Despite the fact that an HIV diagnosis is no longer, as it was 30 years ago, a death sentence—indeed, those infected and properly treated will probably have a normal, healthy lifespan—problems, as we heard during the debate, remain. One is prevention, as my noble

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friend pointed out, and the other is ensuring ever-higher levels of testing. On prevention, there is a great deal of hope and optimism with the development of pre-exposure prophylaxis presenting incredibly exciting opportunities. Although it has been available in the US for some time, it is not yet here, but should, I believe, be available to all those at risk in the UK as soon as possible. As Yusef Azad at the National AIDS Trust—and I pay tribute to its work—put it to me, the very recent PROUD trial looking at the impact of pre-exposure prophylaxis here,

“is a prevention game-changer which we cannot afford to ignore. As a much needed addition to—not substitute for—condom use, its costs are modest when compared with the lifelong costs of treating someone with HIV if we fail to prevent their infection”.

He is absolutely right, and I hope that NHS England will heed those wise words. Action sooner rather than later will save not just lives, but money too. I support everything that my noble friend said. It must be Mickey Mouse economics to spend so much on treatment and so little on prevention.

Similarly, there has been much progress on testing, as we have heard, but the figures for late diagnosis—still above 40%—are shockingly high. To tackle that, I hope that, among other things, the NICE public health guidance recommending that high-prevalence local authorities commission HIV testing to be offered to all those admitted to a hospital and all those registering with a GP is implemented soon. The Government and Public Health England can play a powerful leadership role, and I would be grateful if the Minister could take the lead today in calling for such important initiatives to be implemented.

Of course, key to both testing and prevention is the ongoing problem of stigma. The National AIDS Trust survey on public attitudes published in December last year still makes very depressing reading. If anything, public knowledge and attitudes seem to be deteriorating, and we need to take action to reverse that, otherwise, all the good work on testing and prevention could be in vain. This is, of course, a matter that goes well beyond central government, but local government, the NHS and schools all have a role to play. The Government can, again, take a lead, and I know that the Minister, who has done so much to help in this area in the past, will take up that challenge and this afternoon energise all those involved to redouble their efforts to tackle stigma.

I am conscious that there are no noble Baronesses speaking this afternoon, undoubtedly because of the clash with the debate on International Women’s Day, but I want to say a word or two about the special issues still faced by women with HIV and to cast a quick glance beyond our own shores to where the situation for people with HIV is still incredibly difficult and in some cases horrific. I commend an excellent report published in the past few months by the Salamander Trust, which last summer conducted a global survey on the sexual and reproductive health and human rights of women living with HIV. Of those who responded in a survey that took place in 94 countries, a shocking 89% reported that they had experienced violence or fear of violence since or because of their diagnosis— in their homes, in their communities and even, most appallingly of all, in healthcare settings. Only 50% of

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respondents found their healthcare service providers to be well trained and knowledgeable about their condition. A significant number emphasised the challenges of poverty and the resulting strain that it places on mental as well physical and sexual health. It is little wonder that 80% of respondents reported experiences of depression, shame, loneliness and feelings of rejection.

The report contains a wealth of recommendations about how to improve the specific condition of many women across the globe living with HIV. I hope that the Government will be prepared to support such recommendations. It is an initiative that the Commonwealth in particular could pursue. Progress may be slow—I think that we all understand that—but this is a tangible way in which we could help improve the lot of thousands of lonely, frightened and vulnerable people across the globe.

As so often in debates on this subject, there is much significant progress to applaud and great hope and optimism, but there are problems, too: in tackling stigma in particular. There are serious challenges beyond our shores in tackling the criminalisation of homosexuality, which is turbo-charging the HIV epidemic in much of the world, in dealing with the special problems faced by women with HIV and in ensuring access to healthcare for all who need it. As I said earlier, some of those issues will take time to tackle, but I hope that this debate will again spur us to redouble our efforts both here in the UK and in the wider world one day to bring to an end a horrific epidemic which has already claimed too many lives and will yet claim many more.

4.36 pm

Lord Collins of Highbury (Lab): My Lords, I, too, pay tribute to the noble Lord, Lord Fowler, for his outstanding work on HIV and AIDS both here and globally, advocating action on prevention, treatment and care while attacking discrimination and stigma. As we have heard in this debate, it is estimated that 35 million people are living with HIV worldwide, with 1.5 million AIDS-related deaths in 2013. Here, 6,000 people were diagnosed as carrying the HIV infection in 2013, and 320 people were reported as having AIDS. An estimated 107,800 people are now living with HIV.

As we have heard in the debate, the UK is one of the world’s leading funders of global health. If we are to move beyond investments to control HIV and towards eradication, we desperately need new tools. Where there is an affluent market, as is the case with adult HIV drugs, we can see significant private investment. By contrast, there are very few formulations of paediatric HIV drugs, where the market is smaller and more heavily based in developing countries. UNAIDS highlights the fact that only 24% of children living with HIV currently have access to HIV treatment. Will the Minister support within government the recommendation from the HIV/AIDS APPG that the UK commissions an economic paper to contrast the total costs of developing and purchasing medical tools using the current R&D model with the costs of a delinked model?

As was asked by other noble Lords, including the noble Lord, Lord Crisp, can the Minister explain how the Government will address the growing problem in

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middle-income countries whereby funding is being pulled out from all directions, including from the Global Fund, while the pharmaceutical industry continues to expect MIC Governments to afford higher prices for ARV treatment?

In England, the Health and Social Care Act changed the commissioning and monitoring of HIV prevention, testing, treatment and care services. Conditions that require specialist expertise and medication are the responsibility of NHS England, including HIV treatment. In its Five Year Forward View, NHS England states that it plans to let local commissioners share responsibility for commissioning specialised services, incentivising them to direct funding towards local priorities.

