Department of Health guidance says all police forces in England and Wales have multiagency risk assessment conferences (MARAC). MARACs are victim-focused meetings where representatives from statutory and voluntary agencies share information about high-risk

262 Ibid., p1 263 NICE, Domestic violence and abuse: multi-agency working, Public health guideline (PH50), Recommendations, 26 February 2014 264 Pathfinder, Guidance for General Practitioners responding to domestic abuse, 2020 265 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p40 266 Ibid., p35 267 Pathfinder, Pathfinder Toolkit, June 2020, p104 47 Commons Library Briefing, 20 May 2021

victims of domestic abuse “to produce a co-ordinated action plan to increase victim safety”.268 The agencies attending MARACs vary, but Department of Health guidance says a suggested core membership includes IDVAs, local police, probation, housing, children’s services, primary care, mental health and substance misuse services.269 Representatives from other NHS services “should attend according to the case”.270 Victims of domestic abuse cannot self-refer to MARAC; they are always referred by an agency such as the police or health workers.271 The Department of Health guidance notes that the consent of a competent adult victim is needed to refer them to a MARAC, “unless the public interest test is engaged with the high threshold risk”.272 Guidance published by the Department of Health says that information sharing must be compliant with Caldicott principles. This means if information is shared without an adult’s consent, it must be on the basis of preventing or detecting serious harm or crime.273 Further information is set out in the ‘Confidentiality and consent’ section of this briefing. The Office for National Statistics reported in November 2020 that the percentage of MARAC cases referred by healthcare services has been increasing for the past three years, but constituted only 6.5% of all referrals in the year ending March 2020.274 In contrast, just under two- thirds (65%) of MARAC cases were referred by the police in the same period and 11.4% of referrals came from IDVAs.275 The Department of Health guidance notes there are other multiagency arrangements in place to support victims, including ‘Multiagency Safeguarding Hubs’ (MASH) and ‘Multiagency Public Protection Arrangements’ (MAPPAs). Further information can be found in this guidance. Health service involvement in Domestic Homicide Reviews A Domestic Homicide Review (DHR) is defined by the Home Office as: A multi-agency review of the circumstances in which the death of a person aged 16 or over has, or appears to have, resulted from violence, abuse or neglect by a person to whom they were related or with whom they were, or had been, in an intimate personal

268 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p60 269 Ibid., p18 270 Ibid. 271 Office for National Statistics, Domestic abuse victim services, England and Wales: November 2020, 25 November 2020 272 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p36 273 Department of Health, Striking the Balance: Practical guidance on the application of Caldicott Guardian Principles to Domestic Violence and MARACs, April 2012 274 Office for National Statistics, Domestic abuse victim services, England and Wales: November 2020, 25 November 2020 275 Ibid. 48 The role of healthcare services in addressing domestic abuse

relationship, or a member of the same household as themselves.276 Statutory guidance issued under section 9 of the Domestic Violence, Crime and Victims Act 2004 notes that local Community Safety Partnerships (CSPs), which include health services, should take “overall responsibility for establishing a review”. General practices are also requested to cooperate with DHRs.277 The Domestic Abuse Act 2021 will introduce a new statutory duty for a copy of the DHR’s conclusions to be sent to the Domestic Abuse Commissioner “as soon as reasonably practicable after the report is completed”. It is not yet known when this requirement will be in force.278 DHRs often identify the health service as the only service in touch with both victim and perpetrator. In written evidence on the Domestic Abuse Bill 2019-21, the Inter-Collegiate and Agency Domestic Violence Abuse Forum said: DHRs and NHS Confidential Enquiries repeatedly highlight the need for systemic change across the health system and to better equip healthcare staff with the understanding to identify and appropriately respond to domestic abuse. […] They hold critical information around the safety of the family and can make a significant difference in intervening earlier and ultimately preventing a homicide from happening. Evidence shows however that most often than not these opportunities are missed […]279 The Home Office’s ‘Key findings from analysis of Domestic Homicide Reviews’ (2016) said “a number of reports identified the need to improve awareness of domestic abuse amongst healthcare professionals”.280 Mental health issues were identified in 25 of the 33 intimate partner homicides reviewed, and in all seven cases of familial homicide.281 Recording information The Department of Health guidance provides that when recording information, staff should: Describe exactly what happened […] use the patient’s own words with quotation marks […] record whether an injury and a victim’s explanation for it are consistent […] take photographs and sign and date them as proof of injuries.282

