Responding to Domestic Abuse - Guidelines for Health Care Workers in NHSScotland

RESPONDING TO DOMESTIC ABUSE - GUIDELINES FOR HEALTH CARE WORKERS IN NHSSCOTLAND

PART 1: AN OVERVIEW OF DOMESTIC ABUSE

This introductory section outlines the nature and prevalence of domestic abuse. It presents the Scottish Executive's definition and policy, its action plan and campaign and measures taken so far to address domestic abuse and related issues. It describes the roles and responsibility of NHS and of health professionals in responding to domestic abuse.

Aims of the guidance

The Scottish Executive Health Department has produced these guidelines with the help of a Short Life Working Group comprising experienced professionals, to assist health care workers in all NHS settings to respond appropriately to victims of domestic abuse.

The Group was asked to:

• prepare guidelines on domestic abuse for health care workers;

• advise on how best to raise awareness amongst NHS staff, improve the environment for disclosure of domestic abuse and offer effective help

• state what support health care workers should expect from their NHS employer.

The Group was asked to advise the National Group to Address Domestic Abuse in Scotland and the Scottish Executive on implementation of the guidelines by NHS Boards and Trusts. A list of members of the Short Life Working Group can be found in Annex A.

Domestic abuse in Scotland - what does it mean?

Domestic violence refers to a wide range of physical, sexual, emotional and financial abuse of people who are, or have been, intimate partners, whether or not they are married or cohabiting. Domestic abuse can occur in any relationship and in all social groups, regardless of race, religion, social class or age.

Domestic abuse is a criminal, social and medical problem with serious consequences. It infringes fundamental human rights, and causes far reaching damage to people's lives and development. It is difficult to know how many Scots are experiencing domestic abuse at any one time. Evidence demonstrates that it is widespread and under reported, and the level of repeat incidence is high. It is estimated that anything between a quarter and a third of all women in Scotland will experience abuse at some point in their lives.

Statistics show that in 2000 there were 712 incidents per 100,000 population in Scotland. ¹ 330 people experienced serious assault and 17 people were murdered by their partners in the same year. The Confidential Enquiries into Maternal Deaths in the United Kingdom (2001) notes that of the 378 women whose deaths were reported between 1997-1999, 45 (12%) volunteered information about violence during pregnancy to a health care professional.

Violence may increase when a person experiencing abuse tries to end the relationship, on separation or divorce or, for women, during pregnancy and following the birth of a child. Domestic abuse has harmful, sometimes even life threatening, impact on the physical and mental wellbeing of those affected. Elderly people, same sex couples and people with learning difficulties are particularly vulnerable; they may experience greater difficulty in reporting incidents of violence or abuse.

Domestic violence can take place in any relationship, including gay and lesbian partnerships and abuse of men by female partners does occur. Nevertheless the majority of domestic abuse is perpetrated by men against women, and their children. Of the 660 non-sexual crimes of violence, 559 involved a female experiencing violence from a male perpetrator. ² Therefore this document refers throughout to people experiencing domestic abuse as women.

Definition of domestic abuse

The Scottish Executive has adopted the following definition of domestic abuse:

Domestic abuse (as gender-based abuse) can be perpetrated by partners or ex-partners and can include physical abuse (assault and physical attack involving a range of behaviour), sexual abuse (acts which degrade and humiliate women and are perpetrated against their will, including rape) and mental and emotional abuse (such as threats, verbal abuse, racial abuse, withholding money and other types of controlling behaviour such as isolation from family and friends).

Children in families where domestic abuse occurs may be witnesses to, or also subject to domestic abuse. Exposure to domestic abuse may cause significant harm to children and there is some correlation between domestic abuse and the mental, physical and sexual abuse of children. Other family members, connected to a woman through marriage or through her relationship with her partner, may participate in domestic abuse of the woman, as may members of her own family.

Forms of abuse

The term 'domestic abuse' embraces physical, sexual, or emotional (including financial abuse) and takes specific and identifiable forms. See table 1.

