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Domestic violence: improving the primary care response

Nicola Harwin
Director Women's Aid
PO Box 391
Bristol BS99 7WS

In October 2002, at a major national conference,(1) Hazel Blears MP, Minister for Health and a member of the Ministerial Subcommittee on Domestic Violence, reiterated the government's commitment to a joined-up approach to tackling domestic violence, and in particular noted the role of health services in providing effective early intervention.
For those of us in Women's Aid, providing refuge, advocacy and help to over 200,000 abused women and their children a year, it is welcome news that domestic violence is more firmly on the public health agenda. Over the last five years, the Department of Health and the professional health bodies (the RCM, RCN, RCGP, RCOG, CPHVA and others) have recognised in their guidance and training that health services have a vital role to play as a frontline point of contact for abused women and children and as access to further help and protection.

The scale and impact of domestic violence
Violence against women by partners, expartners and relatives is the most common form of physical interpersonal crime,(2) with one in four women exposed to domestic violence at some point in their lives, regardless of race, ethnic or religious group, class, age, sexuality, disability or lifestyle. Police receive one call per minute from victims of domestic violence, 85% of them women assaulted by men.(3) Domestic violence usually escalates in frequency and severity,(4) and by the time a woman's injuries are visible, violence may be a long-established pattern. One in four domestic violence incidents reported to police in the London Borough of Hackney involves serious injury such as strangulation, stabbing, fractures or attempts to kill or set fire to the victim.(5) Sexual abuse and rape are frequently part of the pattern of abusive behaviour. Nearly half of female homicides are killings by a partner or expartner - two women are killed every week.(6)
Women seem to be at particular risk of domestic violence during pregnancy, with between 4% and 17% reporting abuse in the current pregnancy.(7) Studies show that domestic violence is associated with increases in rates of miscarriages, low birth weights, premature births, fetal injuries and fetal deaths. One report published in 1993 found that 60% of women resident in refuges in Northern Ireland had experienced domestic violence during pregnancy - 13% lost their babies as a result.(8)
Domestic violence has direct consequences for the psychological wellbeing of the abused woman: it is a factor in one in four suicide attempts by women.(9) The impact of domestic violence has been found to have psychological parallels with that of torture and imprisonment on hostages. Psychological effects can include low self-esteem, dependence on the perpetrator, feelings of hopelessness, and a tendency to minimise or deny the violence.
The abuse of women and the abuse of children are also intimately connected. In 90% of incidents of violence within families that include children, those children are in the same or the next room at the time.(10) Domestic violence impacts on children's physical and mental health and wellbeing, and the short-term and long-term effects on children are documented by research as well as by children survivors themselves.(11,12)
Financial costs to health services of domestic violence
Not only does domestic violence have enormous individual and personal costs, but also long-term economic and social costs for society as a whole. In London, at least £278m per annum of public money is spent on responding to domestic violence, with over £580,000 per year (not including hospitalisation and medicines) spent by health agencies in one London borough alone.(13)
In the USA, the cost of direct medical care for domestic violence was estimated conservatively at $1.8b per year in 1995. When other factors are added to this such as days of work missed and decreased productivity at the workplace due to the emotional, psychiatric and other long-term ill health consequences of abuse, the financial toll is huge. Recognition of health, police and social services costs in the USA has been a prime mover in strategic approaches and policy and practice changes.

The role of the health service
After friends and family, the health service is often the first port of call for women seeking help. Health professionals have often provided vital help to abused women and children, and have played a key role in referring families to Women's Aid services. But this has largely been an individual rather than a policy response: lack of understanding and training about the issue, and fear of opening "Pandora's box", has meant that abused women's calls for help are often not understood, and the right questions not asked. Many women living with violence at home are reluctant to reveal their experiences through feelings of shame or misplaced guilt, or fearing, as is so often threatened by their abuser, that their children will be taken away if they report what is happening.
The lack of strategic responses by the health service has been confirmed by the findings of a survey that took place in 2001,(14) funded by the Department of Health as part of a three-year Women's Aid Health and Domestic Violence campaign to increase awareness among health professionals and to improve responses.
Our survey revealed that health responses have improved since the Department of Health launched its resource manual over two years ago. However, only 27% of health authorities had a written policy on domestic violence, with NHS trusts only slightly better at 29%. Of greater concern was the finding that Primary Care Groups and Trusts, who increasingly have more responsibility for healthcare management, were lagging behind - only 9% had any policy on domestic violence, only 25% had any designated staff, and two returned our questionnaire saying it was not relevant to their work.
The survey identified a clear lack of training and support for health professionals on the frontline to implement policies and protocols even where they did exist. Most good practice is dependent on the commitment and interest of dedicated staff, and the appointment of a member of staff with specific responsibility for domestic violence strongly correlates with the development of a domestic violence policy and associated protocols and guidelines.
Other findings included that data collection, monitoring and recording of incidents of domestic violence was extremely rudimentary, issues of confidentiality in the context of domestic violence had not been addressed, and responses to disclosure of domestic violence were inconsistent and often unsatisfactory. Many of the health professionals responding to our survey clearly indicated that significant improvement within primary care organisations is dependent on a national lead to make domestic violence a "priority area" against which performance is measured.
Similar concerns are revealed by a recent research study of nearly 200 survivors using Women's Aid outreach services.(15) A total of 68% of women had had contact with at least one member of the health services in relation to domestic violence, including health visitors (23%), midwives (6%), GPs (49%), and A&E staff (19%). GPs were the second most used frontline service (after the police); however, they were also frequently considered unhelpful by women. Other results included:

  • GPs were good at treating physical injuries; however, women pointed out the failure of GPs to ask about the cause of the injuries or to offer follow-up support. Women wanted to be asked directly about the abuse.
  • Health visitors are key in supporting women and identifying other options for them to leave the violent situation, especially women who are extremely isolated. Women wanted to be given information and referral to support services.
  • A&E staff were often cited by women as either not asking about domestic violence or failing to follow-up after a disclosure of violence. Like other health services, they were seen as having a key role in recording or taking evidence of the violence, so that it could be proved for court or other purposes.