276 Home Office, Domestic Homicide Reviews: Key findings from analysis of Domestic Homicide Reviews, December 2016, p2 277 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p10 278 Home Office, Domestic Abuse Act 2021 commencement schedule, 13 May 2021 279 Written evidence submitted by the INCADVA (Inter-Collegiate and Agency Domestic Violence Abuse) Forum (DAB57), Domestic Abuse Bill, June 2020 280 Home Office, Domestic Homicide Reviews: Key findings from analysis of Domestic Homicide Reviews, December 2016, p33 281 Ibid., p3 282 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p41 49 Commons Library Briefing, 20 May 2021

The guidance says that records can be used as evidence, such as in criminal proceedings if a perpetrator faces charges, and therefore the information should be “sufficiently detailed”.283 Concerns have been raised about GPs charging victims of domestic abuse for letters confirming their injuries to enable them to access legal aid.284 In response to a Parliamentary Question on this issue, Baroness Scott of Bybrook said the British Medical Association had written to GPs recommending they do not charge victims of domestic abuse for legal aid letters.285 At Report stage of the Domestic Abuse Act 2021, the Government said it had decided to legislate to “remedy the gap” left by the non-binding recommendation from the British Medical Association. The Act prohibits NHS healthcare professionals in general practice from charging for the provision of evidence to support a legal aid application from 1 October 2021. Confidentiality and consent The 2017 Department of Health guidance emphasises the importance of keeping information on domestic abuse confidential to protect victims but notes that “in some instances, failure to share information can put victims at risk.”286 ‘Confidentiality: NHS Code of Practice’ sets out the standards required for confidentiality of patient information and consent. The General Medical Council and other professional regulators also provide members with guidance on confidentiality and consent. The Royal College of Midwives published an article on ‘Documenting domestic abuse’ which states “electronic records are transforming how we provide care for women who are victims of domestic abuse”. Department of Health guidance states domestic abuse should never be recorded in hand-held notes.287 The Department of Health guidance outlines situations where consent cannot be obtained or is refused, and provides that “Caldicott principles” should be followed.288 The Caldicott Principles are guidelines applied across the field of health and social care information governance “to ensure that people’s data is kept safe and used appropriately.”289 The principles were introduced in 1997 following a Government Review of Patient-Identifiable Information, chaired by Dame Fiona Caldicott.

283 Ibid. 284 The Telegraph, GPs charging domestic abuse victims up to £150 to confirm injuries, 7 January 2021 285 HL10071, Legal Aid Scheme, Answered on 23 November 2020 286 Department of Health, Responding to domestic abuse: A resource for health professionals, March 2017, p43 287 Ibid., p41 288 Ibid., p43 289 GOV.UK, Press release: NDG announces new Caldicott Principle and guidance on Caldicott Guardians, 8 December 2020 50 The role of healthcare services in addressing domestic abuse

