Recommendations

Recommendations

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Recommendation 1 Plan services based on an assessment of need and service mapping

  • Strategic partnerships (see Who should take action?) should assess the need for domestic violence and abuse services as part of the joint strategic needs assessment. Consult with women, men and young people who have experienced domestic violence and abuse as part of this assessment. Commissioners of domestic violence and abuse services and related services should be aware of the importance of consulting communities that are rarely heard on this matter.

  • Local commissioners of domestic violence and abuse services and related services should undertake a comprehensive mapping exercise to identify all local services and partnerships that work in domestic violence and abuse. (For example, this could include: ambulance services, housing, the police, health, criminal justice, education, probation, safeguarding and social care services. It could also include other specialist statutory, community and voluntary services, such as drug and alcohol services.) Map services against the Home Office-endorsed Coordinated Community Response Model and identify any gaps.

  • Local commissioners (see above) should use the results of the needs assessment and mapping exercise to inform commissioning. They should develop referral pathways that aim to meet the health and social care needs of all those affected by domestic violence and abuse. This includes people with protected characteristics and those who face particular barriers trying to access domestic violence and abuse support services (see recommendations 4 and 9).

  • Regional and national commissioners of domestic violence and abuse services and related services should work with local commissioners to ensure service support extends across local authority boundaries, where necessary, for services such as prisons that cover broader geographical areas.

  • Regional and national commissioners (see above) should work with local commissioners to provide specialist services across local authority boundaries where there is not enough local need to justify setting them up within a particular local authority area. (This could include services to help prevent forced marriages, to help men, and lesbian, gay, bisexual or trans people affected by domestic violence, or for people subjected to 'honour' violence or stalking.)

  • Strategic partnerships should use the results of mapping in the joint strategic needs assessment and other strategic planning tools. They should also make the results widely available to all relevant services and the general public – for example, by publishing a directory of local and national services.

Recommendation 2 Participate in a local strategic multi-agency partnership to prevent domestic violence and abuse

Local authorities, health services and their strategic partners (including the voluntary and community sectors) should:

  • Ensure senior officers from the following services participate in a local strategic partnership to prevent domestic violence and abuse, along with representatives of frontline practitioners and service users or their representatives:

    • health services and the local authority (including the chairs of local safeguarding boards for adults and children)

    • public health

    • sexual violence services

    • housing

    • schools and colleges

    • police and crime commissioners

    • community safety partnerships

    • criminal justice agencies (including probation)

    • the Children and Family Court Advisory and Support Service

    • specialist voluntary, community and private sector organisations.

  • Ensure health and social care practitioners are actively involved in both operational and strategic multi-agency initiatives (for example, multi-agency risk assessment conferences).

  • Regularly review membership of the partnership to ensure it is relevant and inclusive.

Recommendation 3 Develop an integrated commissioning strategy

Local strategic partnerships on domestic violence and abuse, commissioners, clinical commissioning groups and local authorities should:

  • Establish an integrated commissioning strategy. This should include input from domestic violence and abuse services, other relevant services and from people who have experienced domestic violence and abuse. The strategy should:

    • meet the health and social care needs of those who experience domestic violence and abuse (including young people)

    • meet the needs of children and young people who are affected by domestic violence and abuse

    • address the perpetrator's behaviour and health needs

    • meet the needs of all local communities.

  • Ensure the strategy is based on the following principles:

    • aligned or, where possible, integrated budgets and other resources

    • one partner takes the strategic lead and oversees delivery on behalf of the local strategic partnership

    • services address all levels of risk and all degrees of severity of domestic violence and abuse

    • services are based on evidence-based commissioning principles and the local needs assessment and mapping exercise (see recommendation 1).

    • agencies work together to deliver services.

  • Monitor implementation of the strategy and evaluate its effectiveness for different groups. Include both quantitative data on outcomes and qualitative data (such as feedback from service users).

Recommendation 4 Commission integrated care pathways

Commissioners of health and social care services should:

  • Ensure there are integrated care pathways for identifying, referring (either externally or internally) and providing interventions to support people who experience domestic violence and abuse, and to manage those who perpetrate it.

