Reassessing the NICE guidelines on domestic abuse: Adapting to changing realities

Vasumathy Sivarajasingam is a GP in West London and an Honorary Clinical Research Fellow at Imperial College London. She is also the Northwest London Primary Care Clinical Lead (Ealing Borough) for Green Agenda, Adult Mental Health, and Patient Engagement. She is on X: @vasu2776563

In the dynamic realm of healthcare provision, guidelines, and protocols must evolve to mirror societal shifts and legislative updates. The National Institute for Health and Care Excellence (NICE) guidelines on domestic abuse¹ (DA), must now bear scrutiny amid significant changes in our society and legal frameworks.

What Does NICE Recommend Regarding DA?

NICE advocates for several key actions to effectively address DA. Firstly, individuals displaying signs of potential DA should be approached for a private discussion to enquire about their experiences, with a priority placed on privacy and safety. Secondly, those enduring such abuse should receive support from staff trained at either level 1 or level 2, underlining the necessity for adequately trained personnel to handle these delicate situations. Moreover, individuals affected by DA should be offered referrals to specialised support services, emphasising the importance of providing comprehensive assistance beyond immediate intervention. Lastly, individuals admitting to perpetrating DA should also be directed to specialised services, showcasing a commitment to addressing the issue comprehensively, including prevention and rehabilitation. These quality statements collectively form a framework for ensuring a compassionate and effective response to DA within frontline services.

Why Should NICE Guidelines Be Re-evaluated?

The onset of the COVID-19 pandemic has ushered in an era marked by remote consultations and digital communication. This transformation, driven by the NHS Long Term Plan’s emphasis on digitalisation,² has reshaped professional relationships in healthcare. Once considered a niche practice, digital consultation has now become mainstream, offering a sustainable solution to meet the increasing demand for healthcare services while improving access to primary care.

The current NICE guidelines on DA were formulated in 2016, a time when face-to-face consultations were predominant. These guidelines advocate for clinicians to have a low threshold for probing about DA when indicators of abuse are present. However, they fail to address the challenges encountered by clinicians in broaching the subject of DA during remote and digital consultations. This omission becomes especially pertinent as violence and abuse, whether physical or psychological, can lead to long-term mental health issues for survivors.³ Yet, many survivors may not recognise⁴ or be willing to disclose their experiences of abuse, leading to cases being overlooked or unaddressed, particularly in settings where non-verbal cues are limited.

It is crucial to not only encourage patients experiencing DA to disclose their experiences but also to facilitate an environment where clinicians can ask appropriate questions that encourage survivors to come forward. While the current guidelines encourage clinicians to enquire about DA, they historically refrain from recommending routine screening in primary care settings. Implementing routine screening is cost-effective⁵ and aids in early identification, thereby empowering survivors and preventing crises.

The introduction of the Domestic Abuse Act 2021⁶ has introduced significant changes to the legal framework surrounding DA. This act recognises children under the age of 18 as victims of DA if they witness, hear, or experience its effects. However, the 2016 guidelines do not fully align with these updated legal definitions, provisions, and requirements. Healthcare professionals are now tasked with integrating the legal definition of DA into their practice, navigating complex issues such as information sharing while upholding patient confidentiality.

Our understanding of DA has evolved over time, with the recognition of its multifaceted nature, including forms such as coercive control and those facilitated by technology. However, the 2016 guidelines may not fully capture these nuanced understandings, potentially leading to gaps in how healthcare professionals identify and respond to DA cases. Additionally, while the guidelines acknowledge the diverse needs of survivors, they may not explicitly address intersectionality, which considers how various social categorisations intersect to create unique experiences of discrimination or disadvantage. Therefore, a comprehensive approach to addressing DA within diverse populations is warranted.

How Should the NICE Guidelines Be Updated?

Healthcare professionals must receive comprehensive briefings on the latest legislation, with specific reference to the Domestic Abuse Act 2021 in the revised guidelines. This update should explicitly acknowledge the Act’s inclusion of children under the age of 18 as victims of DA, and emphasise the relevance of this legislation to risk assessment and safety planning efforts within both legal proceedings and support services.

Additionally, guidelines should emphasise the importance of trauma-informed care, cultural sensitivity, and intersectionality in addressing DA, ensuring that healthcare professionals are equipped to provide comprehensive support to survivors from diverse backgrounds. Furthermore, specific guidance on how to navigate digital consultations and effectively discuss sensitive topics such as DA should be included to ensure that healthcare professionals can adapt their practice to changing healthcare delivery methods. Mere recognition is insufficient; there needs to be a significant shift in mindset and practice.

Implementing routine screening for DA in primary care settings could aid in the early identification of DA cases, empowering survivors and preventing crises. To achieve this, healthcare professionals, including primary care teams, should undergo mandatory training on effectively addressing DA during digital and remote consultations. Utilising screening tools may prove beneficial in navigating challenging cases of DA.

The current NICE guidelines on DA, initially formulated in 2016 during an era when consultations predominantly occurred face-to-face, fall short of addressing the complexities of modern healthcare delivery and the evolving legal landscape. As we embrace digitalisation and adapt to changing legislative frameworks, healthcare professionals must redouble their commitment to safeguarding and supporting survivors of DA. By aligning with the new legal framework and embracing advancements in practice we can better help those affected by this pervasive issue.

References:

1. National Institute for Health and Care Excellence. Domestic violence and abuse. QS116.2016. https://www.nice.org.uk/guidance/qs116 (accessed 14 Apr 2024).
2. NHS. Digital transformation. https://www.longtermplan.nhs.uk/areas-of-work/digital-transformation/ (accessed 14 Apr 2024).
3. Royal College of Psychiatrists. Violence and abuse are driving mental illness in women and girls, psychiatrists warn. London: Royal College of Psychiatrists; March 2024 Available from: https://www.rcpsych.ac.uk/news-and-features/latest-news/detail/2024/03/08/violence-and-abuse-are-driving-mental-illness-in-women-and-girls–psychiatrists-warn (accessed 14 Apr 2024).
4. Sivarajasingam, V., Webber, I., Riboli-Sasco, E. et al. Investigating public awareness, prevailing attitudes and perceptions towards domestic violence and abuse in the United Kingdom: a qualitative study. BMC Public Health 22, 2042 (2022). https://doi.org/10.1186/s12889-022-14426-9 (accessed 14 Apr 2024).
5. Chen PH, Rovi SR, Pan KY, Johnson MS (2013) Costs Effectiveness of Domestic Violence Screening in Primary Care Settings: A Comparison of 3 Methods. J Community Med Health Educ 3:253. doi: 10.4172/2161-0711.1000253 (accessed 14 Apr 2024).
6. UK Government. Domestic Abuse Act 2021. 2021. https://www.legislation.gov.uk/ukpga/2021/17/section/1/enacted(accessed 14 Apr 2024).

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