Domestic abuse is a hidden public health problem, says Diana Barran

Diana Barran MBE Chief Executive, Co-ordinated Action Against Domestic Abuse danger1

Domestic abuse is gaining strategic importance across all areas of community health care across the UK - and with good reason. Around two women are killed every week by a current or former male partner1, 68% of domestic abuse incidents results in physical injury, and abuse is major risk factor for psychiatric disorders, chronic physical conditions and substance abuse2. Domestic abuse occurs as a pattern of behaviour designed to control a partner or family member. The behaviour can include psychological, physical, sexual, financial or emotional abuse, and it can happen during a relationship or after it has ended. Abuse in the home remains a gendered issue: 89% of those who have experienced four or more incidents of domestic violence are women3. Margaret Mabbott-Smith, the Safeguarding Children Advisor and Domestic Violence Co-ordinator for Bournemouth and Poole Community Health Services, sums up a problem many community health professionals face when dealing with domestic abuse: confident identification. She says: "Health visitors routinely support mums with child behavioural issues, but it's very difficult to tackle these issues from a health perspective if the child is witnessing domestic violence and the practitioner is unaware of it. Community health practitioners need to be confident about recognising and asking about domestic abuse so that vulnerable mothers and children can be referred to specialist services."

In addition to the health implications of living with abuse, the links between child abuse and domestic abuse are well documented. Research shows that 70% of victims at high risk of serious harm have children, the majority of which are under five-years-old4. Professor Munro's recent Review of Child Protection makes many references to the association between child abuse and neglect and the "toxic trio" of parental domestic violence, substance misuse and mental health problems. The Review recommends that community health professionals and early years practitioners"are well placed to identify problems early and arrange access for children and families to therapeutic and support services"5. Thanks to better links between support services and health practitioners and new strategic priorities, there are now multiple ways in which community health and early years practitioners can get involved to support families and children effectively.

Twenty years ago the police saw abuse inside the home as a "domestic problem" and were reluctant to intervene. Thankfully things have changed, but many victims of domestic abuse (statistically women and children are most at risk) are still fearful of seeking help from the police or confiding in community health professionals. Diana Barran's talk at JFHC Live recently was very popular, proving that community healthcare professionals are dedicated to finding the best ways to support the victims of abuse. Diana heads up the charity CAADA, a national charity dedicated to protecting families  from the damaging effects of domestic abuse, and they are at the forefront of helping to shape government policy in the future.   

Establishing links with specialist services  

Good care pathways within your organisation make up the cornerstone of a great and effective response, advises Jo Morrish, Lead CPD Trainer at Coordinated Action Against Domestic Abuse (CAADA), a national charity supporting a strong multi-agency response to the issue. "Practitioners often ask us how they can improve their response to patient victims. The first step is to establish whether your service is linked with local specialist services, so that you're aware of how to refer families who might be living with abuse. Independent Domestic Violence Advisor (IDVA) services can provide appropriate support for adult victims who are at high risk of serious harm. Local areas may also have a Multi-Agency Risk Assessment Conference (MARAC), a multi-agency professionals' meeting where worrying high risk cases are referred for intensive support and safety planning. For patients who are not high risk, a local domestic abuse outreach service may provide more appropriate support." Training can be a useful next step, says Morrish. "Practitioners are understandably nervous about 'asking the question', identifying risk and being able to offer a practical and safe response if a mother does disclose abuse. But it's important to be able to ask about abuse in order to refer women and children to the right services," she says. "Training can give practitioners the knowledge and skills that they need to able to confidently recognise the signs and ask about abuse." The charity provides a range of advanced Continuing Professional Development courses on domestic abuse for health and social care professionals, as well as a one-day practical risk training course which enables frontline professionals to build the confidence, skills and knowledge to use a simple checklist with patients, and refer them to specialist domestic abuse services in their local area.

IRIS in practice  

An innovative training support and referral programme called IRIS (Identification and Referral to Improve Safety) is aimed at GPs and primary care teams. Developed on the back of a research trial, IRIS aims to improve identification of domestic violence by GPs and primary health practitioners and access to expert domestic violence services by patients. IRIS is a collaboration between primary care teams and third sector organisations specialising in domestic violence and abuse in the local area (Next Link and nia respectively). IRIS is now available to be commissioned in all areas across the country. The key components of IRIS include an Advocate Educator based in a specialist support service, a local clinical champion, and a 'pop-up' clinical enquiry tool, which is used by both GPs and the community health team during consultations with patients to assess immediate risk and refer them to the Advocate Educator. Both the clinical and administrative teams receive domestic violence and abuse training from the Advocate Educator and clinical champion. For health visitors that are not based in the office, the clinical enquiry tool can provide a safe recording system to log concerns that professionals might have once they have returned to the practice. "We train clinicians to have a low threshold for asking patients about abuse," says Annie Howell, IRIS Implementation Lead at nia, Hackney. "So symptoms such as depression, anxiety, drug and alcohol use, Irritable Bowel Syndrome (IBS), pelvic pain and headaches will all trigger an enquiry. The Advocate Educator trains GPs to ask a direct question about whether the patient is experiencing domestic abuse, if the patient answers positively, she is offered a referral directly to the Advocate Educator for practical and emotional support." IRIS also provides care pathways for male survivors and perpetrators of abuse. The final trial papers (published in The Lancet) show that the randomised controlled trial was successful - the practices receiving the programme had marked increases in the number of women disclosing abuse and domestic violence referrals. IRIS is now in an implementation phase, and the goal is for it to be commissioned in 12 localities with a view to eventually becoming a standard national package.

