The NHS has long been used to treating the results of domestic violence but targeting the causes and perpetrators is a new avenue in preventive healthcare. Stuart Shepherd reports

Domestic violence remains a shocking issue. This is despite new legislation and strategies to case manage the most dangerous offenders, significant increases in rates of conviction and a fall in the number of incidents.

“These men are motivated to seek help. It’s perverse that there hasn’t been a service for them before”

Incredibly, one in four women in the UK will be a victim of domestic violence at some point in her life. It is the leading cause of morbidity for women aged 19-44 and the leading cause of injury and illness for girls and women aged 15-44. It accounts for a quarter of all violent crime, according to the Ministry of Justice. Victims are more likely to develop psychological problems; studies on victimised women show average rates of depression of 48 per cent and a suicide rate of 18 per cent.

Family life is also severely affected. Children witnessing domestic violence daily are more than twice as likely to have social and behavioural problems than their peers, and research suggests that in 40 per cent or more cases of domestic violence, the perpetrator also inflicts physical and sexual abuse on a child or children in the family.

There is also a massive financial cost. The 2004 study The Cost of Domestic Violence by Sylvia Walby of Leeds University for the government’s women and equality unit estimated it costs health and social services around £1.45bn a year.

Now although in recent years tackling domestic violence has been predominantly framed in the sphere of criminal justice, there is a new relevance for the NHS.

Vital role

“The only way to successfully tackle domestic violence is through a multi-agency approach, linking together police, probation and health services in partnership with the voluntary sector,” health secretary Alan Johnson tells HSJ. “The NHS has a vital role to play in terms of prevention and treatment. Victims inevitably use primary care and accident and emergency services, where support and help can be sought and offered as well as injuries treated.”

Questions relating to health and other public services contributions to reducing domestic violence in the recent cross government consultation Together We Can End Violence Against Women and Girls are concerned with picking up on and responding to early signs of violence and information for professionals about supporting victims. Research has shown a window of opportunity of four hours after an assault, during which a supportive intervention has the most impact. Other targeted interventions include women using maternity services now being routinely asked in private about domestic violence.

Justin Varney, assistant director of health improvement at Barking and Dagenham PCT, admits the NHS in London, for one, “has a long way to go”.

“You find very variable reactions,” he says. “There are examples of good practice - such as the domestic violence advocates in A&E at Guy’s and St Thomas’ foundation trust - but they are few and far between. We do not have a strategic lead chief executive or a champion in public health and there are no strategic networks.”

His PCT has developed its own strategy (see box: local strategy).

Also highlighted in the government consultation is a social marketing project from Hull teaching primary care trust designed to increase the safety of women and children, develop a model for working with perpetrators and evaluate the impact of such a project on the incidence of violent domestic offences (see box).

“We looked at how the PCT could contribute further to the domestic violence agenda. We decided that - as we are well set up in the city in terms of services for women who are victims, through a strong multi-agency partnership that forces police, social work, health and housing specialists to focus, contact and directly support every victim - we ought to try and look at men, the other side of the coin,” says PCT domestic violence clinical and strategic lead Louise Robinson.

It is not a new idea that domestic violence issues are as much about men having problems as women. But it is not a popular topic; organisations that have put money into perpetrator services (which tend to be geared towards men) have had their critics. Until now these organisations have almost exclusively been from the voluntary sector.

“Domestic violence is associated with so many health issues. Unless we start looking at the causes rather than treating the end results we won’t get anywhere,” says Ms Robinson.

“This is a case for health not merely being an absence of disease but a much wider issue; a proactive and preventive service. That’s been our jumping off point for all our work on the perpetrator project.”

The PCT’s domestic violence prevention manager, Mark Coulter, says: “The programme is for men who recognise they have violence or abuse issues with their partner and want to do something about it. This is an early intervention service so these are not men who have been prosecuted, gone through probation and been on the integrated domestic abuse programme, but are at the lower end of the scale.

“Having picked up the phone and made the call those men motivated to change will be offered one-to-one and then group work over a year. They must also agree to their partner being offered independent support from the newly appointed specialist family practitioner. If there are children we will also look at any developmental or behavioural issues.

“These men are motivated to seek help. It’s perverse that there hasn’t been a service for them before. Effectively the only way they might have got help was to hit their partner harder. But all the research shows that once physical violence starts it will escalate in frequency and severity.”

Australian model

The Hull model owes much of its inspiration to the Western Australia state government’s Freedom From Fear project. Launched in 1998 as a 10 year programme, it ran as a social marketing campaign alongside a range of perpetrator support and referral services.