There are now eight Caldicott Principles, as two were added in 2013 and 2020.290 The principle added in 2013 is of relevance when considering cases of domestic abuse: The duty to share information for individual care is as important as the duty to protect patient confidentiality.291 Further information regarding Caldicott Principles and patient confidentiality can be found in the Library’s briefing ‘Patient health records: Access, sharing and confidentiality’. Impact of the Covid-19 pandemic In written evidence to the Home Affairs Select Committee in January 2021, the Domestic Abuse Commissioner said that “for many, this period has led to an escalation of violence and abuse, closed down routes for people to escape safely and made it more challenging to bring perpetrators to justice.”292 The Domestic Abuse Commissioner’s evidence also set out figures provided by domestic abuse organisations showing a rise in calls and contacts between 1 April to 31 December 2020. The number of calls and contacts logged by the National Domestic Abuse Helpline (run by Refuge) increased by 34% compared with the same period in 2019. Furthermore, Respect, the organisation for perpetrators looking for help to stop, reported a 62% increase in calls over the same period.293 Following the shift to telephone and video appointments (telemedicine) concerns were raised about a reduction in opportunities for domestic abuse disclosure. There was also concern about how health professionals would be able to identify signs of abuse. For example, during a debate on ‘Maternal Mental Health’ Sarah Olney MP (Richmond Park) raised the following points: The value of the home visit is that the mother does not need to identify the need for help and then go out and seek it for herself; someone comes to her and asks her how she is. A trained and experienced health visitor can observe mother and baby and identify whether additional support is needed. That kind of support cannot be replicated on Zoom or over the phone. Furthermore, as the Royal College of Psychiatrists has highlighted to me, it is much harder to identify whether there are issues of domestic violence or coercive control between a mother and her partner when contact is one-dimensional.294 The APPG on Sexual and Reproductive Health published a report ‘Women’s Lives, Women’s Rights’ in September 2020 which outlined how the move to telemedicine had brought advantages and challenges. Some women may find it easier to access healthcare confidentially from

290 Ibid. 291 Ibid. 292 Written evidence submitted by the Designate Domestic Abuse Commissioner for England and Wales to the Home Affairs Select Committee, January 2021 293 Ibid. 294 HC Deb, Maternal Mental Health, 10 March 2021, c152WH 51 Commons Library Briefing, 20 May 2021

home rather than “risk drawing attention to their actions by leaving the house to attend a healthcare setting”. The report says some healthcare professionals have reported women are more forthcoming during a phone consultation than a face-to-face consultation.295 However, some healthcare professionals said they had difficulty detecting non-verbal cues via a telephone or video consultation. And the process relies on the patient being able to have an open discussion with their healthcare provider from their own home, or another remote setting. The report notes: For younger women who are living with their family or a victim of DVA living with their abuser, this may create considerable barriers to accessing care.296 In response to the pandemic, the MBRRACE-UK team carried out a rapid review of maternal deaths between 1 March and 31 May 2020. The review found that two women died due to domestic violence during this period (both between six weeks and one year after the end of pregnancy). The review said both women needed safeguarding: Whilst the first woman had multiple problems and had disengaged with services, all conversations were around protection of the child rather than the woman herself. Professionals should never give up trying to develop therapeutic relationships that will enable those subject to abuse to seek support. These enquiries have observed before the need to protect women with multiple disadvantage, who are over- represented amongst women who die during pregnancy or postpartum. The second woman’s care emphasises the need to ensure women can be removed to a place of safety even in the context of public health measures such as lockdown.297 As outlined in section 2.2, healthcare services can play a role in reaching ‘hidden victims’ of domestic abuse including people with disabilities and older people. As Age UK note, the pandemic “has meant many older people are being asked to stay at home” and “this not only makes them more vulnerable to abuse by those they are dependent on, but it also poses a barrier to them seeking help”.298 IRIS, an organisation offering domestic abuse training and support to GPs, published a report summarising the impact of the pandemic on their organisational model and on general practice support for domestic abuse victims. It notes how the pandemic increased the importance of GPs responding to domestic abuse due to the higher prevalence of abuse and usual support routes being more difficult to reach or no longer available.299

295 APPG on Sexual and Reproductive Health, Women’s Lives, Women’s Rights, September 2020, p30 296 Ibid. 297 MBRRACE-UK, Saving Lives, Improving Mothers’ Care: Rapid report: Learning from SARS-CoV-2-related and associated maternal deaths in the UK, March – May 2020, p13 298 Age UK, Older people and domestic abuse during the coronavirus crisis, 11 May 2020 299 IRISi, IRIS Response to the Covid-19 Pandemic: A Rapid Research, November 2020 52 The role of healthcare services in addressing domestic abuse