Naturally, many patient groups are concerned about the impact on service standards leading to a possible postcode lottery. Their concern is heightened by the fact that there are so many outstanding questions about what co-commissioning will look like and no specific announcements related to HIV. What steps will the Minister take to ensure that the overall responsibility for the provision of services is clearly defined? It is also vital that standards of care are maintained across the country.

As we have heard in this debate, particularly from the noble Lord, Lord Fowler, the Government have funded national HIV prevention programmes since 1996. In recent years, funding for these programmes has been progressively reduced. The current English national prevention programme HIV Prevention England—HPE—has been funded for three years until the end of March 2015. Funding for HPE is £2.4 million per year, which is less than the combined funding received by the previous prevention programmes in 2011 and 2012. In December 2014, the Government indicated that they intended to reduce funding for HPE by 50% to £1.2 million for 2015-16.

That decision was criticised by many organisations, who led a public campaign seeking reconsideration, and shortly afterwards it was reversed and a commitment made to fund the programme at current levels for a further year. Will the reallocated budget support a new programme of work or existing activities that are currently paid for with other budgets?

In addition to the national HPE programme, local authorities should be investing in complementary prevention initiatives as part of their public health responsibilities. However, National Aids Trust research shows that less than 0.1% of local funding allocated to public health in high HIV-prevalence areas is being spent on primary HIV prevention. A total of about 1.2 million men have sex with men and black African adults living in England. A budget of £1.2 million means that the national programme has only £l to spend a year for each person in its target audience. Does the Minister believe that that is enough to achieve the programme’s objectives? The estimated lifetime cost of treating someone with HIV is £360,777. That means that even if a £2.4 million programme prevented only seven new transmissions a year, it would save the NHS money. Is there not a strong case for increasing the funding rather than cutting it?

Finally, I raise the issue of pre-exposure prophylaxis—PrEP—to which the noble Lord, Lord Black, referred. Really impressive research from England was released

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last week. I read it at the international retrovirus conference in Seattle. The study recruited men who have sex with men and trans women who were at elevated risk of acquiring HIV. They had multiple partners; condom use was inconsistent or irregular; rates of sexually transmitted infections were high; many participants had needed post-exposure prophylaxis before and recreational drug use was common. Participants were generally well-educated and in full-time employment. The fact that the study has demonstrated such a high and statistically significant level of efficacy with a few hundred participants tells us both about how effective PrEP is and how high the rate of infection is in some groups of gay men.

What is being done to ensure that this highly effective HIV-prevention intervention is made available to those who need it without delay? What work is being done to ensure that prescribing of PrEP is appropriately targeted to those who are most likely to benefit from it?

4.45 pm

The Parliamentary Under-Secretary of State, Department of Health (Earl Howe) (Con): My Lords, I am most grateful to my noble friend for today’s debate on this important issue. All of us know how much he personally has done to ensure that HIV and AIDS remain firmly on agendas, both at home and abroad. I may not be able to give him a medal, but I congratulate him on his book AIDS: Don’t Die of Prejudice, which is very timely and draws on his great experience. It is most welcome given that there is still, as we have heard today, much to do around the world to reduce the stigma and prejudice associated with HIV. I welcome, too, his appointment as a member of the International AIDS Vaccine Initiative.

Compared with many other countries, HIV prevalence in the UK remains relatively low: just under three per 1,000 of the adult population were living with HIV in 2013. Thanks to the Government’s early efforts and the leadership of my noble friend back in the 1980s, we have been spared the higher prevalence rates seen by other European countries and countries in other continents. Our confidential sexual health clinics are doing more and more HIV tests—more than a million in 2013, up 5% from 2012. The NHS continues to provide excellent, high-quality HIV treatment and care for everyone, with 90% having an undetectable viral load. Diagnosed early, the outlook for people with HIV in the UK is very good and most people can expect a near normal life expectancy. We also benefit from government’s sustained investment in Public Health England’s comprehensive HIV surveillance systems.

A 2014 report for the National AIDS Trust by Ipsos MORI reported that overall public support for people with HIV is higher than ever, with 79% of adults agreeing that people with HIV deserve the same level of support as people with cancer. Today, it is much easier to get an HIV test, with virtually all NHS sexual health clinics providing the option of same-day testing results. Like many other countries, we have virtually eliminated mother-to-child transmission of HIV.

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However, we are acutely aware that challenges remain in how we tackle HIV. Although overall HIV prevalence in the UK is very low, there are marked variations. In London, HIV prevalence in men who have sex with men—MSM—is much higher, and in 2013 one in eight men were living with HIV, compared to one in 26 outside London. In 2013, the prevalence rate of HIV was approximately 30 times higher for MSM and black African men and women compared to the general population in England. New diagnoses in MSM continue to increase, with 3,250 MSM diagnosed in 2013. Some of this increase will be due to increased testing but there is evidence of increasing risk-taking behaviours, which prevention services and community groups must address, taking into account the latest research and evidence. Achieving sustained changes in risk-taking is challenging for all.

Today, HIV prevention is just as important as it was in the 1980s. Investment in prevention also makes good economic sense, as noble Lords have argued, given that each new HIV infection represents between £280,000 and £360,000 in lifetime treatment costs alone. I will pick up a point made by the noble Lord, Lord Cashman. Although we have excellent NHS HIV treatment and care services, and antiretroviral treatment is highly effective, we are still seeing too many people diagnosed late, after treatment is recommended. This means they are unable to benefit from that treatment and risk transmitting HIV to their partners. Although we have seen improvements, HIV still attracts stigma, which is unacceptable and can deter people from getting tested and, if positive, taking their medication. I listened with care to my noble friend Lord Black on that theme.