  • Ensure people who misuse alcohol or drugs or who have mental health problems and are affected by domestic violence and abuse are also referred to the relevant health, social care and domestic violence and abuse services.

  • Ensure all service pathways have consistent, robust mechanisms for assessing the risks facing adults who experience domestic violence and abuse and any children who may be affected. This includes ensuring those affected by, and the perpetrators of, the violence and abuse are kept separate from each other when receiving support.

Recommendation 5 Create an environment for disclosing domestic violence and abuse

Health and social care service managers and managers of specialist domestic violence and abuse services and related services (see Who should take action?) should:

  • Clearly display information in waiting areas and other suitable places about the support on offer for those affected by domestic violence and abuse. This includes contact details of relevant local and national helplines. It could also include information for groups who may find it more difficult to disclose that they are experiencing violence and abuse (see recommendation 9).

  • Ensure the information on where to get support is available in a range of formats and locally used languages. The former could include braille and audio versions and the use of large font sizes. There may also be more discreet ways of conveying information, for example, by providing pens or key rings with a helpline number.

  • Take steps to ensure people who use the service are given maximum privacy, for example, by arranging the reception area so that people cannot be overheard.

  • Establish a referral pathway to specialist domestic violence and abuse agencies (or the equivalent in a health or social care setting). This should include age-appropriate options and options for groups that may have difficulties accessing services, or are reluctant to do so (see recommendation 9).

  • Ensure frontline staff know about the services, policies and procedures of relevant local agencies in relation to domestic violence and abuse.

  • Provide ongoing training and regular supervision for staff who may be asking people about domestic violence and abuse. This should aim to sustain and monitor good practice.

  • Establish clear policies and procedures for staff who have been affected by domestic violence and abuse. Ensure staff have the opportunity to address issues relating to their own personal experiences, as well as those that may arise after contact with patients or service users.

Recommendation 6 Ensure trained staff ask people about domestic violence and abuse

Health and social care service managers and professionals should:

  • Ensure frontline staff in all services are trained to recognise the indicators of domestic violence and abuse and can ask relevant questions to help people disclose their past or current experiences of such violence or abuse. The enquiry should be made in private on a one-to-one basis in an environment where the person feels safe, and in a kind, sensitive manner.

  • Ensure people who may be experiencing domestic violence and abuse can be seen on their own (a person may have multiple abusers and friends or family members may be colluding in the abuse).

  • 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.

  • Ensure staff know, or have access to, information about the services, policies and procedures of all relevant local agencies for people who experience or perpetrate domestic violence and abuse.

  • Ensure all services have formal referral pathways in place for domestic violence and abuse. These should support: people who disclose that they have been subjected to it; the perpetrators; and children who have been affected by it (see recommendation 4).

Recommendation 7 Adopt clear protocols and methods for information sharing

Commissioners and service providers involved with those who experience or perpetrate domestic violence and abuse (see Who should take action?) should:

  • Take note of the Data Protection Act and professional guidelines that address confidentiality and information sharing in health services. This includes guidelines on how to apply the Caldicott guardian principles to domestic violence, see Caldicott guidelines. It also includes guidelines on: seeking consent from people to share their information, letting them know when, and with whom, information is being shared, and knowing when information can be shared without consent.

  • Develop or adapt clear protocols and methods for sharing information, both within and between agencies, about people at risk of, experiencing, or perpetrating domestic violence and abuse. Clearly define the range of information that can be shared and with whom (this includes sharing information with health or children's services on a perpetrator's criminal history.)

  • Ensure protocols and methods encourage staff to:

    • Remember their professional duty of confidentiality.

    • Determine when the duty of confidentiality might have to be breached: information should be shared only with the person's consent unless they are at serious risk, and within agreed multi-agency information-sharing protocols.

    • Note that information sharing without consent risks losing trust and may endanger a person's safety.

    • Weigh the risks of sharing information or not by determining whether you are sharing with the aim of protecting someone. It is acceptable to share information if that is the case and you are not sharing data just to alert another agency to a problem.

