1.1. Organisation of Voluntary Sector Specialist Services in England

VSS services in England are typically grassroots nonprofit organisations that provide counselling/therapy, helplines, practical support and advocacy. VSS services frequently provide referral/signposting into and through other local and national services or processes for victim-survivors. Some services are female-only, reflecting the understanding that women make up more than 80% of victim-survivors who report SV (https://rapecrisis.org.uk/get-informed/statistics-sexual-violence/). It is not uncommon for VSS services to be grounded in feminist philosophies, even if they support victim-survivors of all genders. Principles and philosophies that sit alongside a feminist perspective, such as that of being trauma-informed and survivor-centric, are all valuable elements of VSS service support provision. Victim-survivors can access these services via self-referral, referral from health and social care professionals [8], and/or via referrals from Sexual Assault Referral Centres (SARCs). SARCs are National Health Service (NHS) funded centres that provide medical and sometimes practical support, as well as collection of forensic evidence for criminal justice purposes following sexual assault.

The funding and commissioning of VSS services in England have become increasingly complex due to changes in the structure and funding of health [9] and criminal justice services. Funding for VSS services typically comes from charitable bodies plus local and national statutory sources, via health, local governing authorities and criminal justice organisations. To illustrate the complexity of the funding and commissioning picture, NHS England commissions medical aftercare and short-term therapeutic support for victim-survivors. This commissioned work is often carried out by or in partnership with SARCs. Some Integrated Care Boards (ICBs) also commission therapeutic support (e.g., short- to medium-term counselling) for some groups of victim-survivors; however, the commissioning of such services by ICBs varies widely, and in many areas of the country, therapeutic provision for victim-survivors is subsumed under ‘generic’ mental health support. The Ministry of Justice manages the Rape and Sexual Abuse Support Fund (RASASF) in England and Wales. This is a source of funding for, but not limited to, the funding of specialist Independent Sexual Violence Advisors, counselling and therapeutic support, helplines, etc. These services are for recent and nonrecent victim-survivors. The Ministry of Justice also has devolved many key commissioning responsibilities to local Office for Police and Crime Commissioners, who are one of the primary commissioners of specialist services of VSS organisations across England and Wales. Intersecting these primary commissioning routes, some local authorities commission or grant-fund some services (relating, for example, to their duties to support children ‘at risk’ or suffering harm, or as part of their public health duties). The Home Office Violence Against Women and Girls Specialist Fund also offers funding that VSS organisations can competitively bid for, with a focus often on themed calls and innovative projects (rather than sustaining existing services).

This creates a complex network of responsibilities at a local level. It also compounds VSS service difficulties in establishing and maintaining relationships, particularly with public sector providers, not least because there is a prevailing attitude that VSS services are ‘amateur’ and small scale [10] compared to statutory providers.

In some areas, new and untested local models of collaborative commissioning have emerged, such as contracting with a lead provider for a network of local services, which may include VSS providers [11]. One consequence is that the previous model of a mixed economy of provision for victims, which included smaller organisations who are adept at meeting the needs of specific groups at the local level, has become untenable under the drive towards a free-market model and competitive tendering [12]. In other areas, VSS providers are taking the initiative and collaborating between themselves, moving to common standards and seeking to join up services locally via partnerships and consortia [13]. However, little is known about their effectiveness and how they might impact services for victim-survivors. Anecdotally, the sector reports a tendency towards short-termism in funding opportunities and a lack of understanding by some commissioners of the VSS sector’s role and contribution, including confusion regarding which services are responsible for what [11].

In addition to academic evidence gaps regarding funding and commissioning within the sector, we know relatively little about what victim-survivors are currently receiving from VSS services nor the perceived impacts of such services. Where studies do exist, e.g., a national survey with 395 victim-survivors [14] and the Independent Inquiry into Childhood Sexual Abuse [15], we understand that victim-survivors want a choice of specialist support that they can access locally and in a timely way, from well-connected and joined-up services. The specialism of VSS support was noted in one study as being vital in setting the sector apart from how NHS therapy was experienced [16].