The IRIS report notes that whilst there was an initial decline in referrals from general practice to specialist domestic abuse services in March 2020, the level of referrals had resumed to usual levels by July 2020.300

300 Ibid. 53 Commons Library Briefing, 20 May 2021

5. Healthcare initiatives 5.1 Pathfinder Project The Pathfinder project was a three-year pilot which ran from 2017 to 2020 led by Standing Together, as part of a consortium of partners including Against Violence and Abuse (AVA), Imkaan, IRISi and SafeLives.301 The pilot involved locating specialist domestic abuse services within healthcare settings, providing domestic abuse training to healthcare professionals, reviewing NHS Trust Domestic Abuse policies and introducing Domestic Abuse Champion Networks in NHS Trusts, amongst other measures.302 Findings of the Pathfinder pilot informed the ‘Whole Health Model’. This reportedly aims to “transform healthcare’s response to domestic abuse by ensuring a coordinated and consistent approach across the health system including acute, mental health and primary care services.”303 Pathfinder Toolkit Drawing upon the pilot, the Pathfinder Toolkit was launched in June 2020. The Pathfinder Toolkit brings together the main components of the Whole Health Model and is “designed as a stand-alone practical guide for commissioners and strategic professionals in the health sector.304 The Pathfinder Toolkit provides guidance on: Organisational structure and strategy; policy development; the co- location of a Health Based IDVA, the establishment of a Domestic Abuse Coordinator and Domestic Abuse Champions Networks; specialist guidance around how to respond to the needs of BAME, LGBT+, older and disabled survivors; staff training; data collection; patient information campaigns; and establishing referral pathways to local services.305 In response to a Parliamentary Question, Nadine Dorries drew attention to the Pathfinder Toolkit as an example of best practice: […] The Department will continue working with our partners to share best practice. The Pathfinder project developed a toolkit which is available for free online and aims to support development of a model health response to domestic abuse.306

5.2 Health-based Independent Domestic Violence Advisers Independent Domestic Violence Advisers (IDVAs) are professionally qualified, specialist domestic abuse workers, who support high-risk

301 Pathfinder, Pathfinder Toolkit, June 2020 302 Pathfinder, Pathfinder Key Findings Report, June 2020, p7 303 Pathfinder, Pathfinder Toolkit, June 2020, p31 304 Pathfinder, Pathfinder Survivor Toolkit, June 2020, p6 305 IRISi Interventions, Pathfinder toolkit: New model launched to transform health system’s response to domestic abuse, 25 June 2020 306 PQ 77658, Health Services: Domestic Violence, 1 September 2020 54 The role of healthcare services in addressing domestic abuse

victims of domestic abuse.307 IDVAs are often the main point of contact for victims of domestic abuse and “work to assess level of risk, discuss options and develop safety plans alongside the police.”308 IDVAs can also help direct victims to support on other issues, such as housing, mental health or counselling.309 Research has been conducted to assess the effectiveness of basing IDVAs in health settings, such as hospitals. SafeLives published A Cry for Health: Why we must invest in domestic abuse services in hospitals in November 2016. The report concluded that co-locating IDVA services within a hospital setting could significantly improve health and wellbeing outcomes for victims of domestic abuse.310 The report was based on Themis research which took place between 2012 and 2015 and explored the impact of co-locating IDVA services in hospitals. The project included five English hospitals across four geographical areas and reached a total of 692 hospital victims and 3,544 community victims.311 As with other IDVAs, the aim of a hospital-based IDVA is to reduce the risk of further harm and homicide, and to ensure that specialist community-based support is sustained. However, SafeLives note they have an additional responsibility to provide “expert training, advice and support to hospital staff”.312 They also need familiarity with the hospital setting and may require higher clinical supervision.313 The ‘A Cry for Health’ report (2016) notes that the emotional strain is higher than in other IDVA roles. Hospital based IDVAs face the challenge of working with more victims who have complex needs, and with more victims who are at an earlier stage of change and more likely to return to the abuser.314 Specifically, the research found that having hospital based IDVAs led to more referrals to specialist support services, faster identification of vulnerable ‘hidden’ groups of victims, and quicker links with specialist services.315 Having a hospital based IDVA led to improvements in the referral process for victims of abuse. After their introduction, the referrals of victims to MARACs significantly increased. The report notes: In one of the hospitals, there were 11 MARAC referrals in the 11 months before the introduction of the IDVA service; this increased