Table 1 Forms of abuse:

PHYSICAL VIOLENCE	SEXUAL ABUSE/ASSAULT	PSYCHOLOGICAL ABUSE
Biting	Enforced prostitution	Convincing of mental illness
Bruising	Female genital mutilation	Criticism
Burning	Forced pregnancy or continuation of pregnancy	Destruction of personal belonging
Choking/strangling	Forced enactment of pornography	Financial deprivation
Hitting	Forced participation in pornography	Imprisonment
Kicking	Forced sex - anal/vaginal/oral	Forced performance of menial/trivial tasks
Knifing	Forced termination of pregnancy	Humiliation and degradation
Murder	Forced tying up during sexual activity	Isolation from family and friends/work
Punching	Rape	Jealousy and possessiveness
Scalding	Removal of sutures from perineum to facilitate intercourse	Sleep deprivation
Scratching	Sexual assault using objects	Targeted abuse of children, relatives or pets
Slapping	Urinating/defecating on abused	Threats
Starving	Withdrawal of contraception	Verbal abuse

In the Scottish crime survey (2000) 62% of people reporting crimes of threatened or actual domestic abuse said the perpetrator had been drinking alcohol. This may mean that the perpetrator needs help to tackle alcohol problems. Nevertheless alcohol abuse is never a cause, or an excuse, for domestic violence.

National policy framework

The Scottish Executive is strongly committed to raising awareness amongst professionals and the public concerning domestic abuse, improving information about the scale and nature of the problem and ensuring that women and their children get the protection and support they need.

A great deal of cross agency work is already being undertaken in the UK to prevent abuse and to support women and their families who are experiencing domestic abuse. This work emphasises the importance of changing the balance between the 'powerless' nature of the abused against the 'powerful' abuser. Campaigning and pressure groups, research findings and increased public awareness of the problem have brought about a significant change in attitudes, and have directed government's attention to the need to address address domestic abuse effectively in partnership with local agencies and survivors.

Awareness raising

Domestic abuse must become unacceptable in Scottish society so that there is widespread acceptance that responsibility lies with the perpetrators of abuse and that those who are abused are in no way to blame. It is also important to create a climate of belief, so those women experiencing abuse will come forward and receive the support and services they require.

The Scottish Partnership on Domestic Abuse was established in November 1998. It produced A National Strategy to Address Domestic Abuse in Scotland, which includes an Action Plan, supported by Good Practice Guidelines and Service Delivery Standards. The Executive is committed to implementing the Action Plan.

The National Group to Address Domestic Abuse in Scotland

Implementation of the National Strategy and Action Plan is overseen by a National Group of stakeholders, chaired by the Deputy Minister for Social Justice. Its remit is to:

• Oversee the implementation of A National Strategy to Address Domestic Abuse in Scotland

• Review and monitor progress against the Action Plan

• Identify and disseminate good practice

• Identify key issues and develop a coherent national response

• Provide advice in relation to monitoring data and the identification of the research required

• Establish and oversee a structure of specific issue-based groups and local multi-agency groups working within a coherent framework

• Consider links between domestic abuse and the wider issues of violence against women.

The Scottish Executive has allocated a budget of 4.5 million over three years, from 2001-2004, for the implementation of the Action Plan.

The Government's commitment to ensuring the NHS in Scotland provides a responsive, high quality service to anyone experiencing domestic abuse is stated in a number of policy statements:

• The Scottish Needs Assessment Programme (SNAP) (1997)

• A Framework for Mental Health Services in Scotland (1997)

• Scottish White Paper Towards a Healthier Scotland (1999)

• The audit report of maternity services Maternity Care Matters (1999)

• The Priorities and Planning Guidance for the NHS in Scotland 1999-2002 NHS MEL (1998)

• Our National Health: A plan for action, a plan for change (2001)

• A Framework for Maternity Services in Scotland (2001)

• Nursing for Health (2001)

The role of the health service

The health service is in a unique position to contribute to helping people who suffer violence at home get the support they need. Virtually every women in Britain will use the health care system at some point in her life, whether for routine health care, pregnancy and childbirth, illness, injury, or in the role of carer for children or older people. Health services may often be a woman's only contact with professionals who might recognise domestic abuse and intervene. The health service may become a lifeline for women whose freedom is being restricted by a violent partner, or who is reluctant to become involved with the police or the criminal justice system. Health services also have a strong contribution to make to changing public attitudes.

Therefore health services have a pivotal role to play in the identification, assessment and response to domestic violence, in promoting health and through the provision of support and services for women and their children. Any health care professional may have the opportunity to identify someone experiencing domestic violence, and to empower women to get help and support. Early intervention can prevent an abusive situation becoming worse and the level of violence becoming more intense.

In particular, health care workers have a responsibility to:

• be educated and trained in how to best help;

• be aware of a woman's often tentative attempt to seek help - this includes children presenting with a variety of illnesses;

• be sympathetic, non-judgemental and show empathy;

• be responsive within a co-ordinated health service, with links to multi-agency help as required;

• value racial, cultural or religious diversity and be sensitive to women's needs.