    • Distinguish between anonymised data and personal data: the former does not need individual consent, but there should be a protocol in place for sharing such data.

    • Distinguish between situations that involve only adults and those where children are involved: information sharing without consent, or where consent is not given, is necessary when children's safety is at risk.

  • Ensure information-sharing methods are secure and will not put anyone involved at risk.

  • Ensure the protocols and methods are regularly monitored.

  • Identify and train key contacts responsible for advising on the safe sharing of domestic violence and abuse-related information.

  • Ensure all staff who need to share information are trained to use the protocols so that they do not decline to cooperate because of being overcautious or for fear of reprisal.

  • Ensure any information shared is acknowledged by a person, rather than by an automatically generated response.

Recommendation 8 Tailor support to meet people's needs

Managers and staff working in domestic violence and abuse services and staff in all health and social care settings (see Who should take action?) should:

  • Prioritise people's safety.

  • Refer people from general services to domestic violence and abuse (and other specialist) services if they need additional support.

  • Regularly assess what type of service someone needs – immediately and in the longer term.

  • Think about referring someone to specialist domestic violence and abuse services if they need immediate support. This includes advocacy, floating support and outreach support and refuges. It also includes housing workers, independent domestic violence advisers or a multi-agency risk assessment conference for high-risk clients.

  • Think about referring someone to floating or outreach advocacy support or to a skill-building programme if they need longer-term support. Also explore whether they would like to be referred to a local support group.

  • If there are indications that someone has alcohol or drug misuse or mental health problems, also refer them to the relevant alcohol or drug misuse or mental health services (see recommendation 13).

Recommendation 9 Help people who find it difficult to access services

Commissioners and service providers in the statutory, private, voluntary and community sectors (see Who should take action?) should:

  • Help people who may find domestic violence and abuse services inaccessible or difficult to use. This includes: people from black and minority ethnic groups or with disabilities, older people, trans people and lesbian, gay or bisexual people. It also includes people with no recourse to public funds.

  • Identify any barriers people from these groups may face when trying to get help. Do this in consultation with local groups that have an equality remit (including organisations representing the interests of specific groups), and in line with statutory requirements.

  • Introduce a strategy to overcome these barriers.

  • Train staff in direct contact with people affected by domestic violence and abuse to understand equality and diversity issues. This includes those working with people who perpetrate this type of violence and abuse. Specifically:

    • Ensure assumptions about people's beliefs and values (for example, in relation to 'honour') do not stop staff identifying and responding to domestic violence and abuse.

    • Ensure staff know where to seek specialist advice, for example, for people with no recourse to public funds or for people with HIV.

    • Ensure staff are aware that lesbian, gay, bisexual and trans people are also at risk of forced marriage and that 'honour'-based violence might be triggered by someone's gender identity or sexuality.

    • Ensure interpreting services are confidential (often a concern in small communities where a minority language is spoken).

    • Ensure professional interpreters are used. Do not use family members or friends. In some areas this will mean using a national interpreting service or one based in another locality.

Recommendation 10 Identify and, where necessary, refer children and young people affected by domestic violence and abuse

Providers of services where children and young people affected by domestic violence and abuse may be identified and those responsible for safeguarding children (see Who should take action?) should:

  • Ensure staff can recognise the indicators of domestic violence and abuse and understand how it affects children and young people.

  • Ensure staff are trained and confident to discuss domestic violence and abuse with children and young people who are affected by or experiencing it directly. The violence and abuse may be happening in their own intimate relationships or among adults they know or live with.

  • Put clear information-sharing protocols in place to ensure staff gather and share information and have a clear picture of the child or young person's circumstances, risks and needs.

  • Develop or adapt and implement clear referral pathways to local services that can support children and young people affected by domestic violence and abuse.

  • Ensure staff know how to refer children and young people to child protection services. They should also know how to contact safeguarding leads, senior clinicians or managers to discuss whether or not a referral would be appropriate.

  • Ensure staff know about the services, policies and procedures of all relevant local agencies for children and young people in relation to domestic violence and abuse.

  • Involve children and young people in developing and evaluating local policies and services dealing with domestic violence and abuse.