307 ONS, Domestic abuse victim services, England and Wales: November 2020, 25 November 2020 308 SafeLives, SafeLives’ 2019 survey of domestic abuse practitioners in England and Wales, 2019, p4 309 SafeLives, A Cry for Health: Why we must invest in domestic abuse services in hospitals, November 2016, p13 310 Ibid, p14 311 Ibid, p12 312 Ibid, p13 313 Ibid, p58 314 Ibid 315 Ibid 55 Commons Library Briefing, 20 May 2021

to 70 in referrals in the 11 months following the start of the IDVA service.316 The health professionals interviewed as part of the research said that being able to refer patients to the hospital IDVA made it more likely they would ask patients about domestic abuse in line with NICE recommendations. They also reportedly “had greater confidence that identification would result in a meaningful outcome for the victim”.317 Studies, such as the LINKS pilot have investigated locating IDVAs in other health settings including Mental Health trusts. Further information about the role of a Mental Health IDVA is set out in A view from the frontline: the role of the Mental Health IDVA. Health-based IDVAs across England The Pathfinder Toolkit recommends that every NHS Trust should employ at least two co-located Health Based IDVAs depending on the size of the Trust, and embed them effectively within the NHS staff team.318 The Government response to the Joint Committee report on the draft Domestic Abuse Bill said that from April 2020, NHS England are planning for IDVAs to be integral to every NHS Trust Domestic Violence and Abuse Action Plan, as part of the NHS Standard Contract.319 While giving evidence on the Draft Domestic Abuse Bill, the Minister for Mental Health, Inequalities and Suicide Prevention, Jackie Doyle-Price, was asked whether CCGs should fund and commission IDVAs all around the country. The Minister said, “the short answer is yes” and “in principle, these are people who have been welcomed throughout the system”.320 The SafeLives 2019 practitioner survey says the current number of IDVAs based in any health setting is lower than the number recommended in the ‘Cry for Health’ report: The number of IDVAs based in any health setting (68) is still far lower than the number needed to ensure adequate provision in hospitals alone (more than 300, as recommended by SafeLives’ Cry for Health research). The current rate is less than 25% of the minimum required number.321

316 Ibid, p16 317 Ibid, p17 318 Pathfinder, Pathfinder Survivors Toolkit, June 2020, p80 319 HO, The Government response to the report from the Joint Committee on the Draft Domestic Abuse Bill, CP 137, July 2019, para 167 320 Joint Committee on the Draft Domestic Abuse Bill, Oral evidence: Draft Domestic Abuse Bill, HC 2075, 22 May 2019 321 SafeLives, SafeLives’ 2019 survey of domestic abuse practitioners in England and Wales, 2019, p5 56 The role of healthcare services in addressing domestic abuse

5.3 Identification and Referral to Improve Safety (IRIS) The IRIS model has been cited as best practice in general practice for responding to domestic violence and abuse by the Department of Health.322 The model was first trialled in a pilot which ran from September 2007 to October 2009 and saw a six-fold increase in referrals to specialist domestic abuse services.323 The model has subsequently been rolled out to an increasing number of GP practices.324 IRIS offers training, education and support to GPs alongside enhanced referral pathways into specialist domestic abuse support.325 The initiatives focus on supporting female victims of domestic abuse. The latest data shows that from November 2010 to March 2020, 48 areas had commissioned IRIS. More than 1,000 general practices had been fully trained and IRIS programmes had received referrals for 20,544 women.326 The IRISi Improving the General Practice Response to Domestic Violence and Abuse report for 2020 provides further detail on what the IRIS model entails. Following widespread adoption of the IRIS model, research has been undertaken to investigate whether it can be applied more widely, including to other groups and in other healthcare settings. For example, Enhanced Identification and Referral to Improve Safety (known as IRIS+) aims to enlarge the IRIS model beyond female victims of domestic abuse. The initiative aims to explore the viability of an adaptation of IRIS to work with both male and female victims, male and female perpetrators, and children.327 IRIS+ aims to bring together initiatives for different groups into “an integrated training and intervention package with a ‘one-stop shop’ referral route”.328 The research is based on a previous pilot study (HERMES pilot) which demonstrated that male patients present to their GPs as both victims and perpetrators, and that following a specialist training intervention, clinicians’ confidence in responding to male patients affected by domestic abuse increased.329 IRIS+ also seeks to incorporate the findings of the RESPONDS study which sought to “bridge the knowledge and practice gap between domestic violence and child safeguarding”. The RESPONDS study found

