Director of Public Health Annual Report 2021: Domestic violence and abuse

Domestic abuse is a complex societal issue spanning many areas of life and prevention and the response must be multi-layered. The National Institute for Health and Care Excellence (NICE) has published guidance on multi-agency working for domestic violence and abuse (2014) which includes 17 recommendations. These include a local strategic partnership to prevent domestic abuse, the scope, shape and variety of local services; the quality of partnership working; and staff knowledge and skills in identifying and supporting victims of domestic abuse.

Embedding early intervention and prevention into a multiagency response to domestic abuse is highlighted in the government’s Violence Against Women and Girls Strategy (2016 to 2020). The response includes government-led initiatives as well as local authority multi-agency working, safeguarding, and commissioning. It highlights the multi-layered and co-ordinated health, social and criminal justice approaches required to tackle this issue and can be applied to all victims rather than only women and girls.

Historically, many interventions addressing domestic abuse have not been thoroughly evaluated so it is vital that new and existing programmes should be monitored and reviewed to improve the robustness of the evidence.

Some evidence based or potentially effective domestic abuse interventions are highlighted below:

• School-based awareness raising of domestic abuse is known to achieve positive changes in knowledge and attitudes towards domestic abuse and prevent dating violence.
• Campaigns to raise awareness of domestic abuse is a fundamental step in victims and bystanders recognising domestic abuse. This should be combined with signposting the public and professionals to services.
• “Bystander interventions” challenge harmful attitudes, language and behaviour relating to domestic abuse. These interventions – from challenging a disrespectful statement to noticing signs of domestic abuse and offering support – can be undertaken by anyone. Solace Women’s Aid provides training and materials via their website for everyone, as well as information specifically for men.

• Offering safe opportunities to seek help such as campaigns offering code words that victims can use in specific circumstances to alert someone to abuse. As services have moved online, and in-person interactions are replaced with a digital offer, a hand signal or gesture may be preferred to a code word. Examples include the recent ‘Ask for ANI’, ‘Ask for Angela’, and the Zoom signal campaigns.
• Advocacy interventions with victims are based on empowerment, discussing solutions, and settings goals to respond to their situation. These interventions usually link survivors with legal, police, housing and financial services, and many also include psychological or psycho-educational support. NICE recommends that all domestic abuse victims should be provided with advocacy and advice services tailored to their level of risk and specific need. Evidence suggests that intensive advocacy may improve quality of life and reduce physical abuse for one to two years.
• Training of health care professionals in domestic abuse education and advocacy may lead to an increase in awareness, and greater disclosure, identification and referral to domestic abuse services. For example, data from domestic homicide reviews show us that a victim’s contact with services may be limited to their GP so it is vital that GPs are skilled and proactive in recognising signs of domestic abuse and referring patients for urgent help.
• The ‘Identification and Referral to Improve Safety’ (IRIS) training and support programme is an example of an effective health care training intervention, designed for GP surgeries. Evaluation of IRIS showed improved identification of women experiencing domestic abuse and improved referral rates to specialist services (compared to surgeries not trained in IRIS). A recent evaluation across GP surgeries in London showed that of the 144 surgeries trained in IRIS, a 30-fold increase in domestic abuse referrals was seen compared to the those surgeries without IRIS training. These outcomes show that clinician behaviour can be changed in relation to domestic abuse enquiry and referral, for the benefit of the victim. A cost-effectiveness study showed the IRIS programme to have lower costs and greater effectiveness for GP surgeries, compared to surgeries offering usual care (not using IRIS).
• Independent Domestic Violence Advisors (IDVA) are trained to address the safety of victims at high risk of harm from intimate partners, ex-partners or family members. There is evidence suggesting that IDVAs have a positive impact on the safety and well-being of victims experiencing extremely serious levels of domestic abuse. This reduced risk of harm has some effect on reducing the risk of domestic abuse on children.
• Multi-Agency Risk Assessment Conferences (MARACs) are regular multiagency meetings to discuss high risk domestic abuse cases. A coordinated safety plan is enacted to support the victim. The victim is ideally represented by an IDVA. Research indicates that MARACs (and IDVAs) can improve victim safety and reduce revictimisation, and therefore may be a highly cost-effective measure.

Interventions aimed at perpetrators can be either criminal sanctions, or perpetrator interventions and programmes. Only 1% of perpetrators receive any specialist intervention to challenge or change their behaviour.

NICE guidance states that, "There is lack of consistent evidence of the effectiveness of programmes for people who perpetrate domestic violence and abuse." However, "such interventions are an important part of domestic violence and abuse services, and provided they are supported by robust evaluation to inform future commissioning decisions, should be recommended."

NICE has also published quality standards for domestic violence and abuse (2016). The standards are (1) asking about domestic abuse, (2) responding to domestic abuse, (3) referring to specialist services for victims, and (4) referring to specialist services for perpetrators.