  • Monitor these policies and services with regard to children's and young people's needs.

Recommendation 11 Provide specialist domestic violence and abuse services for children and young people

Those responsible for safeguarding children, and commissioners and providers of specialist services for children and young people affected by domestic violence and abuse (see Who should take action?) should:

  • Address the emotional, psychological and physical harms arising from a child or young person being affected by domestic violence and abuse, as well as their safety. This includes the wider educational, behavioural and social effects.

  • Provide a coordinated package of care and support that takes individual preferences and needs into account.

  • Ensure the support matches the child's developmental stage (for example, infant, pre-adolescent or adolescent). Interventions should be timely and should continue over a long enough period to achieve lasting effects. Recognise that long-term interventions are more effective.

  • Provide interventions that aim to strengthen the relationship between the child or young person and their non-abusive parent or carer. This may involve individual or group sessions, or both. The sessions should include advocacy, therapy and other support that addresses the impact of domestic violence and abuse on parenting. Sessions should be delivered to children and their non-abusive parent or carer in parallel, or together.

  • Provide support and services for children and young people experiencing domestic violence and abuse in their own intimate relationships.

Recommendation 12 Provide specialist advice, advocacy and support as part of a comprehensive referral pathway

Health and social care commissioners, health and wellbeing boards and practitioners in specialist domestic and sexual violence services (see Who should take action?) should:

  • Provide all those currently (or recently) affected by domestic violence and abuse with advocacy and advice services tailored to their level of risk and specific needs. This includes providing support in different languages, as necessary.

  • Ensure practitioners are aware of how discrimination, prejudice and other issues, such as insecure immigration status, may have affected the risk that people using their services face.

  • Ensure specialist support services meet national standards of good practice.

  • Ensure specialist advice, advocacy and support forms part of a comprehensive referral pathway (see recommendation 4).

  • Ensure the support is offered (although not necessarily delivered) in settings where people may be identified or may disclose that domestic violence and abuse is occurring. Examples include: accident and emergency departments, general practices, refuges, sexual health clinics and maternity, mental health, rape crisis, sexual violence, alcohol or drug misuse and abortion services.

Recommendation 13 Provide people who experience domestic violence and abuse and have a mental health condition with evidence-based treatment for that condition

Health, police and crime commissioners, health and social care providers and practitioners in primary, mental health and related care services (see Who should take action?) should:

  • Where people who experience domestic violence and abuse have a mental health condition (either pre-existing or as a consequence of the violence and abuse), provide evidence-based treatment for the condition.

  • Ensure mental health interventions are provided by professionals trained in how to address domestic violence and abuse. Interventions may include psychological therapy (for example, trauma-focused cognitive behavioural therapy), medication and support, in accordance with national guidelines.

  • Ensure any treatment programme includes an ongoing assessment of the risk of further domestic violence and abuse, collaborative safety planning and the offer of a referral to specialist domestic violence and abuse support services. It must also take into account the person's preferences and whether the violence and abuse is ongoing or historic.

Recommendation 14 Commission and evaluate tailored interventions for people who perpetrate domestic violence and abuse

Health and wellbeing boards and commissioners who commission perpetrator interventions should:

  • Commission robust evaluations of the interventions to inform future commissioning.

  • Identify, and link with, existing initiatives that work with people who perpetrate domestic violence and abuse.

  • Commission tailored interventions for people who perpetrate domestic violence and abuse, in accordance with national standards and based on the local needs assessment (see recommendation 1).

  • Ensure interventions primarily aim to increase the safety of the perpetrator's partner and children (if they have any). Ensure this is monitored and reported. In addition, staff should report on the perpetrators' attitudinal change, their understanding of violence and accountability, and their ability and willingness to seek help.

  • Link perpetrator services with services providing specialist support for those experiencing domestic violence and abuse (including children and young people). For example, link ongoing risk assessments of the perpetrator with safety planning and support provided by specialist services.

See also recommendations 2 to 4.

