Treating violence as a disease: can a public health approach succeed?

Knife crime, especially deaths of young people, has been making the headlines in recent weeks. And an approach which has a proven track record in Glasgow is now being adopted by the GLA, MOPAC and the Met police to try to tackle the growing levels of violence being seen on London’s streets. Learning from the experience in Glasgow, the police and other agencies are being encouraged to see violence as a public health issue, related to poverty, wellbeing and social deprivation and which, if identified and tackled early, can be prevented.

Contagion: a new way to think about violence

The Violence Reduction Unit was pioneered by Strathclyde Police (now part of Police Scotland), working with health and social care practitioners. Launched in 2005, the approach aims to make earlier identifications of those at risk of becoming involved in violence, and to take a more holistic view of the reasons for violence of all types. The long-term strategy looked at more social and wellbeing interventions to tackle gang violence in Glasgow, which at the time was among the worst in Europe.

The VRU in Glasgow took its inspiration from a scheme in Chicago, which sought to use a World Health Organisation (WHO) approach to tackling the spread of disease but applied it to communities in the hope of curbing the significant rise in homicides in the city. The approach was three-pronged: interrupt transmission, prevent future spread, and change group norms.

In addition to changing the approach to tackling violent crime, the VRU also used a multi-agency approach, involving social services, health care, housing and employment support, to give people a route out of violence and opportunities to find work or training opportunities. One of the key elements to ensuring the VRU is successful are the relationships these people build with individuals in communities.

Identifying young people at risk

Another important aspect of the VRU strategy is to intervene early to identify children and young people who are at risk of joining gangs or becoming involved in gang violence. Research supporting the creation of the VRU suggested that violence (like a cold) is spread from person to person within a community, that violence typically leads to more violence, and that one of the key identifying factors in someone becoming a perpetrator of violent crime is first being the victim of violent crime themselves.

In order to prevent this, staff from the VRU regularly go into schools and are in touch with youth organisations. They also provide key liaison individuals called “navigators” and provide additional training to people in the community, such as dentists, vets and hairdressers to help them spot and report signs of abuse or violence.

There is also a broad view of what a culture of violence is. Work in schools focuses strongly on contemporary issues such as sexting, bullying and gender-based violence. It challenges the attitudes and beliefs that underpin such violence, and encourages young people to recognise and reject these.

A new approach to drug abuse too …?

In November 2018, the Scottish Government launched its new drug and alcohol strategy. One of the notable additions to the strategy was the acknowledgement that (like violence) drug abuse and addiction should be seen, not as a crime, but as a public health issue – an illness which people need support and treatment for.

Looking at how drug abuse is tackled within the criminal justice system and the interactions of addicts, policymakers have identified that many have had adverse childhood experiences, are exposed to drugs and/or alcohol at a young age, and are also at significant risk of being unemployed and homeless.

Creating a holistic package of support which seeks to identify those at risk and directs them towards a range of services to tackle not just the addiction but other trauma or socioeconomic barriers earlier, will, in a similar way to the VRU, give people a sense of purpose and value, and help them to see an alternate route that will allow them to contribute positively to society and improve their own outcomes.

A new way to tackle social issues in the UK?

Tackling the spread of violence through communities is not an easy task, nor is breaking the cycle of crime that many find themselves trapped within, often as a result of family allegiances or geographic location. It is often the case that either you participate, or you become the next victim yourself. More and more young people are feeling the need to carry knives for protection, due to the high levels of fear of becoming a victim.

Identifying those young people who are at risk of turning towards a life of violence at the earliest possible stage is difficult, but has been shown to be effective in helping to tackle violent gang-related crime. Although it is not the only tactic available to police, used effectively in conjunction with other outreach programmes it can be an effective tool in preventative policing, helping to keep communities safe.

The outcome in Glasgow has been largely positive, following the roll out of the Violence Reduction Unit programme. Whether this approach has the same success in London, operating on a larger scale, with different economic and social variables, and in a very different budget climate, remains to be seen. In particular it is worth noting that the Glasgow approach recognised there were no quick fixes, and was based on long-term planning covering ten year periods.

It is to be hoped, though, that changing the way we think about violence within communities may offer a route to tackling it.