Future developments  

Over the next few years, practitioners will hear about more developments to support domestic abuse victims.

The subtle signs of abuse…

In all women:

● Many repeat visits to a GP or medical symptoms with no clear causal factor or adequate explanation - eg depression, anxiety, self harming behaviour or IBS
● Unexpected injuries, especially facial, dental or genital injuries and injuries that might be targeted specifically at a pregnant woman's abdomen or thighs
● Partners who consistently accompany women to medical appointments or ante-natal appointments.

In new mothers:

● Are pressured by a partner to have sex before they are ready
● Are pressured by a partner to refrain from breastfeeding
● Appear isolated, and seem reluctant to reach out to friends or family for support
● Consistently have partners present when health visitors visit the home.

In children:

● Fear
● Withdrawal
● Bedwetting
● Delayed development
● Aggressive towards mother/ partner/other children
● Anxiety
● Problems at school.

Multi-agency work in practice  

Margaret Mabbott-Smith, who enjoys her work as a Safeguarding Children Advisor and Domestic Violence Co-ordinator, talks about her vital role. Margaret's work in this area started over 10 years ago, when she became the health representative on the local domestic violence forum. She quickly became aware that domestic violence was rarely a "one off event", and that it often had a huge impact upon the health of patients - including children. Today her work in the Bournemouth & Poole community regularly takes her into contact with GPs, practice staff, health visitors, and school nurses, where she encourages practitioners to consider the links between patient health outcomes, domestic abuse and children's safeguarding issues. "Because of my passion for domestic abuse support work, I took the time to cultivate more awareness," she explains. "Then, within the context of my role, I developed a multi-agency training package alongside a colleague in the police. This worked well - we were able to provide health professionals with information on new domestic violence legislation that could support victims, thereby providing a much better service." Margaret believes that multi-agency work is absolutely crucial when it comes to providing the right support. "We know that 87% of children in the Bournemouth and Poole area that are on a child protection plan have domestic violence as a feature in their case history. Sharing information is an absolutely crucial aspect of providing the right sort of support for families."

From the outset Margaret had excellent support from the Trust's management board. "The Director of Public Health was fantastically supportive," she says. "When the local Multi-Agency Risk Assessment Conferences (MARACs) were set up to support high risk victims, it became my role to educate and train health professionals about how to assess domestic violence risk. The Director of Public Health wrote a letter to all GPs in the Service asking them to support me in my new work as the health representative for the community services. This really helped establish the right sort of culture to ensure that health practitioners on the ground are considering Violence against Women and Girls in their everyday work." Margaret is pleased with the level of awareness that she is raising amongst her colleagues. "I regularly train staff on how to use CAADA's 'Domestic Abuse Stalking and Honour-based Violence' Risk Identification Checklist. I ensure that significant health information is shared through the MARAC process. Year on year we're increasing the number of patient referrals to domestic violence support services in the area - whether that's to a local refuge, outreach, IDVA or MARAC. The health visitors, school nurses and Primary Mental Health staff take it very seriously indeed, but I've been hugely impressed by the support I've had from GPs as well. It's good to know that we're making a real difference to the lives of local patients and their children." The RCGP has made domestic violence a new clinical priority with two clinical champions, Professor Gene Feder and Dr Alex Sohal, and the Department of Health has produced new guidelines for commissioners of health services and a developed "Taskforce" on responding to violence against women and children. In addition, the National Institute for Health and Clinical Excellence (NICE) is producing new guidelines for domestic violence which are due for publication in February 2014. The guidelines entitled: "Domestic violence: how social care, health services and those they work with can identify, prevent and reduce domestic violence between intimate partners" have been jointly commissioned by NICE and the Social Care Institute for Excellence (SCIE). This means that they are targeted at social care and the third sector, as well as health services. CAADA, the IRIS team and RCGP are also co-producing guidance for GP practice managers on how to respond to domestic abuse as a practice and this will be available through the RCGP website in late Spring 2012. "These developments are timely and appropriate", says Morrish. "Most resources for supporting victims are currently focused on the criminal justice system, but it's not the most effective point for victims to access help, because many women are frightened of going to the police. Community health services are widely used by victims. It therefore makes great sense for more care pathways to be developed in this area," she concludes.

Further information

● CAADA offers professional training to health and social care professionals, including practical risk training for working with domestic abuse victims: . For information on accessing your local MARAC or IDVA service, please contact . A MARAC Toolkit for community health professionals can be downloaded at
● For information on IRIS visit or contact the IRIS Implementation Leads directly:
● Annie Howell, email: , tel: 0207 683 1270 ext 227
● Medina Johnson, email: , tel: 0117 925 0680
● New Department of Health guidelines for commissioners of health services on Violence against Women and Girls contain suggested outcome measures and case examples: [Accessed April 2012] 



1) Smith, Osborne, Lau and Britton, 2010/11 [Accessed April 2012]
2) Flatley, Kershaw, Smith, Chaplin and Moon, 2009/10 [Accessed April 2012]
3) Walby and Allen, 2004  [Accessed April 2012]
4) Howarth, Stimpson, Barran, & Robinson, 2009 [Accessed April 2012]
5 ) Munro, 2011 [Accessed April 2012]