In 2013, the department published A Framework for Sexual Health Improvement in England, setting out our ambitions to improve sexual health and well-being for all. These include reducing the rate of sexually transmitted infections, including HIV, using evidence-based prevention and treatment initiatives; tackling HIV through prevention, including increasing access to testing to enable earlier diagnosis and treatment; and tackling the stigma, discrimination and prejudice often associated with sexual health and HIV.

Late diagnosis is included as an indicator in the public health outcomes framework and progress is being monitored. Since we published the framework, we know that HIV testing services are changing and becoming more innovative and focused around the needs of people. A good example of that is self-sampling HIV tests to reduce undiagnosed and late diagnosis of HIV.

Self-sampling HIV test schemes, such as those provided through the HIV Prevention England programme and the 56 Dean Street clinic in Soho, show that new types of tests are acceptable. Importantly, they appeal to people who choose not to use traditional services, and they are picking up undiagnosed HIV. An assessment of more than 4,000 people using self-sampling HIV testing services in November 2013 indicated that the majority had never had an HIV test, yet were reporting high-risk behaviour. It is encouraging that the rates of late diagnosis are improving, albeit slowly—down from 57% in 2004 to 42% in 2013. However, I agree that we

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need to do more to reduce this. Last year, we removed the ban on the sale of self-testing kits, which will eventually provide further options for testing.

Healthcare services, including general practice, especially in high-prevalence areas, have a key role in offering HIV testing. We were pleased to fund the Medical Foundation for HIV & Sexual Health to produce a web-based interactive tool to make testing easier in primary care. That was launched by MEDFASH last November.

Finally, my noble friend Lord Fowler referred to the prevention budget. We are committed to protecting the national HIV prevention budget for next year. I agree with him that we will need to be more ambitious and innovative in our plans to prevent the spread of HIV. We will be announcing our plans very shortly and these are likely to include a contract with the Terrence Higgins Trust for the HIV Prevention England programme, but we are also keen to be more innovative and ambitious in our response. At that time, the answer to one of the questions posed by the noble Lord, Lord Collins, will become clearer.

I will endeavour to answer as many questions as I can in the time available but I will of course write to noble Lords whose questions I cannot answer today. The noble Lord, Lord Collins, referred to a lack of clarity, as he perceives it, in the overall responsibility for commissioning these services. We recognise that the public health and NHS reforms have presented some challenges for sexual health services, and a number of actions have been taken or are planned. Public Health England has worked with partners, including the Local Government Association, and last summer published Making it Work: A Guide to Whole System Commissioning for Sexual Health, Reproductive Health and HIV. It is planning to undertake a review of commissioning arrangements for sexual health and HIV, similar to the one just published for drugs and alcohol.

My noble friend Lord Fowler called for a new campaign to promote testing. As I mentioned, the level of testing in sexual health clinics is increasing, which is encouraging. More than 1 million tests were carried out in 2013, which was an increase on the previous year. I agree that that level needs to increase, with action by local authorities, especially in high-prevalence areas. We need to offer new ways of testing, as I mentioned—for example, home sampling.

The noble Lord, Lord Cashman, rightly said that engagement with HIV charities was vital in determining the way forward. We see 2015-16 as a transition year towards a longer-term plan for sexual health promotion and HIV prevention. Public Health England will engage with key stakeholders on their new strategy, and my department has been discussing 2015-16 contracts since last November.

My noble friend Lord Black mentioned stigma. I remind us all that it is not just the NHS or the Government who have a role to play here, it is everybody. Community and faith groups, the media and individuals all have a part to play in eliminating HIV-related stigma. We should not forget some of the good news, part of which is that people with HIV are now protected by UK equalities legislation. The department’s framework for sexual health improvement is clear that there is a

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need to build an honest and open culture, where everyone can make informed decisions and responsible choices about relationships and sex.

The noble Lord, Lord Cashman, referred to the role of local authorities. We believe that local authorities are best placed to make decisions on investment in HIV health promotion services and primary prevention services. Reducing the late diagnosis of HIV is included in the public health outcomes framework, as I mentioned. We have provided local authorities with £8.2 billion of ring-fenced funding for public health, including HIV prevention. I completely understand the arguments in favour of the ring-fence; it has played an important part in ensuring a smooth transition of services and will continue to apply through the next financial year. We have always intended to review the need for it after that. We will do that during discussion on the next spending round, but of course it is for the next Government under the ensuing comprehensive spending review to decide on the continuation of the ring-fence.

In primary care, there is evidence that HIV testing is acceptable to patients and healthcare professionals. My department was pleased to fund the Medical Foundation for HIV & Sexual Health for its HIV testing in primary care project, launched last November.

I just mention the issue of PrEP and Truvada, referred to by my noble friends Lord Fowler and Lord Black and the noble Lord, Lord Collins. The recent results from the trial are encouraging. Further work is needed, and NHS England has set up an expert committee to consider the results of the PROUD study and whether PrEP should be provided by the NHS. Some outstanding issues are being considered in that process which prevent us forging ahead immediately with any action. For example, there is the evidence supporting use in other higher-risk groups, such as black African groups, and whether the recommendation should be for daily treatment, as in the study, or only to protect individuals for a certain high-risk event. The service model is also important here. I can write further on that to noble Lords.

I hope that I can reassure my noble friend Lord Fowler on the continuation of methadone and reducing the harm that drug-taking can cause. Again, I shall write to him on that subject, as I shall to the noble Lord, Lord Crisp, and all those who have spoken about global issues. For now, my time is up. I thank all contributors for their expert speeches, to which I shall respond.

4.58 pm

Sitting suspended.

Women: Domestic and Mental Abuse

Question for Short Debate

5 pm

Asked by Baroness King of Bow

To ask Her Majesty’s Government what assessment they have made of the role that women’s refuge centres play in protecting victims of domestic and mental abuse.