The way forward for policy and practice
When it comes to domestic violence there is clearly an important role for healthcare professionals in relation to disclosure, evidence collection, and referral to legal and welfare services such as Women's Aid.
There has recently been lively debate about the pros and cons of "screening" and "routine questioning".(16) In their report to the National Screening Committee,(17) based on a review of existing research, the authors argued that a health service-based screening programme for domestic violence is not justified at present. Practitioners working in new UK initiatives (some funded through the Home Office Crime Reduction Programme) agree that national screening on the medical model could not be introduced at present as health professionals are not ready and there are dangers of nonexperienced staff probing insensitively about abuse, with no backup systems or interventions.
However, many of these activists argue that "routine questioning" rather than a medical model of screening should be the focus of intervention. This is already working in some areas when linked to a comprehensive training programme for health professionals, protocols for questioning, support systems for staff and women, and appropriate referral systems as part of a multiagency response to domestic violence, which prioritises the safety of the survivor and holds the perpetrator accountable.
Taking domestic violence seriously will also mean reviewing existing principles and procedures (for example handheld notes, or the presence of partners in obstetrics care) in a way that will maintain the safety and confidentiality of domestic violence survivors, who may not wish to take any action at that point and who may fear disclosure as a further risk to their safety.
Unless a strategic approach is developed within the health service, natural reticence about the "privacy of family life" will mean that opportunities for effective intervention are missed. Health providers do not need to reinvent the wheel. Through the work of Women's Aid and multiagency domestic violence forums, there are now a number of excellent good practice guides, training materials and resources that have been developed. An effective health service response also requires the development of new ancillary support services, ideally through partnership with organisations like Women's Aid.
Stronger policy guidance is also required. There has been as yet no comprehensive Department of Health circular on domestic violence, nor is it mentioned anywhere in the NHS Plan, and current new priorities for the NHS do not overtly include domestic violence. Some of the other priorities for health (child protection and opportunities for the socially excluded, for example) may well enable improved delivery of services in relation to domestic violence where connections are made between these different areas of need. But is it really acceptable that a major social problem, which has such a huge impact (both directly and indirectly) on the health and lives of one in nine women currently using health services, can be addressed only if piggybacked onto other more popular targets and reforms?
In the USA, a strategic approach has significantly reduced the homicide rate of women killed through domestic violence and changed the lives of many others. At the National Conference on Health and Domestic Violence in London in October 2002, one question remaining for many of the 230 delegates was - how much political will is really there?


  1. "A Stitch In Time". National Conference on Health and Domestic Violence: Royal College of Obstetricians and Gynaecologists, London; 22 October 2002. Organised by Women's Aid in association with the Greater London Authority.
  2. Mayhew P, Maung NA, Mirlees-Black C. The 1992 British Crime Survey. London: HMSO; 1993.
  3. Stanko E. National domestic violence snapshot. London: Brunel University; 2000.
  4. Andrews B, Brown GW. Marital violence in the community. Br J Psychiatry 1988;153:305-12.
  5. Kay T, Kent JH. Women victims of domestic violence. BMJ 1997;299:1339.
  6. Home Office. Criminal statistics. London: Home Office Research and Statistics Department; 1992.
  7. Mezey GC, Bewley S. Domestic violence and pregnancy. BMJ 1997;314:1295.
  8. McWilliams M, McKiernon J. Bringing it out into the open. Belfast: HMSO; 1993.
  9. Stark E, Flitcroft A, Frazier W. Medicine and patriarchal violence: the social construction of "private" events. In: Mullender A, Morley R, editors. Children living with domestic violence. London: Whiting and Birch; 1994.
  10. British Medical Association. Domestic violence: a health care issue? London: BMA; 1998. p.32.
  11. Saunders A. It hurts me too. WAFE, NISW, Childline; 1995.
  12. Mullender A, Morley R, editors. Children living with domestic violence. London: Whiting and Birch; 1994.
  13. Stanko E, Crisp D, Hale C, Lucraft H. Counting the costs: estimating the impact of domestic violence in the London Borough of Hackney. Swindon: Crime Concern; 1998.
  14. Barron J. Health and domestic violence survey. Bristol: Women's Aid Publications; 2001.
  15. Humphries C, Thiara R. Routes to safety. Bristol: Women's Aid Publications; 2001.
  16. Safe, the national domestic violence quarterly. Spring and Autumn 2002 issues. Bristol: Women's Aid Publications; 2002.
  17. Ramsay J, Richardson J, Carter YH, Feder G. Appraisal of evidence about screening women for domestic violence. Report to National Screening Committee. London; 2001.

Further reading
Bewley S, Friend J, Mezey G. Violence against women. London: RCOG; 1997.

Peckover S, Marshall K. Understanding domestic violence: training pack. London:CPHVA;2001.

Department of Health. Resource manual for health care professionals. London: Department of Health; 2000.

Humphreys C. Mental health and domestic violence. A research overview paper presented at the "Making research count" seminar on Domestic Violence and Mental Health: Coventry; 2002.

Royal College of Nursing. Domestic violence: guidance for nurses. London: RCN; 2000.