Domestic abuse may present in any area of practice and clinical provision and therefore health care workers need to be alert to, and develop the skills to respond effectively to any signs and indicators. Those who experience domestic abuse may be patients or staff. Many may be very reluctant to tell anyone about abuse. Practitioners should be mindful that women currently experiencing domestic abuse may also have experienced other forms of abuse including childhood abuse. If a household includes children there may also be child abuse.

These guidelines should assist a more consistent and comprehensive response. In addition the national helpline service, NHS 24, will provide support for women in future by ensuring that when women call for advice, their needs are properly identified and that they are directed to the most appropriate advice or service.

Effective inter-agency working

Some women experiencing domestic abuse decide to leave their abusive partner, while some decide to stay. No one service or agency can deal with all problems related to domestic abuse in isolation. A National Strategy to Address Domestic Abuse in Scotland includes standards for inter-agency working, which describe what services a women experiencing domestic abuse has a right to expect from the agencies to whom she turns for help. Whatever their circumstances they need access to a range of services and support, medical, social and practical. To meet these needs, support services should be informed, efficient, pro-active, and multi-agency. Health care staff should familiarise themselves with the role and functions of the various statutory and voluntary organisations so that accurate information can be shared with women experiencing abuse, and appropriate referrals made.

The police

The police take cases of domestic abuse very seriously. Most police officers have received training in handling cases of abuse and most local forces have domestic violence liaison officers specifically to deal with such cases. All officers should be equipped to handle initial contact with women who have been sexually abused or subjected to domestic abuse, in an professional and sympathetic manner. Assault is a criminal offence and if a woman has been physically assaulted, the police may arrest the offender.

When the police are notified of an incident of domestic abuse the woman can expect them to:

• respond quickly to her call;

• talk to her separately from the violent person;

• arrest the perpetrator where there is sufficient evidence;

• arrest the perpetrator if they have broken the terms of an interdict with power of arrest or bail conditions;

• arrange for medical treatment for the woman if she needs it;

• keep records of all incidents of domestic violence against the woman.

If the woman decides to leave, the Police may accompany her back home and protect her if she wishes to collect any belongings.

Hitting Home (1997), a thematic study of eight Scottish police forces' response to domestic abuse, recommended that police forces should develop a common definition of domestic abuse for operational use by all forces so that:

• patterns of behaviour can be monitored and repeat incidents identified;

• consideration of further investigation can take previous incidents into account;

• future protection of the woman and any children can be considered by police and other interested agencies;

• police performance can be monitored at individual and organisational levels;

• strategy can be adjusted accordingly at local and force level.

The police definition now in operation is:

"Domestic violence is any form of physical, non-physical, or sexual abuse which takes place within the context of a close relationship, committed either in the home or elsewhere. In most cases this relationship will be between partners (married, co-habitant or otherwise) or ex partners."

Police forces have collected statistics on incidents satisfying this definition since 1 April 1999, aided by the work of the Scottish Criminal Statistics Committee.

In an emergency, anyone experiencing abuse should dial 999 and ask for 'POLICE'. If a 999 call is made to the Police and interrupted, the Police will always trace the call and attend at the house.

The legal profession

A solicitor can provide information about a woman's legal options, her eligibility for legal protection and local court practice. Some solicitors provide a first consultation free of charge. Scottish Women's Aid (see part 5) can provide names and addresses of experienced solicitors that women have found helpful.

If the woman's partner is arrested, charged and goes to court, bail may be granted. In certain circumstances the court may decide to grant bail subject to conditions. Bail conditions may restrict the partner's movements and provide the woman with some protection, and time to consider what to do next. It is for the court to decide whether to impose conditions and what those should be.

Protection is available through civil law as well as criminal law. A woman can apply to the court, through a solicitor, for an Interdict. This is a court order, which prohibits her partner from doing anything set out in the order. It may, for example, prohibit him from coming within a certain distance of their home.

She may also apply, again subject to certain conditions relating to her own or her partner's occupancy rights, for a Matrimonial Exclusion Order, which requires her partner to leave the household and allows her and any children to remain in the family home. If she is married or cohabiting and is a joint owner or joint tenant or has been given occupancy rights by the court, in certain circumstances a woman can apply for a Matrimonial Interdict with a power of arrest attached. This allows the police to arrest her partner if he breaks the terms of the interdict.

The woman may need to apply for Civil Legal Aid to obtain an Exclusion Order or Interdict. Any income above the level of Income Support will be taken into account in assessing whether she should contribute to legal costs.