Recommendation 15 Provide specific training for health and social care professionals in how to respond to domestic violence and abuse

Organisations responsible for training and registration standards and providers of health and social care training (see Who should take action?) should provide different levels of training for different groups of professionals, as follows.

  • Training to provide a universal response should give staff a basic understanding of the dynamics of domestic violence and abuse and its links to mental health and alcohol and drug misuse, along with their legal duties. In addition, it should cover the concept of shame that is associated with 'honour'-based violence and an awareness of diversity and equality issues. It should also ensure staff know what to do next:

    • Level 1 Staff should be trained to respond to a disclosure of domestic violence and abuse sensitively and in a way that ensures people's safety. They should also be able to direct people to specialist services. This level of training is for: physiotherapists, speech therapists, dentists, youth workers, care assistants, receptionists, interpreters and non-specialist voluntary and community sector workers.

    • Level 2 Staff should be trained 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 violence and abuse, how it affects people's lives and the role of professionals in intervening safely. Staff should also be able to respond with empathy and understanding, assess someone's immediate safety and offer referral to specialist services. Typically this level of training is for: nurses, accident and emergency doctors, adult social care staff, ambulance staff, children's centre staff, children and family social care staff, GPs, mental health professionals, midwives, health visitors, paediatricians, health and social care professionals in education (including school nurses), prison staff and alcohol and drug misuse workers. In some cases, it will also be relevant for youth workers.

  • Training to provide a specialist response should equip staff with a more detailed understanding of domestic violence and abuse and more specialist skills:

    • Level 3 Staff should be trained to provide an initial response that includes risk identification and assessment, safety planning and continued liaison with specialist support services. Typically this is for: child safeguarding social workers, safeguarding nurses, midwives and health visitors with additional domestic violence and abuse training, multi-agency risk assessment conference representatives and adult safeguarding staff.

    • Level 4 Staff should be trained to give expert advice and support to people experiencing domestic violence and abuse. This is for specialists in domestic violence and abuse. For example, domestic violence advocates or support workers, independent domestic violence advisers or independent sexual violence advisers, refuge staff, domestic violence and abuse and sexual violence counsellors and therapists, and children's workers.

  • Other training to raise awareness of, and address misconceptions about, domestic violence and abuse issues and the skills, specialist services and training needed to provide people with effective support. This is for: commissioners, managers and others in strategic roles within health and social care services.

Organisations responsible for training and registration standards and providers of health and social care training should ensure:

  • The higher levels of training include increasing amounts of face-to-face interaction, although level 1 training can be delivered mostly online or by distance learning.

  • Face-to-face training covers the practicalities of enabling someone to disclose that they are affected by domestic violence and abuse and how to respond.

Recommendation 16 GP practices and other agencies should include training on, and a referral pathway for, domestic violence and abuse

  • NHS England, commissioners and GPs should commission integrated training and referral pathways for domestic violence and abuse. This should include education for clinicians and administrative staff in GP practices on how to make it easier for people to disclose domestic violence and abuse. It should also include education for clinicians on how to provide immediate support after a disclosure and how to make referrals to specialist agencies.

  • Managers of specialist domestic violence and abuse services, clinical commissioning groups and public health departments should work in partnership with voluntary and community agencies to develop training and referral pathways for domestic violence and abuse.

Recommendation 17 Pre-qualifying training and continuing professional development for health and social care professionals should include domestic violence and abuse

Organisations responsible for training and registration standards and providers of health and social care training (see Who should take action?) should:

  • Ensure training about domestic violence and abuse is part of the undergraduate or pre-qualifying curriculum, and part of the continuing professional development, for health and social care professionals who come into contact with service users. It should be delivered in partnership with local specialist domestic violence and abuse services and include face-to-face contact, even if it is mainly delivered online.

  • Implement a rolling training programme that recognises the turnover of staff and the need for follow-up. The training strategy should:

    • be clear about the level of competency needed for each role (see recommendation 15)

    • refer to existing accredited materials from specialist organisations working in domestic violence and abuse, if they are suitable

    • ensure the content on domestic violence and abuse is linked to child welfare, safeguarding and adult protection services, and vice versa

    • follow the recommended content for each level (see recommendation 15).