If you liked this, you may also be interested in other articles exploring policy lessons from other countries:

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The Dickensian disease: TB in 21st century England

England has the second highest tuberculosis (TB) rate in Western Europe, and a rate that is more than four times as high as in the US. Why is this seemingly Dickensian disease making a comeback in England today? And what is being done to tackle it?

The TB capital of Western Europe

Figures show that TB cases are centred on large urban centres; Manchester, Birmingham and Coventry to name just three. However London accounts for almost 50% of all cases of TB reported in England. A third of London boroughs are classed as ‘high incidence’ by the World Health Organisation (WHO), placing them in the same band as countries like Iraq and Rwanda, with more than 40 confirmed cases per 100,000 people per day.

In 2013 there were 3,500 new cases of TB diagnosed in the capital. Healthcare professionals stress the importance of early diagnosis and treatment as being a key strategy to eradicating the disease.

Stigmatisation is a real issue

TB is strongly associated with poverty and research has suggested that many people do not seek treatment for the disease because they are embarrassed about the potential repercussions of having to tell family members, support workers or employers. This not only poses a risk to the infected person, but significantly increases the chances of passing the infection on to others.

Similarly, statistics show that cases of TB are particularly prevalent among homeless populations and other vulnerable minority groups. Delays in seeking treatment, already-reduced immunity, pre-existing strains of the disease which can reoccur, and overcrowded shelters can all contribute to spreading the disease, which is caught through prolonged contact with an infected person (the bacteria is spread through airborne droplets).

Another barrier to effective treatment is misdiagnosis by general practitioners.  As a result there has been a conscious effort in London in particular to educate general practitioners and other primary healthcare workers on possible symptoms in the hope that it will help increase rates of diagnosis and treatment, and reduce the number of new cases.

A public health emergency?

However, the rise of antibiotic and drug resistant strains of the disease is making treatment of TB even more difficult. A full course of treatment of non-drug resistant TB bacteria can take up to two years in some cases. If the strain is drug resistant, patients can be taking as many as 9 different drugs a day, many of which have severe side effects and can be life-limiting in themselves.

Doctors have suggested that the rise of these drug resistant strains is not being taken seriously by Public Health England, or other associated bodies and that drug resistant TB should be considered as a public health emergency. In 2014 the LGA produced guidance on the public health role which should be taken on by local authorities to tackle TB locally within communities.

Updated guidance and treatment programmes

In early 2016, the National Institute for Health and Care Excellence (NICE) published updated guidance on TB, with a particularly strong focus on: early treatment; targeting vulnerable groups; and improving education and awareness of the disease for patients and GPs on how to spot symptoms.

Prior to this, in 2015, Public Health England produced a collaborative strategy, in partnership with NHS England, to tackle TB in England. The strategy looks at how health boards, local authorities and national bodies can cooperate to achieve national outcomes on TB diagnosis, treatment and eventual eradication. The report considers the creation of nine regional TB control boards, who would work alongside national bodies to achieve these national objectives. London-specific objectives and strategies were published in October 2015.

Practical support for sufferers in communities

Find & Treat  provides screening, advice and practical assistance to TB services and allied health and social care services in London. In partnership with Groundswell (a charity supporting homeless people), the team behind Find & Treat also recruit, train and support former TB patients who have experienced homelessness to work as peer advocates in their TB awareness team.

The Mobile X-ray Unit (MXU) now screens almost 10,000 socially vulnerable people at high risk of TB annually. The screening service operates in every London borough, and is regularly called to support the control of TB outbreaks nationally. University College London Hospitals (UCLH) host the service on behalf of NHS London, and are close to rolling out the Find & Treat initiative nationally (as recommended by NICE). Additionally in London there are two designated ‘hub’ hospitals, in the north and the south of the city with designated teams of TB specialists.

To further increase the profile of TB, prevention and treatment, actress Emma Thompson has been appointed as the Mayor of London’s TB Ambassador. This follows her son’s diagnosis with TB in 2011. Since her appointment she has been a very public face of TB awareness, regularly attending clinics and health drives to encourage people to get tested for the disease.

As the statistics have shown, TB rates are frighteningly high in some areas of the UK, and particularly in London. It is hoped that increased guidance and public awareness will help stop the increase of cases and avoid the potential public health epidemic which could arise in London as the population grows and pressure on NHS services intensifies. There is added incentive to curb this spread as the rise of antibiotic resistant strains becomes more prevalent.

