Launched in 2021, the Domestic Abuse Act was introduced in the UK to enshrine in legislation the response to Domestic Abuse across all agencies – from the police and courts to local authorities and service providers. Issued by the Home Office under the DA Act, the Domestic Abuse Statutory Guidance was published on the 8th of July 2022 and is aimed at statutory and non-statutory bodies working with victims, including children or perpetrators of domestic abuse. It is designed to support organisations, such as the NHS, to identify and respond to domestic abuse, as well as promote best practices. Amongst other things, the document recommends:
“Implementing the IRIS (Identification and Referral to Improve Safety) Programme. IRIS is an evidence-based intervention to improve the general practice response to domestic abuse through training, support to practice teams and having a DA specialist embedded in practices. It is nationally recognised as best practice and has informed NICE guidance.”
At the same time, NHS England also produced and shared “Domestic Abuse and General Practice”, a rapid read to all general practices, safeguarding leads, Primary Care Networks (PCNs) and Integrated Care Systems (ICS) teams across England recommending the IRIS Programme model as a strategy to tackle DA during consultations. And there is more to come.
Over the next few years, other strategies and recommendations are expected to be implemented as part of the DA Act – and many of them will focus on improving the identification and response to Domestic and Sexual Violence and Abuse in healthcare settings. “IRISi is committed to developing and implementing evidence-based interventions to improve the healthcare response to DA within general practices, sexual health clinics and other healthcare environments. As a result, several Integrated Care Boards (ICBs) which have committed to commissioning IRIS and ADViSE are many steps ahead compared to other areas. We have evidence that our programmes work for both patients and health care professionals as well as being a good use of public funds.”
“According to the Department of Health, 80% of women in a violent relationship seek help from health services and these are often a woman’s first, or only, point of contact. We know, for certain, how important it is to provide the right training, support and referral pathway so these professionals can address this based-gendered issue in a more efficient and holistic way”, explains Medina Johnson, CEO at IRISi.
Before we explore more on how the DA Act may impact healthcare settings across England and how the ICBs should address this issue, here are other key messages extracted from the Domestic Abuse Act and from the Domestic Abuse Statutory Guidance.
1) What is Domestic Abuse?
According to the DA Act, Domestic Abuse can be defined as:
(2) Behaviour of a person (“A”) towards another person (“B”) is “domestic abuse” if—
(a) A and B are each aged 16 or over and are “personally connected” to each other, and
(b) the behaviour is abusive.
(3) Behaviour is “abusive” if it consists of any of the following—
(a) physical or sexual abuse
(b) violent or threatening behaviour
(c) controlling or coercive behaviour
(d) economic abuse (see subsection (4))
(e) psychological, emotional or other abuse
and it does not matter whether the behaviour consists of a single incident or a course of conduct.
(4) “Economic abuse” means any behaviour that has a substantial adverse effect on B’s ability to —
(a) acquire, use or maintain money or other property, or
(b) obtain goods or services
(5) For the purposes of this Act, A’s behaviour may be behaviour “towards” B despite the fact that it consists of conduct directed at another person (for example, B’s child).
(6) References in this Act to being abusive towards another person are to be read in accordance with this section.
(7) For the meaning of “personally connected”, see section 2.
Section 2: Definition of “personally connected”
(1) Two people are “personally connected” to each other if any of the following applies —
(a) they are, or have been, married to each other
(b) they are, or have been, civil partners of each other
(c) they have agreed to marry one another (whether or not the agreement has been terminated)
(d) they have entered into a civil partnership agreement (whether or not the agreement has been terminated)
(e) they are, or have been, in an intimate personal relationship with each other
(f) they each have, or there has been a time when they each have had, a parental relationship in relation to the same child (see subsection (2))
(g) they are relatives
(2) For the purposes of subsection (1)(f) a person has a parental relationship in relation to a child if —
(a) the person is a parent of the child, or
(b) the person has parental responsibility for the child
(3) In this section —
“child” means a person under the age of 18 years
“civil partnership agreement” has the meaning given by section 73 of the Civil Partnership Act 2004
“parental responsibility” has the same meaning as in the Children Act 1989
“relative” has the meaning given by section 63(1) of the Family Law Act 1996
2) What is the role of the Domestic Abuse Commissioner?