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Baroness King of Bow (Lab): My Lords, I want to open this debate by considering the fundamental importance of housing. I always remember that when I first became an MP, I received a leaflet called “Don’t Make Me Laugh”. Because of very poor-quality housing three of the children living in a particular house in my constituency, which had dripping wet damp on all the walls, had bad respiratory and asthmatic conditions. The doctor had said to the mother, “You must make sure that your children don’t laugh”. The importance of housing should be seen as a fundamental public service, in the same way as education or health, because a successful housing policy is never just about bricks or mortar. This is particularly true when you add domestic violence to the mix.

As we all know, domestic violence accounts for one in four murders in British society—murders of a woman by her partner or ex-partner—and costs our economy an extraordinary £15.7 billion per annum. Just think of the waste, never mind the human misery, which is unquantifiable. I spoke at an event last night for Housing for Women. Its domestic violence helpline received 2,000 calls last year. It is just one small charity working in the area. Across the country, the police receive a call from a survivor of domestic violence every 30 seconds.

I initiated this debate because I have been particularly struck by the work of Women’s Aid, an incredible organisation which works to help women and children survivors of domestic violence. It is expert in the matter and it understands—and would like us and those in Government to understand—that we need a needs-led intervention for this issue. Critically, we need to help women and children achieve long-term independence. I want to say how much I welcome the Government’s announcement of new money, which I will come back to. The problem is that it is a short-term stop-gap measure. It is none the less clearly very welcome and I genuinely thank the Government for what they have done there.

The Women’s Aid annual survey found in 2014 that a third of all referrals to refuges were turned away. A third of those women who arrive looking for shelter and seeking refuge from violence, and sometimes despicable torture as well, were turned away. Women’s Aid would like to see a national network of specialist domestic violence refuges that are protected and have a new model of sustainable funding.

I begin with an example of a survivor case study because quite often when we talk about the human misery, the statistics do not quite capture the experience. I will give only one example; I have given many others in many other speeches on many other occasions. Mandy experienced 18 years of domestic violence at the hands of her partner, which included severe physical abuse, rape and humiliation in front of her children. Every element of her life was controlled by her partner. He made her leave her job when she got a promotion. She tried to escape on numerous occasions but he would track her down. He hacked into her medical files, broke into her property and repeatedly attacked and threatened the whole family until she went back.

Mandy’s eldest son witnessed a particularly horrific attack in which Mandy nearly lost her life. Her son was so traumatised when his father was let out of

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prison that he committed suicide rather than live in constant fear of his father coming back to get them. Without specialist refuges for Mandy to go to and services which understood the level of danger they were in, she does not think that she would be alive now. They provided not only a roof over the heads of her and her children, but specialist knowledge to help protect her from a dangerous perpetrator. They helped her to rebuild her life and gave her the ongoing support she needed.

That is what Mandy needed then. What we need now is a new model of funding and commissioning that promotes a sustainable service and high-quality care. Going back to what the Government have done, in November 2014 the Government responded to the SOS campaign by announcing a £10 million fund for specialist domestic violence refuges. The fund will seek to deal with some of the problems that I and others, including Women’s Aid, have pointed out, very vocally, around the need to keep refuges open, first and foremost, to ensure that non-local women are not restricted from accessing services and to improve what provision there is. As I have said, this £10 million fund is extremely welcome; however it will end in March 2016. This will impact Women’s Aid and the other incredible organisations up and down the country that seek to protect women in such terrible circumstances. These will be left in the same position that they were in last October: they have no long-term, sustainable funding.

This debate also touches on the issue of mental abuse and I want to flag up some of the issues there. Clearly, domestic violence has an enormous effect on one’s mental health. A third of all female suicide attempts and half of those by ethnic minority women are attributed to past or current experiences of domestic violence. Some 70% of women psychiatric in-patients and 80% of women held in secure psychiatric facilities have a history of physical or sexual abuse. That is an incredible figure. If we are to deal with those women who have the biggest problems, we need to deal with the issue facing 80% of them, which is a history of physical or sexual abuse. Clearly, the impact on children is devastating.

My noble friend Lady Thornton has previously highlighted cases in the south-west of England and in Chester West and Chester, where vulnerable women fleeing domestic violence no longer have access to specialist accommodation, or where numbers of women and children from outside local authorities are being capped. I know that the Government are aware of this issue. What will happen when this funding round ends? The Minister will also know that there are still authorities where services are not available to women from outside the area. Obviously, if one is fleeing a psychotic, violent perpetrator, one wants to get as far away as possible, not to be in the same authority.

In Northamptonshire, the county council planned to cut all its support for domestic violence refuges. After a successful campaign with Labour colleagues and the refuges themselves, the council backed down. However, the funding has been reduced, especially for Nene Valley Christian Family Refuge, one of the few organisations in the area to support women. It helps women who have been brought over for arranged or forced marriages and who are especially vulnerable.

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I trust that the Minister shares my concern that such vital services are being put at risk. What advice does he have for refuges that are seeking long-term funding beyond 2016? Does he agree that we need a new, sustainable model? Does he agree, in particular, that if we focus only on high-risk victims, we fail to appreciate the fluid nature of risk? We need to look at need as well as risk or we will not get a full picture.

Finally, in the time remaining, will the Minister make a statement on the Government’s understanding of the gendered nature and impact of abuse? Too often, the professionals charged with dealing with this subject, as we saw in the Statements to Parliament this week on child abuse in Oxfordshire, are simply not aware of how their decisions endanger vulnerable people, often young women. Those experiences lead to a lifetime of catastrophe. I truly thank the Government for averting catastrophe for some women like Mandy, but should we not do more to avert catastrophe for all women like Mandy?

5.10 pm

Baroness Newlove (Con): My Lords, I thank the noble Baroness, Lady King, for drawing the Committee’s attention to the plight of women and men who experience domestic abuse, and the availability of refuges for them. In my role as Victims Commissioner for England and Wales, I have met many women who have suffered almost unimaginable abuse at the hands of their partners and have been faced with homelessness as a result. The Government’s commitment to assist women, and in some cases men, to escape the abuse that they are suffering is admirable. However, it is clear that more needs to be done.

