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Iris – Identification and Referral to Improve Safety Introduction

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IRIS – Identification and Referral to Improve Safety


IRIS is the first European randomised control trial of an intervention to improve the health care response to domestic violence and abuse. It aims to determine the cost-effectiveness of a general practice based domestic violence training and support programme and measure two outcomes:

  • Referral of women to a domestic violence agency providing advocacy

  • Recording of disclosure of domestic violence in the patient’s medical record

It is a targeted intervention working with female patients aged 16 to 90 experiencing current or former abuse from a partner, ex-partner or family member. IRIS provides advocacy and referral for women, referral for children and sign-posting information for male victims and for perpetrators.

The IRIS trial

The IRIS randomised control trial took place in Bristol and Hackney in 48 practices during 2007-10. 12 practices in each site were allocated to the intervention part of the trial and 12 in each site were in the control part.

The intervention practices received:

  • practice based training, audit and on-going support

  • a prompt (to enquire about domestic violence abuse and ask a safety question) in the medical record in the form of a pop-up called HARKS

  • a named advocate-educator linked to the practice and based in a specialist domestic abuse. The advocate-educator acts as a consultant to the practice team and is the person to whom patients wanting support are directly referred

  • support for the practice champion who was the lead IRIS contact in the practice

  • posters and cards to put up in the practice and give to patients and additional resources, including care pathways, provided to practice staff

Interim results

Data was collected from the patient records for a twelve month period in each intervention practice from the date of their second training session. Data was also collected from control practices for the same twelve month period.

The trial appears very successful with very positive results both in terms of identification and referral of patients. The final trial paper, cost effectiveness analysis and PREMIS data (a measure of change in clinician attitude and behaviour regarding domestic violence) are all being prepared for submission for publication by early 2011. In addition a qualitative analysis of service-user interviews will be available.


Advocacy has been shown to benefit victims and survivors of domestic violence. The Health Technology Assessment review of all controlled studies of advocacy interventions for survivors showed improvement in mental health and quality of life (HTA review 2009). Victims are also more likely to be safer when multiple services are offered (Safety in numbers, 2009, CAADA).

Domestic violence costs the health service £1.7 billion per year with the major costs being to GPs and hospitals (The cost of domestic violence update, 2009, Walby). There are high costs associated with referrals to specialist services, particularly women’s health and mental health services. The pilot study for IRIS in east London found a cost/QALY of £2,450. While this is expected to be slightly higher for IRIS, it will be well within the NICE guidelines.

IRIS supports PCTs to fulfil their statutory obligations under The Human Rights Act, The Crime & Disorder Act and the Gender Equality Duty as well as to fulfil safeguarding duties to children and vulnerable adults.

Implementation of IRIS (IRISimp)

Bristol PCT and City & Hackney PCT have already commissioned the IRIS model and each is funding a full time advocate educator within their PCT area to continue the work begun in the trial and increase the number of practices involved.

The Health Foundation who funded the trial has agreed a further two years’ funding for phase 2 of IRIS, IRIS implementation (IRISimp) and this is to implement the model nationally in other PCT areas. IRISimp is developing a package for commissioning and a national advocate-educator accredited train the trainer programme. IRISimp is currently discussing the project with a number of PCTs across the country.

Commissioning package

The commissioning package is currently being developed and will be available from December 2010. To implement the IRIS model financial investment is necessary from the local PCT/commissioning consortia. The money is provided to a local specialist agency to enable them to provide the IRIS intervention to the local general practices. An advocate-educator is recruited, trained and accredited by IRISimp and then based in the specialist support service. A local clinical lead is engaged to promote the service to clinical colleagues and support the training in practices. If this person is a practising clinician, locum costs are paid to cover their time on IRIS.

The cost of setting up and implementing the project is circa £50K. The cost includes:

1 WTE advocate educator based in a specialist support service and working with 25 practices Locum costs for clinical lead Medical record prompt and IT support Complete training and resource package Support network for advocate-educators

Next steps

For more information, please contact:

Annie Howell, IRISimp Development Lead Medina Johnson, IRISimp Development Lead

0207 6831270, ext: 227 07725 676016 0117 925 0680 07912 478011

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