322 Department of Health, Responding to domestic abuse: A resource for health professionals, 8 March 2017 323 IRISi, IRIS Response to the Covid-10 Pandemic: A Rapid Research, November 2020 324 The Health Foundation, Improvement in practice: The IRIS case study, February 2011 325 IRISi, Improving the General Practice Response to Domestic Violence and Abuse, 2020 326 Ibid 327 University of Bristol, REPROVIDE: IRIS+ 328 University of Bristol, REPROVE: IRIS+, IRIS+ development 329 Ibid. 57 Commons Library Briefing, 20 May 2021

many GPs and practice nurses were unsure how to respond appropriately to children exposed to domestic abuse.330 A feasibility study was carried out in four GP practices in Bristol between 2016 and 2018 to test the concept of IRIS+. Following the study, clinicians said the initiative “filled a service gap for male patients and children/young people affected by domestic abuse”. The initial findings note that the IRIS+ hub received referrals for a “substantial number” of children alongside their non-abusive parent, and “the identification and referral of children exposed to domestic abuse is a breakthrough in the general practice setting”.331 IRIS ADViSE (Assessing for Domestic Violence in Sexual Health Environments) sought to adapt the IRIS model to sexual health clinics. The evaluation of the pilot found that over 3 months, the domestic abuse enquiry rate was 61% and domestic abuse was identified in 7% of cases.332 The evaluation report notes that even though routine enquiry wasn’t implemented for all patients, it demonstrated a “marked improvement” in relation to the three months preceding the intervention pilot where no cases of domestic abuse were identified at either location.333 Research is also reportedly underway to investigate whether the IRIS model can be adapted for use in pharmacy settings.

5.4 Initiatives in mental health services Due to the association between domestic abuse and mental health, several initiatives have been trialled to improve responses to domestic abuse in mental health services. Promoting Recovery in Mental Health (PRIMH) aimed to improve mental health service responses to domestic and sexual violence.334 The PRIMH intervention had the following aims: • Develop clear policies and care pathways for service users and staff who disclose experiencing or perpetrating domestic and/or sexual violence • Promote the message that domestic and sexual violence is ‘core business’ for Trusts • Create a workforce that is knowledgeable, skilled and confident in enquiring about and responding to disclosures of domestic and sexual violence

330 University of Bristol, RESPONDS, About RESPONDS 331 University of Bristol, REPROVIDE: IRIS+, IRIS+ research 332 IRISi, The IRIS ADViSE Programme: Assessing for Domestic Violence and Abuse in Sexual Health Environments, 2019 333 Horwood J, Morden A, Bailey JE, et al, Assessing for domestic violence in sexual health environments: a qualitative study, Sexually Transmitted Infections, 94:88-92, 2018 334 Against Violence and Abuse, Promoting Recovery in Mental Health 58 The role of healthcare services in addressing domestic abuse