We hear a lot about statistics relating to the prevalence of domestic abuse. We know for example that: one in four women will experience domestic violence or abuse at some point in their lives; that almost 100 women are killed every year as a result of an act of domestic abuse; and that on average a domestic abuse victim will attempt to flee the perpetrator several times before they successfully manage to do so. Local housing authorities have a clear duty towards victims of abuse. Housing and accommodation provide a pivotal role in making sure that victims can be made to feel safe by providing them with a refuge from the abuse they are suffering.

There is a real problem in the availability of accommodation for women escaping abusive partners. While there are many refuges undertaking commendable work, they are buckling under the pressures of being able to provide a place of safety for all victims who need it. The lack of availability at refuges across England and Wales tells a sad story. Knowing that a victim can access such services might help them to feel more able to escape their abuser. However, where victims are continually being told that there is insufficient space for them at refuges, or where housing authorities are unable to provide appropriate accommodation, this important lifeline presents an increased risk that the victim will remain where she is and possibly risk her life by continuing to stay with the perpetrator.

I commend the Government’s recent funding of £10 million and I was heartened to see that the bidders had to demonstrate how they could develop sustainable

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services for victims, together in partnership with other authorities and sector specialists. In all the work that I do with communities and victims of crime, I have always said that valuable partnerships need to be sustainable partnerships. While domestic abuse victims need to know that they have a safe place through the provision of a refuge space or alternative housing accommodation, they must also be able to have access to other support services that are needed as a result of being in the refuge. I am not suggesting that specialist and support services need necessarily to be co-located at refuges or local housing centres, but the wide range of services and support that a victim will need when they have left the perpetrator are properly recognised. This will also include financial support and legal advice. In addition, it is likely that some women may also need help and support to manage or treat mental health issues as a result of any mental abuse they have also experienced during an abusive relationship.

We are all aware of the different forms that domestic abuse can take. Some victims will experience mental health issues as a result of the abuse they are suffering and some victims may in fact be abused because they have a mental health condition. Abuse can also very often worsen an existing condition. It is so important that any refuge provision or alternative housing solution recognises this and can facilitate intervention from mental health professionals where needed. The noble Baroness, Lady King, highlighted the outstanding work of Women’s Aid. Figures from Women’s Aid reports show that domestic abuse is the most prevalent cause of depression, anxiety and other mental health difficulties in women. It is so sad to hear that 70% of women psychiatric in-patients and 80% of those in secure settings have a history of physical or sexual abuse. It is all well and good for there to be an increase in the quality of refuge and alternative accommodation provision, but what really needs to be in place is a recognition of what specialist support women need to help them when they leave an abusive partner.

Staff at refuges should be required to complete training on mental health awareness so that these issues can be identified and victims assisted in accessing the right services for their specific needs. I do not wish to criticise the few services that do exist to help women accessing mental health support when they are placed in refuges or alternative accommodation. Rather, what I am trying to say is that we must not lose sight of the fact that some women are so traumatised they may not realise that they need specialist support in addition to a housing solution.

I do not consider myself to be a professional politician or a policymaker. My experience comes from being a victim of crime and seeing how agencies do not work together. In fact, I stand here today in this debate still going through those issues. I do not pretend to have all the answers, but from meeting and speaking with many victims of domestic abuse, I know that it is a complex and emotional issue which cannot be resolved by a one-size-fits-all response. This is why it is important that the Government consider how such support can be provided across the board so that victims of domestic abuse can be kept safe from further harm and further traumatisation through providing quality practical support. The biggest obstacle to this is that government

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departments, such as those responsible for homelessness, health and social services issues, do not seem to join together to address this issue. This simply is not good enough. There needs to be joined-up support across all the agencies, and women must be supported to grab the whole of their problems in the order that makes most sense to them.

The fact that we are having this debate today shows how we and society have moved forward in speaking about and recognising the nature and prevalence of domestic abuse, more so perhaps than previous generations. However, I know we can often become desensitised and be made complacent by facts and figures. We must remember that there is a real person behind each of these figures who has suffered, and continues to suffer, dreadful abuse despite the very best intentions of government and policymakers.

I am sickened and saddened by the numbers of domestic abuse victims suffering from mental health issues, more so when I hear that there is little funding available for those who can provide the services and specialist help to support these victims. I know the feeling of not feeling safe outside your home, and for these victims to not feel safe inside their homes because of the horrific abuse received by their partners must be hell on earth. These victims need to be listened to, and their experiences understood, to ensure that the most appropriate support can be identified for them. In doing so, we will provide a co-ordinated, accessible response which genuinely makes a difference to their lives.

5.19 pm

The Lord Bishop of Derby: My Lords, I, too, congratulate the noble Baroness, Lady King, on securing this debate. I shall offer a brief case study and try to highlight some of the issues that we need to consider together. The contributions of the noble Baronesses, Lady King and Lady Newlove, and the briefing pack graphically show the scale and challenge of this issue.

To escape from domestic violence and mental abuse, people need safe space, because that is what they do not have, which is what is so destabilising. I shall explore what safe space looks like and how we might try to provide it securely so that it is genuinely safe. In Derby, where I work, an excellent organisation, Refuge, won a contract in November 2013 to provide a women’s refuge in the city. There are 25 spaces available and it is always full. There are probably 40 or 50 children as well as the women involved. There is a very high turnover because the contract states that the accommodation can be provided for 12 weeks only. That is the deal, so you create a bit of safe space, but as soon as you start feeling safe, you have to move. It offers a resettlement service for up to three months, which is good, but all the research shows that women need at least five or six months to begin to feel safe and settled. The aspiration for safe space is being frustrated by the 12-week turnover and the three-month limit on resettlement. The further graphic statistic that Refuge has shared with me is that 50% of the women it deals with have experienced death threats. That is the degree of unsafeness which we are trying to create an alternative to and a refuge from.