Studies comparing VSS services with statutory provision have reported a preference for VSS services, with these rated more highly across counselling and psychotherapy, and other forms of support [10, 16, 17]. Such a preference reportedly comes from the independence, flexibility, empowerment and specialism of VSS provision [5]; elements statutory services have been criticised for not providing [11]. Not only can victim-survivors become dissatisfied from attempts to seek support from services but they can also be secondarily traumatised by institutions through the betrayal arising from inappropriate attempts at support [15, 18]. The study reported in this article was designed to address these empirical gaps by informing the evidence base about how VSS services are funded and commissioned. Importantly, it provides new insights into how these arrangements affect those connected with the services—namely, staff, volunteers and victim-survivors.

2.1. Theoretical Framework

The rationale for drawing on this theory was its potential to help understand and explain the prominence and distinctiveness of the voluntary sector in providing support to victim-survivors of SV. The theory also helps to surface the unique features (and perceived limitations) that shape their response to their client group. During the study, we revisited this theoretical framework frequently, reflecting on how it was shaping and informing our methodologies and subsequent analyses. We used the theory as the guiding framework for data synthesis, with this flexible and reflexive use of theory being advocated by Bradbury-Jones and colleagues [21].

2.2. Ethics Approvals

The study was subject to the following ethical approvals: The University of Birmingham Science, Technology, Engineering and Mathematics ethics committee in February 2020 (ERN_19-1152A) and October 2020 (ERN_19-1152B). Research governance approval was granted by the Health Research Authority (HRA) and Health and Care Research Wales (HCRW) in January 2021 (REC reference: 20/HRA/6042). The Association of Directors of Children’s Services (ADCS) (Ref: RGE201005) and the Association of Directors of Adult Social Services approved sharing the survey weblink(s) among their members.

All participants provided informed consent, and no ethical issues arouse across the duration of the project. We sought multiple opportunities throughout the study to ensure equality and diversity in our samples. We discuss this further in the limitations section.

2.3. Study Design

The study was divided into three empirical phases: Phase 1: Exploratory interviews with commissioners and providers and focus groups with victim-survivors. Phase 2: National survey of service providers and commissioners. Phase 3: Case study analysis of four areas in England. The study protocol outlining these phases was published at the beginning of the study [22]. Primary data from the different phases are beginning to be published elsewhere, specifically from Phases 1 [23] and 2 [24]. These individual-phase papers are important, but the aim of this current paper is to provide an overview and synthesis of data from across the different phases, located in one place. To avoid duplication, we have not presented primary data in this article. We present the overall empirical findings from the study, along with the overarching themes and recommendations arising from the work.

Co-production was built into the study from its inception; initially through the development of the research proposal with lived-experience co-applicants, plus the addition of five lived-experience co-researchers working on the study. The co-researchers worked with the academic team on data collection for the victim-survivor interviews (see below), data analysis (of the survey and interviews) and dissemination activities. This highly participatory methodology was intended to amplify the voices of victim-survivors; enhance the collection of meaningful data; empower victim-survivors who were participating in the research; and promote learning and development of new skills among all team members.

2.4. Data Synthesis

Synthesis of data from the different phases was led by the lead author and verified through several iterations with the rest of the team until consensus was achieved. The first part of the process involved a deductive approach [27] by using the broad statements that were held within the data as the starting point and making sense of them with reference to the specific details of our theoretical framework. In practice, this involved taking the findings from each phase and mapping them onto the theoretical framework [19], seeking the closet fit to each of the constructs. Once this stage was complete, verification and agreement with the wider team took place, resulting in no further revisions to the framework. Table 6 sets out an overview description of each theme and linkage to findings within each of the three study phases. The table does not provide an exhaustive account of the links between themes and the empirical data; rather, it intends to map how the study’s empirical findings support the key, over-arching themes.

2.5. Development of a New Model

Inspired by Urie Bronfenbrenner’s ecological systems theory [28], we captured the integrated findings conceptually and diagrammatically (Figure 1). Bronfenbrenner’s ecological model holds that an individual is influenced by the reciprocal relationships between a person and their environments (and the different ‘systems’ in that environment). Presented as a pattern of concentric rings, the individual exerts influence on and is influenced by the different systems. The model shows the influence of micro- and macrolevel factors associated with SV and how a victim-survivor might operate and interact with the five systems, from proximal to distal.