“The media campaign succeeded in getting the target men [to call] the helplines and brought domestic violence as an issue out in to the open more,” says Mark Francas, who led the formative research behind the campaign and is now global deputy head of market researchers TNS Political and Social.

“The evaluation showed the campaign prevented and reduced abuse and brought about some positive shifts in beliefs of what was acceptable among the target group.”

Freedom From Fear won many plaudits and was eventually adopted by a number of other Australian states. In the NHS, Hull is the first PCT to take such a step.

“This [project] may seem controversial,” says Alan Johnson, who is also the local MP, “but unless we tackle the root causes of abusive behaviour we will never break the cycle. We will be watching how the Hull project develops and looking at how it can contribute to the plethora of work we are doing in the NHS to address domestic abuse.”

The Hull scheme will include two phases of evaluation; the first to look at the delivery of its social marketing and how that was received and the second, running over two years, to examine the impact of both the campaign and service on men’s and women’s attitudes to and awareness of domestic violence across the city.

Such innovative work and the interest the PCT says it has had from around the NHS is encouraging. But understanding of domestic violence across the service varies.

Frontline health service professionals have a number of guidance documents - including the Department of Health’s Responding to Domestic Abuse - to help them consider and work with victims of domestic violence. But they lack any consistent monitoring of their implementation.

Economic sense

While the economic case for a good understanding of the issues, including early intervention and diversion services, includes dramatic reductions in repeat attendances at A&E and walk-in centres, improved performance and, ultimately, improved life expectancy figures, concerns remain around the commissioning of services.

“The organisations we work with now need to be engaging and exploring issues of service specification with commissioners,” says Women’s Aid policy and services manager Deborah McIlveen. “Domestic violence impacts on health inequalities, a topic high on the NHS agenda, so we have been developing national service standards and commissioning guidance to assist local strategic partnerships.”

“I don’t know of any evidence or evaluation of the implementation of guidance such as Responding to Domestic Abuse,” says Jo Todd, chief executive of Respect, a membership association for UK domestic violence perpetrator programmes. “This isn’t exclusive to health but a problem we notice is that while they may get it right at policy level, when it comes to implementation it’s either piecemeal or not picked up at all - and there is no accountability for that.”

Davina James-Hanman, director of the Greater London Domestic Violence Project, echoes all these concerns and those of Dr Varney in Barking and Dagenham.

“The pockets of excellent practice are almost always down to a few key individual champions rather than something systemic, embedded and fully mainstream within the NHS’s response,” she says.

Former DH national domestic violence co-ordinator Christine Mann, the first consultant nurse for domestic violence and now an independent consultant, says: “It is vital all the opportunities frontline health professionals have to spot risk, offer advice and refer to specialist services - for both perpetrators and survivors of abuse - are supported by strong organisational direction. All NHS organisations should have domestic violence strategies; for patients and, as employers of large numbers of women, for their staff as well.”

Local strategy

Barking and Dagenham PCT’s moves to combat domestic violence include recruiting a full time domestic violence strategic implementation lead and developing a strategy, training, resources and a website.

“About 18 months ago we began addressing some of the serious challenges in getting the NHS in London to engage in domestic violence and stop seeing it just as a social care and crime issue,” says assistant director of health improvement Justin Varney.

“We learned a lot about staff anxieties regarding conversations about domestic violence,” he says. “The website provides some guidance and resources to help staff across London and beyond.”

Motivating change in behaviour: social marketing in Hull

Above all the function of Hull PCT’s social marketing campaign on domestic violence is to improve the safety of women and children being abused or at risk of abuse.

Getting the research done, developing the social marketing campaign and establishing a programme that helps men change their behaviour have all been challenging considerations.

Professor Nicky Stanley of the University of Central Lancashire carried out formative research to inform the campaign, consulting focus groups representing a cross-section of many of the people - including some known perpetrators - to whom ultimately the service will be directed.

With a brief to talk about their attitudes and understanding of domestic violence and learn what effective behaviour changing messages might look like, some of the men participating were prepared to disclose that they had been perpetrators of domestic violence but were not known as perpetrators to services. It was an early and thought provoking finding of the research.

Other key findings included domestic violence being described as a hidden issue. High levels of male violence were seen as embedded in the local culture of Hull, a city where traditional values, until very recently, had been slow to change. Contributing factors such as low self-esteem, difficulties in expressing sensitive issues and images of masculinity such as asking for help being seen as not “manly” behaviour.

Concerns about the effects of domestic violence on children were considered to be the most effective motivating messages, with the men being keen to maintain a positive image of themselves in their children’s eyes.