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Of course, there is an issue about resourcing and models of provision. The February 2015 APPG report states:

“The current model for funding specialist domestic and sexual violence services is not fit for purpose”.

Since 2011, Refuge has had funding reductions in 80% of its service contracts, with some contracts cut by up to 50%. That is the background of our case study on some of the issues. People desperately need safe space and the struggle is to provide it and to fund it.

What might safe space look like, and where are we failing? Because of the lack of resources and of stable provision, there are fewer specialist services, especially for minority-ethnic communities and disabled women, so they are not being offered a safe enough space because there is not special provision for people in those categories. Similarly, Refuge reports that in some local commissioning the tenders specify mixed-bedroom provision. That may be an economic factor if you are short of money, but one of the things women are trying to get into a safe space for is to step away from a strong male environment. They need to be protected from that. To have tenders that specify that is rather alarming. That is not safe space either. As the noble Baroness, Lady King, said, there is a tendency to spend our money in our space and therefore to say that we will support local women only. As she said, women need to cross the boundary to feel safe, so if the space is going to be genuinely safe it needs to be shaped across boundaries, which requires more imagination about funding streams and how they can be deployed.

Another issue is the short contracts for commissioning. Refuge and others win one or two-year contracts. That is a start, but if you are going to build a reputation in a community for a safe and stable place, it needs to be there, because people learn about these things through gossip. It is only if it is there and stable that it feels safe to potential consumers. If every couple of years there is a new provider, a new image and all those new things that anybody has to put in to get established, the very people we are trying to help are going to wonder whether the new provider is up to it and what it is about. To construct a safe space requires stability, so that is a challenge for how we use limited funds. The danger is that if we do not get the provision of safe space right then, as we all know, women in vulnerable situations flee to the streets, which are the most unsafe spaces in our society.

I understand this very difficult problem of limited resources, but there are two issues that I want to raise. If we are serious about safe space being constructed and maintained, how can we marshal our funds so that there is stable provision, proper recognition of specialist needs and proper fluidity across local authority boundaries? We also have to encourage the statutory agencies that hold and administer funds to be proactive in working with the voluntary and faith sectors about the added value that we can bring along with the other forms of stability and safe space. As we found in considering the Modern Slavery Bill, in which I was involved, faith and voluntary groups can provide space alongside statutory providers. We are just there to love people, really, which helps people to feel safe, alongside all the proper provision of a bed and room of a certain size.

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When the Minister replies, I encourage him to look at the limits of resources, how best to create a safe space that is stable, dependable and flexible for the right specialisms—that is a pretty big ask—and how faith and voluntary groups can be challenged to put their resources alongside the statutory ones to make the provisions as stable and effective as possible.

5.26 pm

Lord Farmer (Con): My Lords, I, too, am grateful to the noble Baroness, Lady King, for securing another debate on this important and, sadly, prevalent issue of domestic abuse. I hope that the Government are aware of the encouraging paradigm shift that is happening right now in domestic abuse services, such that many are now intervening early to prevent many women ending up in refuges. I must, however, stress at the beginning that I understand that the women and children who need the safety that refuges provide have typically somehow survived the most terrifying and sustained attacks on their bodies and personhood imaginable. Until we see the elimination of domestic violence—thankfully, many organisations are working towards that ambition—those safe havens will be needed.

Former hedge fund manager Diana Barran set up the greatly respected organisation Co-ordinated Action against Domestic Abuse, or CAADA. Diana’s starting point then and now is, “What would you want for your best friend?” Being safe in her own home rather than living in secrecy in a refuge, possibly at the other end of the country, must be the goal if at all possible. CAADA, renamed as Safe Lives, recently concluded that it needs a fresh approach if it is to provide the best help, and it is strongly endorsing a paradigm shift towards early intervention, prevention and a family-based emphasis in domestic abuse work—all without in any way deprioritising safety, hence the new name.

I want to use my time today to draw your Lordships’ attention to how the best available practice in the country is seeking to achieve that shift and how policy can and must support it. My simple point is that intervening early is vital to break the cycle of domestic abuse that so many men and women are caught up in.

Although nothing excuses violence and it is by no means inevitable, childhood exposure to domestic abuse is one of the most powerful predictors of becoming both a perpetrator and a victim as an adult. However, organisations are increasingly grasping the urgency of working across the whole family, with victim, perpetrator and children being helped with all that they are contending with so that they can move on, but with safety of course the top consideration.

Atal Y Fro, for instance, Welsh for Safety in the Vale, was formerly known as the Vale of Glamorgan Women’s Aid. The name change reflects its broader base of working. It has become convinced over years of practice that if it works only with the mother and children, it is just putting a sticking plaster on the problem. It also refers to those using their service as men, women and children, rather than perpetrators and victims, not least to reflect the complexity of what is going on in many households where there is violence.

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Many of your Lordships will know that research has revealed a typology of abuse, and that different forms require different solutions. Coercive and controlling abuse, or intimate terrorism, is not the same as situational couple violence, violent resistance or separation-instigated violence. In addition, Professor Murray Straus’s research has made it clear that a surprisingly similar proportion of women and men use violence against their partner, and one in seven men report being abused by their partner or ex-partner. However, as men are usually stronger than women, they tend to inflict far greater physical harm.

I want to lay out four ways in which we can intervene early and how policy can support this paradigm shift. First, it is imperative that families are helped to build strong parent and child relationships in the early years to lay the foundations for secure relationships throughout life. Children who know that they are loved and cared for and who have learnt valuable interpersonal skills are far less likely to grow up feeling that they need to use violence in relationships or that they will inevitably be on the receiving end. Recent YouGov polling for the Centre for Social Justice found that 73% of the public think that tackling abuse requires acknowledging that perpetrators were themselves young victims.

