A Cry for Health

Why we must invest in domestic abuse services in hospitals

This page is about the Themis research project and its final report, A Cry for Health. In November 2012, Themis was launched as the first research project of its kind in the UK. It set out to explore the impact of co-locating Idva (independent domestic abuse advisor) services in hospitals. The aim was to develop the evidence base to highlight the benefits of stronger links between the health sector and domestic abuse services through innovative models.

A Cry for Health builds on the findings of SafeLives’ report, Safety in Numbers, which recommended that the health response to domestic abuse needed to be strengthened. The report summarised extensive research into the negative impact of domestic abuse on the physical and mental health of women with both short- and long-term health consequences. In SafeLives’ report, Getting it Right First Time, nearly a quarter (23%) of victims at high risk of harm and 1 in 10 victims at medium-risk went to Accident and Emergency (A&E) because of acute physical injuries. In the most extreme cases, victims reported that they attended A&E 15 times.

  • £1.73 billion

    is the calculated cost of domestic abuse to the NHS

    (with mental health costs estimated at an additional £176 million)

  • £15.7 million

    would be the cost of securing a team of specialist Idvas for every NHS acute provider in England

If domestic abuse were to be responded to effectively when identified in hospital, wider and more detrimental costs could be minimised and harm to victims and children avoided. In the current climate of budget cuts, the value of researching, smarter and more cost-effective interventions for domestic abuse is obvious. Evidence from research studies exploring the effectiveness of health professionals asking about domestic abuse shows that without a service to which they can immediately refer, such as a hospital-based Idva service, the opportunity to intervene will be ignored or ineffective.

SafeLives initiated the research across four geographical areas, examining five English hospitals that had adopted the approach of locating specialist domestic abuse services within their A&E and Maternity units. In each of the four areas, a comparison group of domestic abuse victims from a community domestic abuse service was also recruited. We interviewed: hospital staff, hospital-based Idvas, Idva Service Managers and Commissioners at all sites to understand how the service works in practice, and establish learning points in relation to the effectiveness of the model.

A Cry for Health presents the first multi-site evaluation of hospital-based specialist domestic abuse services conducted in the UK. The project reached a total of 692 hospital victims and 3,544 community victims in the three years we were collecting data.

Read the final report: A Cry for Health

We found people we were identifying through A&E were not known by other services.

Comissioner, Cry for Health

Key findings

It makes neither human nor financial sense to ignore the needs of victims and their children – and without this provision, we will continue to fail people who most need help. We have listed the research key findings below. For more details on these and additional context,  see our full policy report, A Cry for Health.

Health and domestic abuse are inextricably linked.

Domestic abuse has a profound and long-term impact on our physical and mental health. And victims who seek medical assistance are more likely to have mental health difficulties, substance misuse issues and additional vulnerabilities.

Our research found that

  • Our research found that

    of victims identified in hospital had mental health concerns

    compared with 35% of victims who engaged with a community service

  • Our research found that

    of victims identified in hospitals had post-traumatic stress disorder (PTSD)

    compared to 6% of community victims of domestic abuse

  • Our research found that

    had been to A&E for an overdose in the last six months

    compared to 3% of community victims

We need to address mental health issues as well as the domestic abuse that victims are suffering.  Unless we do this, our current efforts to reduce one or the other will be seriously undermined.

Domestic abuse isn’t just about the injuries we can see: the hidden harm to victims and children is even greater.


We are missing opportunities to support victims and reduce the impact on their health and wellbeing.

This issue cannot and should not be dealt with by the police alone. The Crime Survey England and Wales found that four out of five victims do not call the police. Health professionals are ideally placed to identify victims; our research found that 56% of hospital victims had accessed A&E in the year before getting help. These missed opportunities to intervene are especially important for victims who are not in contact with other agencies.

Our research showed clearly, that without the provision of specialist support to respond to a disclosure of domestic abuse, clinical staff are unlikely to ask about it.

Currently, victims go to hospital, visit their doctor, talk to their midwife. And yet all too often, we are not asking the question. In about half of cases, victims are being discharged back into the arms of the perpetrator who put them there.


Domestic abuse already puts enormous strain on our NHS. With a small investment, we can unlock the potential in our health service and make victims safer, faster.

Domestic abuse costs £1.73 billion to the NHS already. Our doctors and nurses already do an incredibly tough job. We cannot expect them to find the time and space to ask the question, in the right environment that supports a victim to disclose, without specialist services to refer onto. We must have clear referral pathways to specialist domestic abuse provision with the training and focus to reassure victims and support them in their long journey to being safe and well.

Our research has found that it would only cost £15.7m for every NHS acute provider to have a robust Idva service. That is £100,000 per hospital. It would provide help for 15,000 additional victims a year.

A Cry for Health report

There is no point asking the question if we’re not going to do something about it. It’s like opening a nasty cut and not doing anything about it.


We do leave a lot of work to them [Idvas]... They do so much more with patients than we could ever dream of doing because of time. Their role is so important. I don’t know what we would do without them.

A&E Consultant, Cry for Health

About hospital-based Idvas

The role of the hospital-based Idva:

  • To provide immediate support and advice to victims of domestic violence within hospital
  • To link individuals and families to longer-term community based support
  • To provide hospital staff with expert training so that they have the confidence to ask about domestic abuse

Immediate support and advice

Victims of domestic abuse in hospital are often in the immediate aftermath of a crisis: severe physical assault, drug/alcohol related medical needs, attempted suicide or self-harm. The risk of immediate harm must be reduced; particularly when hospital release is imminent (half of the clients in hospital are still in a relationship with the perpetrator which means they face additional risk).

Hospital Idvas provide practical support, empathy and understanding. The safety needs of the client are paramount, as well as ensuring longer term community support. The Idva may:

  • liaise with the police regarding bail conditions/remand,
  • engage with housing and refuge providers,
  • work with community and hospital-based mental health/drug/alcohol services,
  • organise applications for civil remedies,
  • refer to adult and/or children’s social care (both within and outside of the hospital)

The aim of the hospital Idva is to reduce the risk of further harm and homicide, and to ensure that specialist community-based support is sustained.

Linking victims and their children to the support they need

When an individual is assessed as being ‘high risk’, an Idva will ensure that the victim is referred to the Marac. They will act as an advocate for their client within a multi-agency context, supporting the client to access safety as well as working with longer terms services such as outreach based in the community.

Providing expert training, advice and support to hospital staff

In hospital environments where staff turnover is high, training should be embedded as a core aspect of the Idva role. It should be delivered in multiple forms such as regular safeguarding training, drop-in sessions, workshops and staff inductions. The content will vary, but may include: the dynamics of domestic abuse, the stages of change, the relationship between domestic abuse and complex needs (drug and alcohol, mental health, disabilities, age, pregnancy) medical signs and symptoms of abuse, effectively asking about abuse and responding to disclosures, risk and referring to Idva and the Marac process. It is advised that training also includes Information Sharing and Confidentiality Guidelines for high risk cases or cases where there are adult or child safeguarding concerns. Effective training will translate into confident staff who feel able to ask about domestic abuse safely and also typically results in staff disclosures.

About Idvas in maternity units

More about our work on health and domestic abuse

A Cry for Health report

Report outlining the current response to domestic abuse victims in hospitals and the benefits of investing in hospital-based Idvas.


A national project to transform healthcare's response to domestic violence and abuse by ensuring a coordinated and consistent approach across the health system.

Whole Health London

A three-year project on a whole health approach to transform the health response to victims and perpetrators of domestic abuse across the capital.

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