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Home is where the harm is

Cuts to domestic violence services make interventions in primary care even more vital, writes Seeta Bhardwa

The shocking reality of domestic abuse, in particular the slow, suffocating trap of ‘gaslighting’, recently came closer to public consciousness through the unlikely source of The Archers. The Radio 4 soap, gripped the nation with the story of Helen Titchener and her husband Rob, an outwardly respectable man intent on controlling her life.

But for 1.1 million British women last year, that storyline was a reality. And for the two women a week in the UK killed by their partners, the story comes to an horrific but avoidable end.

National domestic violence charity Refuge told Independent Nurse that the number of women it supports has increased on average by 20% year on year with around 4000 women needing its help on any given day.

The charity also revealed that 30% of domestic violence cases either start or will intensify during pregnancy thus highlighting the crucial role midwives and nurses can play in recognising and helping women suffering domestic abuse.

Janet Fyle, professional policy advisor from the Royal College of Midwives, says that, in light of this, it is important for midwives to ask all women questions about their relationships with their partners. ‘There are a number of training packages for midwives in order to support them to ask women the difficult questions, including videos and guidelines from NICE.’

Aside from the immediate injuries from assault, domestic violence can result in a range of long-term mental and physical health complications. These include chronic pain, gastrointestinal disorders, psychosomatic symptoms and eating disorders, says Melanie Hayward, a senior lecturer in children’s nursing at Buckinghamshire New University.

Women can also contract sexually transmitted infections, be at increased risk of substance abuse and develop a number of mental health conditions such as post-traumatic stress disorder, anxiety, depression and suicidal thoughts.1

Limiting funding

Domestic violence is one of the biggest issues affecting women and children in this country and statistics on the number
of women experiencing it have remained ‘stubbornly high’ over the last decade, says Refuge.

Despite this, many women’s services in the community have been the victim of funding cuts, not unlike other crucial services that are dependent on government and public funding.

Woman’s refuges, however, have been hit hard by cuts to local authority services. 2 Ms Fyle says that organisations such as women’s refuges have suffered over the last five to 10 years with cuts to the funding they receive. ‘Such organisations depend partly on government funding and on other public and general donations to them,’ she says.

In March this year, the then home secretary Theresa May launched a strategy, Ending Violence against Women and Girls, outlining progression for women’s services over the next four years. In the report, the government pledged £80million over the next four years, which will ‘provide core support for refuges and other accommodation-based services, helping local areas ensure that no woman is turned away from the support she needs’.3

The strategy contains a section on strengthening the role of the health services, recognising that abused women will access them more often the non-abused. Healthcare workers are also the professionals that women would be most likely to confide their experiences in.

Refuge welcomed the additional funding but says that while on the surface £80million may seem like a lot of money, ‘when you take into account the gaping hole left by year-on-year reductions in funding from local authorities, it is clear that this will not bridge the gaps nor bring back the services that have been wiped out in recent years.’

Since 2011, Refuge has experienced cuts to 80% of its services, with some being cut by up to 50%.

Ms Hayward says that health visitors, who in turn have their own recruitment and retention issues have been heavily affected by these cuts too. ‘These roles are filling the gap; providing one-to-one support, creating safety plans, and in some cases liaising very closely with the police and social care around legal and contact issues.’

Working together

National charities such as Refuge run training sessions for health professionals which include guidance on how to recognise abuse, how best to support women when they disclose abuse and how to refer women on to specialist services.

Refuge has said they also have frontline staff who co-locate in hospitals and maternity units so they can share knowledge and best practice with staff and and offer support to women.

Three boroughs, including the London Borough of Hackney, have funded MARAC liaison nurses who work with GP practices and third sector organisations to support women who disclose experiences of domestic violence. A MARAC or a multi-agency risk assessment conference is a meeting consisting of a number of different agencies and organisations where information is shared on the high-risk domestic abuse cases.

Jessica Woods, the MARAC liaison nurse in Hackney, London, says that her role only recently became permanent, when previously the post was hired on a yearly contract. The funding for the role comes from Hackney CCG.

GPs in Hackney also use a pathway system called IRIS to refer women who raise concerns about domestic abuse. IRIS is a system set up on the GP’s computer to flag up if the client presents on numerous occasions with certain problems such as unspecified abdominal pain.

‘There is a long list of all different health conditions that could potentially be related to domestic violence and IRIS will alert the GP to consider domestic violence as a cause,’ says Ms Woods. ‘And then they ask the client and if the woman says she is experiencing domestic violence they can make a referral via IRIS to the Nia project.’ IRIS has been rolled out in other areas, but has yet to be rolled out nationally says Ms Woods.

Nia is an independent organisation that works with women who have been victims of domestic violence in Hackney and Haringey. Ms Woods says she primarily works with Nia but will also work with other organisations such as Refuge and Women’s Aid.

She also says that as a former health visitor, their role is slightly different in working with women as usually there will be young children involved. ‘Generally they would be referring them to children’s social care but we do encourage them to undertake risk assessments too and refer to the MARAC too in high-risk cases.’

Ms Woods also believes that they may be the only area that works with perpetrators as well to understand the root cause of the problem.

The ground-breaking work and the role of the MARAC liaison nurse in Hackney understands that tackling domestic violence is a collaboration of healthcare professionals and women’s charities and services.

But cutting these services and isolating women at risk is compromising their basic human rights and sending out a message that their lives are not valued. An Archers fan who set up a semi-jokey appeal for Helen Titchener ended up raising £200,000 for Refuge. Real-life women deserve this sort of support too.


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1. Health effects of domestic violence. 2013.

2. As the ‘Archers Trial Week’ begins, refuges in England and Wales are in crisis. 2016. Women’s Aid.

3. Ending Violence against Women and Girls

Strategy 2016 – 2020. 2016.HM Government.

4. Domestic Violence: what can nurses do?