Secondly, it is essential that we encourage positive relationships in schools by building supportive school cultures, ensuring that students who need it can access counselling and mentoring services—great examples being Place2Be and Chance UK—and providing effective relationship education. The Government have acknowledged the very high prevalence of adolescents in abusive dating relationships by including 16 and 17 year-olds in the new definition of domestic abuse. Worryingly, patterns set in adolescence can define relationships in adulthood. Voluntary sector programmes such as those run by Love4Life in Loughborough aim to help adolescents develop the skills to enjoy non-violent, equal relationships, increase understanding of domestic abuse, encourage appropriate attitudes and reduce abusive behaviours. The Government should make relationship education mandatory and call it that, and teach the biology of sex, which is already mandatory, separately. Teachers often find relationship education very hard to deliver, so schools should draw in the voluntary sector as its outsider status means it can add real value.

Thirdly, there should also be help for high-conflict and otherwise risky couples going through key transitions such as pregnancy or early years of parenting, or when parents decide to separate. Couple relationship education programmes, as well as the help for parents mentioned earlier, needs to be offered in the community, ideally in family hubs. In its recent report, Fully Committed, the Centre for Social Justice extensively describes how Sure Start children’s centres should be evolved into one-stop shops in every community. These would offer a much wider range of help to parents to tackle the root causes of family breakdown and disadvantage.

Fourthly, prevention of ongoing and future abuse is also taking place where couples are being helped to explore staying together. Increasingly, and very carefully, mainstream service providers are no longer taking the break-up of the abusive relationship as their starting

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point of help for victims in cases of situational couple violence. However, couple counselling can be positively dangerous in cases of intimate terrorism.

Many people on the receiving end of domestic abuse desperately want to keep the family together but know that that can happen only if the abuse stops. If both partners have a strong desire to work the issues through, and whoever is being violent is taking full responsibility for their actions, therapeutic support can help end that abusive behaviour. It is very important to acknowledge that that may not mean that the couple stay together. Troubled families programmes must include this help for couples, where appropriate, as part of their drive to equip parents to provide safe, stable and nurturing relationships. Again, CSJ/YouGov polling found that three-quarters of the public agreed that services should be available, if they wanted them, to help couples stay together.

Returning to Safety in the Vale, there is much to learn from how to work with a range of organisations in a one-stop shop to help families with medium to low-risk abuse to reshape and restore their lives. Current evidence suggests that it has helped two-thirds of families to stay together safely through a strategy of education, prevention and intervention in the community—EPIC. This involves different evidence-based perpetrator programmes for men and women, a healthy relationships programme in every school in the Vale of Glamorgan, and couples work. The current pilot is largely being paid for through charitable foundations, but once it has proven its effectiveness, the aim is that local authorities can commission it with confidence. Its annual cost is around £83,000 with a conservative estimate of cost savings of around £1.4 million.

Finally, Safety in the Vale is still running a refuge, but it is straining with every sinew to drain away all need for it. Can the Minister please inform me where and how government policy is keeping in step with this promising shift towards early intervention?

5.35 pm

Lord Ashton of Hyde (Con): My Lords, I, too, am very grateful to the noble Baroness, Lady King, for initiating this debate, and for the other very interesting contributions on this important subject. I have no experience of women’s refuges, but I live in an all-female household with a wife, four daughters and two female dogs, so I have a strong interest in the opportunities available to women in the UK today and the terrible effects of domestic abuse when it occurs.

I want to make it clear that the Government believe that high quality refuge provision plays a vital role in protecting victims of domestic abuse who find themselves in a situation so difficult that they are forced to flee their own homes. Being able to access a specialist domestic abuse refuge at the point a victim chooses to leave home can make the difference between life and death. The right reverend Prelate talked interestingly about safe space in this regard.

The Government’s approach to strengthening refuge provision is underpinned by clear legal duties to homeless victims, robust standards and significant investment. We are strongly committed to maintaining a resilient

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national network. That is why on 25 November last year in this House, my noble friend announced a £10 million fund to strengthen and boost refuge provision for vulnerable victims, as referred to by the noble Baroness, Lady King. That funding was put in place to respond to the concerns expressed by the sector. We will shortly announce the successful areas which will receive funding—unfortunately not in time for this debate. A significant number of local housing authorities will benefit from a share of the £10 million.

That funding will see local authorities working closely with some of the 400 specialist domestic abuse support providers, such as Refuge or My Sisters Place, which was advocated by the right reverend Prelate. Not only will it stop refuges closing but it will increase the number of bed spaces, improve services in existing refuges and place local refuges on a more sustainable footing. That is not all that we have done to ensure the long-term quality of provision in England. In November 2014, we used powers in the Housing Act 1996 to publish strengthened statutory homelessness guidance. This was developed with help from Women’s Aid, Imkaan and SafeLives, and it sets out clear standards of support that victims of domestic abuse can expect to receive.

Those standards cover a broad range of service areas including safety, health and well-being, children and young people and prevention. All those who will receive funding have signed up to these exacting standards and we expect others to follow suit now that they are under the statutory guidance. We know that these standards are effective as they were developed, as I said, with help from Women’s Aid and were derived from the national quality standards.

Although I think that the whole Committee agrees that refuges can play such an important role protecting victims at their most vulnerable, we must do all we can to prevent a situation from reaching crisis point. That begins to address the question that my noble friend Lord Farmer put at the end of his speech about early intervention. We are determined to continue to reach out to young people to encourage them to challenge unacceptable attitudes and behaviours. For example, the Home Office’s This is Abuse campaign is helping to reach young people. Only by preventing violence and abuse in the first place can we hope to make a sustainable change over the long term. Education has a very important role to play in encouraging young people to build healthy relationships. That is why we are committed to working with schools and other experts to ensure that young people are receiving age-appropriate information that allows them to make informed choices and stay safe.