Vaccination programmes, effective treatment centres and early intervention community initiatives, as well as investment in research and development for new drugs to treat the disease effectively, will be key to ensuring positive outcomes for all those affected by, or at risk of, TB in the UK.


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Further blog posts from The Knowledge Exchange on health:

What’s preventing preventative policy?

governmentBy Stephen Lochore

I recently blogged about the potential benefits of preventative policy-making – an approach that aims to prevent or reduce the risk of social and economic problems. But if prevention really is better than cure, why isn’t prevention universally accepted and implemented?  What are the challenges, barriers and limits to preventative policy?

  • Funding and budgets are usually short-term while preventative policy requires long-term commitment. It may take decades for a preventative approach to deliver outcomes, yet require significant up-front spending. When faced with shrinking budgets, it may seem expedient to cut preventative spending rather than services that more immediately benefit local communities.
  • Changing priorities can undermine preventative approaches.  Much political attention is currently focused towards economic development, and it has become harder for many public bodies to maintain spending on activities that don’t explicitly target economic growth, even if they would save money in the long-term.  Public opinion fluctuates, and often focuses on local solutions rather than high-level holistic approaches.  Yet preventative policy often depends on long-term commitment.
  • Preventative intervention is difficult to evaluate – partly because of the long time-scale, sometimes compounded by a lack of obvious measures of success, but also because the problems such interventions try to address usually cut across policy domains, making it difficult to determine the net impact of any individual initiative among an ever-changing set of interrelated interventions.  To put it another way, preventative policy faces problems of both measurement and attribution.  This puts it at a disadvantage when there is an expectation to demonstrate measurable progress.
  • There is limited evidence about ‘what works’ in preventative policy.  The policy-making cycle operates at a different timescale to that needed to create a robust evidence base.  The Big Lottery suggests longitudinal studies of at least five years to support research into prevention.  People often quip that politicians want quick answers… the other side of the argument is that researchers only want to give comprehensive answers!
  • Public sector budgeting isn’t well suited to those ‘wicked’ issues that cut across departmental and service lines. Preventative spend in one area may save money in another by reducing demand for services.

Long timescales, interdependent issues, and limited evidence, all mean that preventative intervention carries a high level of uncertainty, and can be seen as risky.

There are also some general tensions within policymaking that are exacerbated when taking a preventative approach.

  • Participatory policymaking – communities may prioritise locally identifiable outcomes rather than long-term, holistic interventions.  Issues that are important at a local level (e.g. noise pollution, traffic congestion, litter) are not always the same as those policymakers seek to address, particularly using a preventative approach.
  • Centralised processes to establish good practice and monitor progress versus greater autonomy for localised decision-making and freedom from central interference.
  • Using evidence to follow established practice balanced against policy and research innovation to try and to evaluate new approaches. The relative paucity of evidence about some areas of prevention and early intervention mean that policy risks need to be taken, and policymakers have to accept uncertain returns and some risk to reputation.
  • Activities that have a predictable return or accepted value versus those that have potential for greater positive impact but less certainty.

Despite these challenges, prevention is a policy imperative throughout the UK, if for no other reason than its potential to reduce future public spending. However, it’s particularly notable in Scottish policymaking.

The Scottish Government designated prevention as one of its priorities for reform in its response to the Christie Commission on the Future Delivery of Public Services. The influence of the preventative principle can be seen in the Single Outcome Agreements (SOAs) produced by local authorities and their respective Community Planning Partnership. The guidance to CPPs issued by Scottish Government in 2012 explicitly stated that SOAs “should promote early intervention and preventative approaches”.

Prevention aligns with some of the other principles behind the CPP process in Scotland and public service reform elsewhere  – the idea of co-operation between levels of government, pooling resources and sharing benefits.  It may be risky, but it’s an imperative that all organisations involved in funding, designing and delivering public services ought to embrace.