Anyone who is being harassed can apply to the Sheriff Court for a Non Harassment Order if an individual has done anything that causes alarm or distress on at least 2 occasions. The court can also be asked to award damages arising from the harassment. In addition, if a person is convicted of an offence involving harassment the Procurator Fiscal can ask the court to impose a Non-Harassment Order on the offender to protect against any future harassment in addition to the sentence imposed by the court. Breach of a non-harassment order (whether made by a criminal or civil court) is a criminal offence punishable by up to 5 years imprisonment, or an unlimited fine, or both.

The woman may be able to receive criminal injury compensation. For information on this and a fuller explanation of legal terms, see Glossary. (pg 40)

The local authority

Housing

A woman may be considered homeless if she has accommodation but it is probable that occupation of it will lead to abuse from someone else who lives there or who used to live with her. If found to be homeless a woman would be considered to have a priority need for housing if she had dependent children, was pregnant, was at risk of domestic abuse or otherwise vulnerable.

The Code of Guidance on Homelessness,³ which local authorities are required to take account of in exercising their function to house homeless people, sets out guidance on what might constitute such vulnerability.

Homeless people in priority need are entitled to permanent accommodation if they have not made themselves 'intentionally homeless' or other accommodation if they are considered intentionally homeless. Women escaping domestic violence or external violence should not normally be deemed intentionally homeless.

Placement in another local authority area, with the woman's consent, may be useful where there is a need to get away from the perpetrator of violence. The Housing (Scotland) act 2001 amended the allocation provisions of section 20 of the Housing (Scotland) Act 1987 to ensure that in the allocation of their houses a social landlord shall take no account of whether an applicant is resident in their area if that applicant wishes to move into that area because he or she runs the risk of domestic violence. This applies equally to local authorities and registered social landlords. Local authorities also have the power to repossess and transfer council tenancies. In the case of a relationship breakdown, this could be used to transfer the tenancy to a woman at risk.

Social Work

Legislation relating to the 'local authority' does not only refer to Housing Departments, but to the whole council, including social services. Social services, and particularly the Emergency Duty Team, can be a vital resource and initial point of contact for many women. Their functions include help with emergency accommodation, benefits and finances.

The local authority social work service has statutory duties to protect children, and to safeguard and promote the welfare of children in need in their area.

Perpetrators' programmes

As part of their preventive strategies, a number of local authorities criminal justice workers provide programmes for men convicted of domestic violence offences. Such programmes include intensive educational programmes based on behavioural therapy. The Scottish Office independently and positively evaluated two Scottish programmes, the Domestic Violence Probation Project in Edinburgh and the CHANGE Project in Stirling in 1996. The aim of such programmes is to encourage men to identify and re-think some of the beliefs, attitudes, expectations, and fears, which may underpin their use of violence. All programmes focus on the man's responsibility for his behaviour and on the impact on his partner and children.

To ensure that such programmes are effective and do not collude with perpetrators they should be compatible with the Statements of Principle and Minimum Standards of Practice issued by RESPECT, the National Association for Perpetrators Programmes and Associated Women's Support Services. This is a UK-wide body. Such programmes must have procedures for consulting confidentially with the partners of men on the programme and should have partner support services running alongside the men's programme.

Men on such programmes often attend as a condition of a Probation Order and their failure to attend or co-operate with the programme will result in them being returned to the court for an alternative sentence to be imposed.

DOMESTIC ABUSE - GOOD PRACTICE IN SCOTLAND The Domestic Violence Probation Project is a probation project run by Edinburgh Council. It is designed to educate men to end their abuse and referrals are made by the Sheriff Court as part of the probation order. The Domestic Abuse Service Development Fund is funding a Working with Men Partnership to extend this service to men who have not been through the court system. The Fund has also supported partner working for those women in relationships with men on the DVPP.

The voluntary sector

Over the last two decades women's groups have campaigned vigorously on the issue of men's violence against women. These campaigns have succeeded in raising the profile of domestic abuse and in creating a less tolerant attitude towards abuse behaviour.

Scottish Women's Aid (SWA) is a key campaigning and support organisation run by women for women. It provides a network of independent, locally based services offering information, support and safe refuge for women, children and young people who are experiencing, or have experienced, domestic abuse. Scottish Women's Aid currently has 39 affiliated and 6 non-affiliated groups providing about 360 refuge places throughout Scotland. SWA also offer training to external agencies on domestic abuse and raising awareness.

DOMESTIC ABUSE - GOOD PRACTICE IN SCOTLAND A multi-agency website is now available for information on domestic abuse, and strategies to tackle it, within Dumfries and Galloway - the first such regional site in Scotland. The address is www.dumgal.gov.uk/domesticabuse