Baroness King of Bow: While the Minister is on the subject of a sustainable future, is there anything he can do within government to assure Women’s Aid that a sustainable, long-term funding solution might be found?

Lord Ashton of Hyde: I will come to that. As I was saying, education in schools is very important. Maintained secondary schools are already legally required to teach sex and relationship education, and we expect academies

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to do so, but I take my noble friend’s point about separating those two key areas. I will come to the measures that the Government are taking later.

Rather than waiting for a crisis to happen, one of the strengths of today’s homelessness services is that local housing authorities are reaching out proactively to those in need and helping them to avoid a crisis in the first place. Since 2010, more than 20,000 households experiencing domestic abuse have had their homelessness prevented by sanctuary schemes installed by local authorities working with the domestic abuse support sector. Of course, they have to have victim approval.

Supported by an investment of £6.5 billion over this spending review period, interventions such as family mediation, resolving rent arrears and sanctuary schemes all help to prevent problems escalating out of control. Frequently, it is the local authority working hand in hand with the voluntary and community sector which helps get the lives of victims and their families back on track. The Troubled Families programme, for example, will target an extra 400,000 troubled families, thanks to the investment of an additional £200 million. Our research shows that 29% of families on the current programme have experienced domestic abuse in the past six months and that is why the expanded programme will use domestic abuse as a specific indicator of eligibility.

We have a strong record on tackling domestic violence and abuse. For the first time ever, this Government provided £40 million for specialist local domestic and sexual violence support services. Our approach is set out in our Call to End Violence Against Women and Girls strategy published in 2010 and updated each year. We will be publishing a further update shortly. It has put in place a tough legislative framework and strong protections to support victims of domestic abuse, which is overseen by the Home Secretary through an inter-ministerial group.

I now come to some of the questions I was asked. The noble Baroness, Lady King, generously acknowledged that the £10 million was welcome and that it is a stop-gap. It is a limited amount of money. She has just asked me what advice I will give to the Government and what commitment I can make on behalf of the Government about future funding. She knows how government works. I am unable to give total government commitment at the moment, particularly six weeks before an election. We have put that £10 million funding in place for two years in response to concerns and we have made clear that that funding is a priority. I expect that to continue and we will prioritise this matter when we are thinking about future spending after the election, if we are in a position to do that.

The noble Baroness also asked for advice for refuges which are seeking to survive past 2016, which is a similar point. The duties to vulnerable women in homelessness legislation will remain. New standards will ensure that the standards are maintained and meet the needs of victims. In fact, we prioritised funding in response to the issues that Women’s Aid and Refuge raised. I would expect that we would prioritise this matter and continue to do so when we think about future spending plans after the election.

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There was mention, too, of the fact that women are being turned away from refuges. The Government fund UKRefugesOnline, so that victims and those who work to support them can find appropriate accommodation. Also, the new strengthened statutory guidance places clear expectations on how local authorities commission and organise their refuge provision. The guidance makes it clear that available bed spaces or support should not be restricted to local people only. The homelessness legislation also protects victims of domestic abuse by placing a duty on local authorities to provide accommodation to those vulnerable people who find themselves homeless as a result of fleeing domestic violence.

The noble Baroness also asked about the impact of local authority cuts on refuge services. The DCLG’s statutory best value guidance to local authorities makes it clear that councils need to avoid making disproportionate cuts to the voluntary and community sector. They have un-ring-fenced many of these funds, so that the local authorities have flexibility in their use of funds. This duty will make it clear to them that they are not allowed disproportionately to cut the voluntary and community sector. There is some good news. Local authorities’ own estimates show that 91% expect a growth in their business rates income, which would equal about £400 million.

My noble friend Lady Newlove complained that we do not join up government support enough. I absolutely acknowledge that it is difficult to co-ordinate service delivery across government. We recognise this, and recognise that one size does not fit all. The Government’s commitment to tackling these dreadful crimes is set out in the call to end violence against women, as I said, which is driven by the Home Secretary. The Public Services Transformation Network funding, which is backed by the Cabinet Office and the Treasury, is also enabling local areas better to fit services to victims’ needs. For example, Essex has developed a strategic approach to commissioning a wide range of wrap-around services, including refuges, outreach, support for children, survivor support groups and an enhanced perpetrator strategy, and they are all included so that victims can get the help that they need.

The right reverend Prelate asked about women being moved on before they are ready. They should not be being moved on in that way; it is right that victims, when they are given the chance, move on when they are ready so that others can find a place of safety, but they should not be moved before then. As I mentioned, the Public Services Transformation Network helps local areas better to fit services to victims. We are clear that services must meet the needs of victims, and our guidance says that.

The right reverend Prelate also mentioned getting the faith and voluntary sector to work alongside government. The guidance is clear that, when commissioning services to help to support homeless victims, authorities should not exclude any sector. In fact, our experience shows that those sectors often know the best, do the best jobs and are better able to relate to and thus support victims—so I completely agree with him.

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As for commissioning guidance, decisions on how best to find services for victims of domestic abuse are local matters, and we think that it is right that they should be handled at local level.

To support effective local commissioning, the Government held a series of local road shows with local commissioners last year to share best practice in effective commissioning. New standards published by the DCLG make it clear that the needs of those with a protected characteristic must be met in refuges.

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I think that I have answered most of the questions that I was asked. If not, I shall be very happy to write later.

Finally, I thank all noble Lords for participating in this hugely important and varied debate, which rightly has the attention of the Committee. I wish all noble Lords a very good weekend, including Sunday of course, which will be International Women’s Day.

Committee adjourned at 5.50 pm.