Embedding domestic abuse into health strategies

The impact of domestic abuse on health and mental health can’t be underestimated. Health professionals are also often the first point of contact for domestic abuse victims, but very often domestic abuse is not included within national or local health strategies.

NHS Devon Clinical Commissioning Group realised that this was something that they needed to change and employed Collette Eaton-Harris to looking at embedding the needs of domestic abuse victims into its health systems.

“In July 2020, I joined NHS Devon Clinical Commissioning Group as the first domestic abuse and sexual violence (DASV) lead.  The role was created to embed improvements in the response to people affected by DASV; patients and staff, and to build upon the progress Devon had made under the Health Pathfinder project.

My role is unusual; domestic abuse and sexual violence are often framed as a criminal justice or social care issue, and rarely as a health issue. This presents a challenge; the identification and recording of DASV is not embedded in our health systems.  A lack of visibility makes it difficult to quantify the unmet need.

But the impact of abuse on health is significant[1], and it is health professionals that victims of abuse are most likely to have contact with and to whom they are most likely to disclose. Whilst an estimated four out of five victims of domestic abuse never contact the police[2], the health service is the setting in which women’s help-seeking commonly occurs[3].

We started by developing a strategy, drawing upon Health Pathfinder, the expertise of colleagues in the health service, partners across the wider system and the lived experience of survivors.  

Our strategy was underpinned by a number of principles. 

Our approach included a response to people affected by DASV who work within health.  This felt critical to building the right culture.  To create a context in which health professionals can give the best response to patients, we need to ensure we are modelling that in how we support staff.  We started with raising the profile of DASV as workplace and health issues.  Now DASV is included in our induction presentation to new staff, it is identified in workforce development plans and we have a dedicated DASV page on our intranet. We will be reviewing our organisational policy, building a network of champions who staff can speak to for advice and will plan to explore how to build good practice into commissioning processes.  This principle also encompassed developing our response to staff who perpetrate violence and abuse – an area that is often less well developed within organisational policies.  We are in turn supporting provider services to develop their response to staff by sharing tools, offering training and supporting the case for health IDVAs.

We decided our strategy should consider people using harmful behaviours.  On the frontline there is less confidence around asking patients whether they are concerned about their own thoughts or behaviours and to do this outside of mental health services is not common practice.  Local Domestic Homicide Reviews indicated that some individuals had accessed GP services prior to committing homicide, suggesting an opportunity to reach people in this setting and prevent harm. All of our workstreams consider a response to people harming, be this through targeted training, commissioning a service or policy development.  We know there are still gaps, in particular people at risk of committing sexual harm is an area that needs greater focus. We are now in the process of commissioning an Interpersonal Trauma Response Service for Primary Care and this will enable us to develop our approach to people who harm alongside a service for those who’ve experienced harm.

We recognised that across our services, there is a lack of confidence in talking about and addressing sexual violence.  We decided to incorporate both domestic abuse and sexual violence in a joint strategy. Taking this approach does not mean ignoring the nuanced differences in forms of abuse, but it has encouraged us to think in terms of interpersonal trauma rather than segmenting our approach by categories of abuse. This works well when you want to encourage frontline practitioners to apply a trauma lens when meeting patients.

Approaching the strategy through a trauma lens makes sense to health colleagues. Trauma impacts upon health far beyond the point that abuse stops, and this was clearly evident in our pilot of a Primary Care identification model IRIS.  In a considerable number of cases the abuse was non recent, but the health impacts were ongoing.  We were the first IRIS site to include a response to sexual violence through a collaboration between local domestic abuse and sexual violence services and we’re looking at how that success can be replicated in other settings.

We are continuing to learn a lot about trauma informed approaches from colleagues at Plymouth City Council who have been working to make Plymouth a trauma sensitive city since 2012. Their Trauma Informed Network has inspired activity in the rest of the County and has shaped our prototyping.

Our strategy is implemented through a number of forums.  A steering group comprised of safeguarding leads from provider services meet to work on place-based improvements.  One of the benefits of sitting within the CCG is that I’m able to work across, spreading the resources and facilitating the sharing of good practice. As example we took learning from a local DHR and procured resources for GPs and hospitals including toilet door stickers and lanyards to prompt enquiry and response.  These are simple, practical tools that help embed better practice and by learning from individual Trusts we were able to share that practice across the rest of our health settings.

Through this forum we’ve supported the case for health IDVAs (independent domestic violence advocates).  Last July we had 2 health IDVAs on fixed term contracts, they are now permanently funded by their Trust and we have an additional 4 health IDVA services being piloted.

The systems elements of our strategy are implemented through the Whole Systems for Whole People group, a prototyping and learning forum of commissioners from the local authorities, the OPCC (Office of the Police and Crime Commissioners) and the CCG (Clinical Commissioning Group) .  In this forum we innovate and experiment with ways to organise for the benefit of people affected by trauma and/or who have complex needs.  

Our driving ethos is wanting structures to work for people, not expecting people to fit into  structures.  We recognise services are often siloed, thresholds too high for many and that people feel ‘bounced’ between services.  We want to develop whole person, contextualised, assets and strengths-based commissioning approaches. 

As the Whole Systems for Whole People group, we carried out a piece of work listening to people across Devon affected by or who work in services responding to sexual violence.  The ambitions articulated through that work led to us being selected, in collaboration with Cornwall, as NHS England’s first Sexual Violence Trauma Pathfinder site.

Alongside our strategy, we’ve considered how the CCG DASV role can embed in the wider system to offer support to our partners.  I sit on strategic DASV forums and MARAC (Multi Agency Risk Assessment Conference) steering groups, lead on the CCG Domestic Homicide Review response and will be chairing occasional MARACs. We’re transitioning to an Integrated Care System in 2022, the values of which emphasise co-creation, collaboration and partnerships- closely aligned to the approaches we’ve taken. 

There is lots more we want to achieve in our strategy and this new structure will support our progress towards creating a system that responds to the health, care and safety needs of our local people.”  

[1] IRISi, Guidance for Commissioners

[2] Crime Survey of England and Wales 2012/13 (2014), Why the victim did not tell the police about the partner abuse experienced in the last year

[3] Department of Health (2017) Responding to Domestic Abuse: A Resource for Health Professionals. Bit.ly/DHDomesticAbuse