 

Further reading

Christie Commission on the future delivery of public services

Climate change, Single Outcome Agreements and Community Planning Partnerships

Renewing Scotland’s public services: priorities for reform in response to the Christie Commission

Preventative spending and the ‘Scottish policy style’

The preventative agenda in Scotland is a worthy initiative, but the tensions inherent in its execution may yet undermine it

The Idox Information Service has a wealth of research reports, articles and case studies on public policymaking. Abstracts and access to subscription journal articles are only available to members.

How preventative policymaking could benefit local authorities

Crossing out problems and writing solutions on a blackboard.By Stephen Lochore

Preventative policy and spending aim to address the root causes of social and economic problems. In public policy, it’s most commonly applied in the fields of health and social care, early years education, welfare and criminal justice (reducing offending).

Early in November, I spoke at a seminar organised by the Scottish Centre on Constitutional Change and SCVO which explored preventative policy in Scotland.  While we inevitably spent some time discussing the challenges, there was a strong collective feeling about the advantages of a preventative approach to policymaking.  Continue reading

World Alzheimer’s Day: can we reduce dementia risk?

Older woman with Alzheimer's in a chair

Image courtesy of Flickr user Vince Alongi using a Creative Commons license

By Steven McGinty

On the 21st September, Alzheimer’s organisations across the world will be carrying out events to raise awareness about Alzheimer’s and dementia. The event, a key part of World Alzheimer’s Month, was launched by Alzheimer’s Disease International (ADI) in 1994, with the aim of highlighting the tremendous work carried out by Alzheimer’s organisations.

Each year, a new theme is selected for World Alzheimer’s Month, and this year the focus will be on how we can reduce the risks of developing Alzheimer’s and dementia. In support of this event, I’ve decided to look at some of the statistics on dementia, as well as review the latest evidence on reducing the risks.

Continue reading

Low-level child neglect is a high-stakes issue

Upset boy against a wall

Guest blog by Emily Buchanan, Research Manager, NFER

Earlier this year, an Action for Children report highlighted that neglect is the most common form of child abuse in the UK today.

Up to one in 10 children across the UK suffers from neglect; it is the most frequent reason for a child protection referral, and it features in 60 per cent of serious case reviews into the death or serious injury of a child. So, how is our research seeking to support those tirelessly campaigning to end child neglect? Continue reading

The way forward for mental health services for children and young people

Black and white photo of young girl.

Image courtesy of Flickr user darcyadelaide using a Creative Commons license

By Steven McGinty

“Not fit for purpose” and “stuck in the dark ages”

These are two of the phrases used by the Care Minister, Norman Lamb, to describe mental health services for children and young people in England. The minister admitted that young people are being let down by the current system and has announced that a new taskforce will look into how the system should be improved.  To coincide with this review, I decided to look at the current situation for children and young people with mental illness, as well as highlight some of the main themes from the latest evidence.

The Office for National Statistics (ONS) reports that one in ten children and young people (aged 5-16) have a clinically diagnosed mental health disorder. This covers a broad range of disorders, including emotional disorders, such as anxiety and depression, as well as less common disorders such as autism spectrum disorders (ASD) and eating disorders. Approximately 2% of these young people will have more than one mental disorder. The most common combinations of disorders are conduct and emotional disorders and conduct and hyperkinetic disorders.

The likelihood of a young person developing a mental disorder is increased depending on a number of individual and family/ social factors. There are a whole range of risk factors, but some of these include:

  • having a parent in prison
  • experiencing abuse or neglect
  • having a parent with a mental health condition
  • having an autistic spectrum disorder (ASD)

It’s important to note that mental illness is complex, and that not everyone in these risk groups will struggle with it. This is particularly true when a young person is in receipt of consistent long-term support from at least one adult.

The impact of mental illness can be particularly difficult for young people. For instance, the National Child and Adolescent Mental Health Service (CAMHS) Support Service reported that young people who suffer from anxiety in childhood are 3.5 times more likely to suffer from depression or anxiety in adulthood. There is also an increased chance of young people coming into contact with the criminal justice system, with Young et al highlighting that 43% of young people in prison have attention deficit hyperactivity disorder (ADHD). The Centre for Mental Health also suggests that young people with mental health problems struggle to achieve academically, as well as in the employment market.

When a government minister condemns his own department, it’s evident that there are severe problems.  However, this does not have to be the case.

Below I’ve outlined some of the key lessons to come from evidence on what makes a good mental health service for children and young people.

Continue reading