• Develop closer links with relevant local domestic and sexual violence multi-agency partnership structures and service providers.335 The evaluation report made 10 recommendations, which included embedding domestic abuse training into long-term training provision and improving the identification and response to domestic and sexual violence perpetration.336 Linking abuse and recovery through advocacy (LARA) The LARA pilot involved reciprocal training between mental health and domestic violence services, and a direct referral pathway to domestic violence advocacy for psychiatric service users.337 Following the pilot, clinicians had “improved knowledge, attitudes and behaviours” and service users “reported reductions in the frequency/severity of violence and unmet needs and an increase in social inclusion at follow-up”.338 Following the LARA intervention, King’s College London published the LARA-VP (Linking Abuse and Recovery through Advocacy for Victims and Perpetrators) manual in 2018. The LARA-VP manual aims to help mental health professionals identify and respond to historical as well as current domestic abuse, and “emphasises the importance of taking a whole family approach”.339

5.5 Pharmacy schemes Safe Spaces The charity Hestia’s UK Says No More campaign partnered with Boots UK, Superdrug, Morrisons and independent pharmacies in May 2020 to provide Safe Spaces in their consultation rooms for people experiencing domestic abuse to contact specialist domestic abuse services.340 Both the General Pharmaceutical Council and Royal Pharmaceutical Society have encouraged all pharmacies to consider taking part in the scheme.341 In October 2020, Hestia published a report which estimated that one in four pharmacies across the UK facilitated a Safe Space in their consultation rooms. Since the launch of the scheme there have been at least 3,700 visits to a Safe Space.342

335 King’s College London, Promoting Recovery in Mental Health: Evaluation Report, August 2016, p49 336 Ibid, p54 337 K. Trevillion, S. Byford, M. Cary, D. Rose, S. Oram, G. Feder, R. Agnew-Davies and L. M. Howard, Linking abuse and recovery through advocacy: an observational study, Epidemiology and Psychiatric Sciences, Published online 30 April 2013 338 Ibid, p10 339 King’s College London, LARA-VP: A resource to help mental health professionals identify and respond to Domestic Violence and Abuse (DVA), 2018 340 Hestia, Domestic Abuse in Lockdown, October 2020, p4 341 General Pharmaceutical Council, Pharmacies encouraged to become Safe Spaces for victims of domestic abuse, 1 May 2020; Royal Pharmaceutical Society, Pharmacies as safe spaces from domestic abuse, 1 May 2020 342 Hestia, Domestic Abuse in Lockdown, October 2020, p4 59 Commons Library Briefing, 20 May 2021

Ask for ANI The Ask for ANI (Action Needed Immediately) scheme was launched on 14 January 2021. The GOV.UK website says that “by asking for ANI, a trained pharmacy worker will offer a private space where they can understand if the victim needs to speak to the police or would like help to access support services such as national or local domestic abuse helplines.”343 In response to a Parliamentary Question on 25 January 2021, Victoria Atkins said “there are currently more than 2,600 pharmacies participating”; there is an on-going sign up process.344 The Government published a series of documents to support the roll-out of the scheme, including guidance for pharmacies and an Understanding domestic abuse document. This document suggests pharmacies might wish to adopt the Safe Spaces scheme alongside Ask for ANI.345 Concerns were raised, such as by Women’s Aid, that pharmacists would receive insufficient training to administer the scheme.346 The Safeguarding Minister, Victoria Atkins, addressed training during a debate on ‘Domestic Abuse and Hidden Harms during Lockdown’ on 14 January 2021.The Minister said: The Ask for ANI scheme is focused at the moment on victims of domestic abuse. There has been a huge and careful training programme of the pharmacists who are currently participating. Nearly 8,000 members of staff have been trained in Boots alone. They will be very knowledgeable about what to do when somebody walks into their chemist’s seeking help.347

343 GOV.UK, Pharmacies launch codeword scheme to offer ‘lifeline’ to domestic abuse victims, 14 January 2021 344 PQ 140857 [Domestic Abuse], 25 January 2021 345 HM Government, Understanding domestic abuse for the Ask for ANI codeword scheme, 1 December 2020, p18 346 Women’s Aid, Women’s Aid responds to Ask for Ani codeword launch, 14 January 2021 347 Commons Deb, Domestic Abuse and Hidden Harms during Lockdown, 14 January 2021

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