Primary and maternity health care are particularly favourable settings in which to offer proactive identification of women affected by domestic violence and referral pathways to support services. Health practitioners within these settings have opportunities to detect and deal with injuries and symptoms related to domestic violence and can create a confidential and safe space in which to ask sensitive questions. There is potential for offering longer consultations and continuity of care and for developing a patient–provider relationship and a philosophy of care that promotes shared decision making and recognises the social aspects of health. This chapter is designed to help health practitioners think about the types of intervention feasible within their health care setting, and strategies for successful implementation.

Interventions require endorsement from senior clinicians and managers to help create and foster a ‘domestic violence aware’ culture. They also have an important function in endorsing change, such as the introduction of domestic violence clinical guidelines and training, and in identifying resources (e.g. staff, time and finances) so as to ensure the sustainability of any intervention. If there is no clinical lead for domestic violence, it is possible to incorporate the issue within an existing NHS lead role, such as safeguarding children or vulnerable adults. Even as a junior doctor, you can champion the issue in the department.

This is required in identifying and supporting women affected by domestic violence and before delivering any training programme. Sensitisation activities include: giving presentations or lectures on the prevalence and health impact of domestic violence and national policy recommendations surrounding it; inviting representatives from domestic violence specialist organisations to give talks; and discussing actual case studies of domestic violence in clinical meetings. Interested doctors and midwives can be part of this process; such clinicians are sometimes referred to as ‘clinical champions’ for domestic violence. You can be part of this process even as a junior in training. It is good practice for clinical champions to be formally recognised and supported in their activities by managers. They might undertake a literature search or a brief waiting room survey on domestic violence to collate local data on the extent of the problem and, as identified experts, they are also the liaison with local multi-agency domestic violence fora and crime and disorder-reduction partnerships. Observing or attending meetings can be a useful training opportunity for a junior doctor.

These provide clear guidance on interventions, maintain staff and patient safety, and deal with confidentiality and responsible information sharing. Guidelines might include asking questions about domestic violence of all women versus just those with risk markers. They ought to consider a safe system for documenting domestic violence in the patient record (whether/when the patient was asked about domestic violence, her response and any referral offered). This might be via printed notes, a ‘stamp’ or a pro forma. Particular care has to be taken with handheld notes or where information might not be ‘safe’ or confidential. Regular audits with feedback can be performed to motivate staff, implement change and monitor practice. Department of Health (2005) and National Institute for Health and Care and Excellence (2014) guidelines can be adapted to the local context. Make links with academics with expertise on gender violence and health in order to jointly apply for funding to conduct research. A junior might adapt a guideline, customise it locally and pilot, audit and implement it.

Many specialist domestic violence services offer training. Training, preferably mandatory, should take place within the health care setting. It should be delivered regularly in order to capture new and rotating staff. Experiential evidence shows that training programmes are best designed collaboratively between specialist domestic violence organisations and clinicians, who can comment on how best to introduce enquiry or documentation practices into their routine clinical care.

Case studies and research used in training should be relevant to the health care setting and trainers should take into consideration the practitioners’ clinical environment, roles and responsibilities. Health practitioners can provide examples of actual domestic violence cases for discussion in the training. Pre-training assessments are recommended, as different members of staff will have different skills, knowledge and experience, and will require different levels of training. Learners can be motivated by being informed that they will become more skilled practitioners, equipped to ask deeper questions about ‘what’s going on at home’ – particularly with those patients who do not attend, do not comply, have complex needs or discharge themselves against advice. They will learn that these are not ‘difficult patients’, but patients with difficult problems.

Training has to be department-wide in order to ensure competence of the whole team. Using clinicians as co-trainers helps to gain acceptance, as they model good practice and can legitimately deal with staff resistance. Consider incentive schemes such as linking the training to continuing professional development. Reinforcement training activities such as sharing good practice in dealing with domestic violence cases and updates from trainers are important to sustaining change.

Appropriate pathways for women affected by domestic violence depend upon what services and resources are available locally. Whether health practitioners are proactively identifying domestic violence or not, they must establish links with local organisations to which they can refer women and children affected by abuse.

A number of models have been tested in primary and maternity care settings in Europe (see Boxes 25.1, 25.2 and 25.3). Other examples that might be adapted can be found in a recent scoping study, which identified best practice recommendations for implementing and sustaining interventions (Bacchus et al., 2012). Finally, a recent systematic review provides the international evidence for interventions in health care settings. This needs to be referenced as Feder et al. 2009 which is in the reference list so that people know how to access it