Figure 1 adapts Bronfenbrenner’s ecological model to map how the organisation and funding of VSS services shape the experience of victim-survivors. The model helps to explain the precarious and at times desperately long journey that some victim-survivors are forced to navigate when seeking specialist support. It also indicates that at a policy level, investment from government could transform aspects of service delivery by providing commissioners with the resource to invest in VSS services. However, other factors—such as the way that decisions are made, partnerships forged and ‘on the ground’ practice developed—also shape the sustainability and quality of services for victim-survivors. Figure 1 is intended to capture the relationship between micro- and macrolevel factors, thus illustrating how crucial the impacts of commissioning can be on individual victim-survivors.

3.1. Co-Producing the Study Recommendations

The event was instrumental in developing the recommendations presented in this article. Additionally, postevent, we have had the opportunity to elicit further feedback from colleagues from VSS organisations and we are confident that this co-production process has resulted in the following 14 recommendations that are both usable and relevant. The recommendations are also underpinned by discussions with key stakeholders that took place throughout the study. For example, the study team liaised with the Ministry of Justice during the development of the Victim’s Bill (now the Victims and Prisoners Act 2024) and made a written submission during the development of the Women’s Health Strategy. The recommendations outlined below do not appear in priority order and are numbered for the purpose of reference, rather than hierarchy, and we draw particular attention to their interconnection. These recommendations are intended primarily as an orientating framework for all parties involving in the funding and commissioning of specialist services, including commissioners, grant funders and VSS organisations. There is particular emphasis on recommendations for commissioners working at national and regional levels, across health, criminal justice and social care.

3.2. Contextualising the Findings and Recommendations Within a Broader, Health and Social Care Context

This study provides important new empirical evidence from a national perspective about the complexity and precariousness within the VSS sector, with short-term funding from state and independent bodies generating considerable instability for services. It also found examples of the positive difference the longer-term, co-produced funding and commissioning arrangements could make. Concern over existing practice has changed the range and type of support available to victim-survivors of SV. As described by Robinson and Hudson [16], there has been the introduction and expansion of SARCs to provide a range of immediate, short- and longer-term support and assistance to victim-survivors of SV. Over the same period, however, there has not been a similar development and support of VSS services, prompting concern about service quality, as well as long-term sustainability of the sector. As others have highlighted, such precariousness negatively affects staff morale and retention and can undermine sector leaders’ ability to work in a strategic and creative way [31]. It also creates instability for victim-survivors around the longevity of the services they need and use.

The study findings have shown the considerable challenges of competition for funding across the sector, balanced with insights into positive models of partnership working. Our findings regarding the problems of short-term funding have been acknowledged previously as an undermining factor for organisational stability, particularly in respect of staffing [30]. Evidence indicates that size matters. Large organisations may be better equipped to leverage funding [30], whereas smaller VSS organisations have fewer resources to dedicate to the tendering process. Robinson, Hudson and Brookman [8] report how one of their SV practitioner interviewees commented that ‘agencies subsume their mutual hatred in a desire to secure funding’ (p.419). While they acknowledge that the situation is not quite so bad as to instil hate between multiagency SV partners, they do acknowledge that services are frequently ‘scrabbling around’ for small pots of money. Resonating with our study findings, we found considerable challenge and competition in terms of funding, but far from ‘hatred’, a significant respect between organisations in the sector, who ultimately share the same goal of supporting victim-survivors of SV.

Our study evidences the pressured environment in which practitioners operate across the VSS sector, associated with ‘complexity’ in the lives of those they support and the increase in service demand. Similarly, interviewees in the study by Hester and Lilley [5] described the specialist Independent Sexual Violence Adviser (ISVA) role as one that is varied and complex. More recently, Horvath and colleagues [32] reported that the ISVAs and ISVA managers who completed their survey were experiencing some psychological distress and moderate-to-high vicarious trauma. Perhaps unsurprisingly, the study showed how ISVAs holding high caseloads experienced more psychological distress than ISVAs with lower caseloads. Additionally, the longer the ISVA spent working with clients who have been subjected to SV, the more likely they are to experience vicarious trauma. Like those from our study, these findings show the human cost of pressured VSS environments.