The DA Act implemented the statutory office of the Domestic Abuse Commissioner who plays a pivotal role in overseeing and monitoring the provision of domestic abuse services across England and Wales. This work will include services across the healthcare system.
3) What does the DA Act say about coercive control and non-fatal strangulation?
The DA Act amended a number of offences; threats to share intimate images, also known as revenge porn; and, in the case of coercive control, the definition now includes former partners and family members under the term ‘personally connected’. The creation of the new offence for non-fatal strangulation in an attempt to control or induce fear, came into force in June 2022. Work is already underway with NHS England, Health and Justice colleagues to explore guidance and processes for this new offence.
4) How is NHS England incorporating the DA Act in its practice?
In response to the DA Act and the publication of the statutory guidance, NHS England is developing a national programme of work exploring how the NHS implements both the Act and the statutory guidance (including the anticipated Serious Violence Duty) to better support victims and survivors. This work will be led by the Clinical Director for Domestic Abuse and will seek to build upon existing areas of best practice, explore areas of growth in NHS provision for supporting victims and survivors but also shining a light on the key role the NHS can play in early intervention and prevention for domestic abuse.
The statutory guidance is clear that health professionals have a crucial role in identifying, responding to and supporting both victims and perpetrators of domestic abuse. Those working within the NHS are viewed as trusted professionals who often have access to patients on their own, sometimes even in their own home, during times of increased vulnerability.
5) What is the role of the Integrated Care Boards concerning the DA Act?
The guidance places a huge emphasis on multiagency working, particularly in regard to information sharing. Agencies must work together and share information to ensure they are able to draw on all the available information held within each agency to build a full picture of the victims, including children, and perpetrators. This is particularly crucial for the recently established ICBs to consider how agencies will work together at place-based levels to fulfil their statutory duty to share information pertaining to domestic abuse.
IRIS and ADViSE have been already tackling Coercive or Controlling Behaviour (CCB), non-fatal strangulation and other signs of Domestic Abuse within healthcare settings
In April 2022, the Home Office initiated a consultation on their Statutory Guidance Framework on Coercive or Controlling Behaviour (CCB), aiming to cover more comprehensively some aspects of the new DA Act (2021). As a result, several offences were amended, including the definition of coercive control, which now includes former partners and family members under the term ‘personally connected’.
The guidance also reinforces the importance of understanding CCB as a pattern of abuse which causes a wide range of impacts on victims, affecting their mental and physical health. For IRISi this is crucial. Documenting abuse is a core element of the IRIS and ADVISE models, and all clinicians are trained to ‘Recognise’ and ‘Record’ abuse within the medical record. The statutory guidance recognises, explicitly, the role medical records will play in providing evidence of CCB within the criminal justice context.
“This is something which we already contemplate in our interventions, and it puts IRIS and ADViSE sites, as well their commissioners, in a position to demonstrate how they already adhere to the guidance within their current IRISi provision. For us, this is another opportunity to impress on clinicians the importance of accurately recording abuse, as well as its impact. Also explicitly mentioned in the guidance as a form of coercive and controlling behaviour is withholding medical treatments and using a victim’s health status to “induce fear and restrict freedom of movement”, explains Medina.
This means that if patients are accompanied by a controlling partner, evidence of this within the medical record could be useful. The guidance talks about the need to collect evidence of impacts on victims and not just focus on behaviours, and IRIS-trained clinicians are in a unique position to do this.
As for non-fatal strangulation, it is important to state that this, again, is a gendered crime, and women who experience it are more likely to be killed, even after just one incident of strangulation.
In outlining who the Domestic Abuse Statutory Guidance is useful for, it explicitly mentions a number of Health Bodies including NHS England and NHS Improvement; Integrated Care Systems (ICS); NHS Trusts; and NHS foundation trusts. This is important for individual IRIS and ADViSE site commissioners and an important point to consider if you are thinking about funding IRIS and/or ADViSE.
There are other areas mentioned in the guidance which link to what IRISi currently provides within the IRIS and ADVISE interventions. These include the importance of recognising and documenting the impact of reproductive coercion; the impact of abuse on children as victims-survivors of domestic abuse in their own right; the role of GPs in monitoring those with firearms licenses; and recognition of how domestic abuse, and coercive controlling behaviour, in particular, impact on the mental health and well-being of victims-survivors.