Victim-survivors are, in turn, impacted by these pressured service delivery environments. Echoing wider findings, in our study, we heard consistent testimony from victim-survivors about the challenges of finding the right support and, moreover, accessing this support at the right time for them. This can have a particularly detrimental impact on victim-survivors who have ‘complex’ needs [31]. However, according to Robinson and Hudson [16], some of this can be mitigated through harnessing the advantage of being a VSS organisation, where independence and flexibility are perceived as a strength for gaining access to victim-survivors and maintaining their engagement/confidence.

The study has provided clear evidence of the value that victim-survivors place on VSS services. This is a finding that we had expected, and it is one that has been highlighted by others in earlier research, for example, Maine [33]. It is a finding that needs to be reinforced, however, given the challenges that the sector continues to face in providing sustainable, specialist provision to all victim-survivors. VSS services are seen to provide a space where victims can tell their story without the fear of judgement [16]. They often provide the only ‘safe space’ where disclosure and support tend to be consistently positive and where victim-survivors are ‘held’ in that space [5]. Like earlier research that has shown the value of survivor-centred, trauma-informed approaches [34, 35], our study has highlighted the importance of SV support being needs-led, feminist and trauma-informed, encompassing survivor empowerment and gender awareness.

The important role played by VSS organisations in helping victim-survivors overcome the trauma of SV, and in getting SV recognised as a significant social problem, cannot be overstated [35]. Trauma-informed support involves identifying survivors’ strengths, prioritising their autonomy and considering how identity and context influence their experiences and needs [36]. Becoming a trauma-informed organisation requires organisations to move away from traditional models of support and to re-evaluate their practices and policies so that they operate through a trauma-focused lens [37].

Pemberton and Loeb [31] argue that given that SV impacts women at disproportionate rates compared to men and that SV results from power inequities, the healing journey for survivors must take such issues into account. Feminist therapy specifically acknowledges the mental health risks associated with living in a patriarchal and hegemonic environment [32] for women and men. It espouses feminist values that are premised on the idea of believing women and respecting their confidentiality and autonomy [8]. The study has also shown the importance of survivor empowerment and gender awareness within VSS service delivery. Kulkarni [35] talks of intersectional trauma-informed services, which aligns well with our study findings. Intersectional approaches underscore the ways in which social categories, such as race, class, ability, gender and sexuality, interact to shape victim-survivor experiences and how individuals frequently contend with multiple oppressions [34]. It is this complexity in the lives of many victims-survivors of SV that mirrors the complexity of the commissioning landscape.

3.3. Study Limitations

Conceptually, we grappled with how best to define and operationalise the concept of specialist services for victim-survivors of SV, cognisant of the different ways that services can provide valuable care and support to victim-survivors. We sought to differentiate between services who can and do support victim-survivors but who do not ‘specialise’ in SV, i.e., staff do not receive bespoke training or are required to have specific knowledge, and/or services are not designed primarily or exclusively with the needs of SV victim-survivors in mind. As the aim of the study was to identify, map and explore support for victim-survivors of SV specifically, we judged that this distinction was important to uphold for reasons of conceptual clarity. However, an unintended result of this definition was that it may have excluded the contribution of services with multiple specialisms and/or services that victim-survivors from specific groups are more likely to turn to [38]. This exclusion seems most apparent in terms of not including minoritised women’s services who did not state that they prioritised specialist support around SV but whom regardless would have been accessed by minoritised victim-survivors. This also applies to other specialist services supporting victim-survivors who are minoritised by virtue of their disability and/or sexuality.

Despite these limitations, there were some mitigating factors regarding equality and diversity among study participants. For example, women are disproportionately represented among victim-survivors of SV, and this is reflected in our samples. However, one of our case study sites offered VSS services specifically for men. As a result, the study findings hold insights from the perspectives of male victim-survivors and services, which are likely to have been missing otherwise. Further, as the demographic table indicates, the proportion of victim-survivor participants who identified as being a disabled person was far greater than the proportion of practitioner/commissioner participants. We interpret this as a reflection of the well-documented association between experiences of violence and abuse and poor physical and mental health.