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The public health solution to rising levels of violence

London’s mayor wants to treat knife crime as a public health issue, writes Alex Turnbull

The UK is suffering an epidemic of violence, as police in England report a 22% rise in knife crime. This figure was revealed amid a spate of stabbings in London earlier this year. In 2017, 40,000 offences involving knives or sharp weapons were recorded by police – the highest level in 7 years. Gun crime has also increased by 11% to 6600 offences. Additionally, 2018 is likely to be on course to be the worst year in a decade for child murders, with 37 children and young people stabbed to death since January.

With extensive cuts to funding, frontline policing services are struggling to manage the crisis, forcing policy makers to look to other options to stem the tide of violence. Could a public health model be the answer to mitigating this crisis? After all, if we believe that the public can be educated out of risky behaviours, such as drinking and smoking, why not violence.

London’s Mayor, Sadiq Khan, recently grasped the nettle when he announced the creation of a ‘violence reduction unit’,a model adopted from Scotland. ‘The causes of violent crime are extremely complex, involving deep-seated societal problems like poverty, social alienation, mental ill-health and a lack of opportunity,’ said Mr Khan. ‘Since I became Mayor, I’ve been working tirelessly with local councils, charities and community groups on a public health approach to tackling serious violence, but it’s clear we need to do more to support them in driving down not just knife crime, but all forms of violent crime.’

‘The new Violence Reduction Unit is a positive step to tackle the current scourge of violent crime in London. We need to provide a safer future for our city’s young people where reducing violence offers them better life opportunities, good health and the chance to live,’ said Regional Director for Public Health England, Dr Yvonne Doyle.

‘We need to think differently about how violence takes root and adopting a public health approach where we listen to communities, use the best available evidence and try new ideas, could provide real solutions to the causes and triggers of violence.’

Violence reduction

In January 2005, Police Scotland established the Violence Reduction Unit (VRU). The unit’s aim was to target all forms of violent behaviour, in particular knife crime and weapon carrying among young men in and around Glasgow.

The VRU was influenced by the World Health Organisation’s World Report on Violence and Health (2002), which said that the public health sector is directly concerned with violence not only because of its huge effect on health and health services, but also because of the significant contributions that can and should be made by public health workers in reducing its consequences. Public health can benefit efforts in this area with its focus on prevention, scientific approach, potential to coordinate multidisciplinary and multisectoral efforts, and role in assuring the availability of services for victims.

Public health complements existing approaches to violence, which are mainly reactive, by focusing on changing the behavioural, social, and environmental factors that give rise to violence.

The VRU became the only police force in the world to adopt a public health approach to violence. Treating it like a ‘disease’ the unit sought to diagnose the problem, analyse the causes, examine what works and for whom and develop solutions, which once evaluated, could be scaled up to help others.

In practice, what this means is the VRU reach out to schools, healthcare providers and social care institutions, with the aim of reaching the ‘clients’ and assessing the root cause of their behaviour. There are many ‘co-morbidities’ to violence, such as alcohol abuse, drug addiction, an abusive childhood, and homelessness. If these can be tackled by health and social care services, the patient is less likely to become a repeat offender, thus relieving the strain on policing, who can then focus on only the most violent offenders.

Given that only around 40% of violence is reported as crime, a key area of focus was how to mobilise the health and care system to combat violence. For example, if a patient attends accident and emergency with stab wounds, once the immediate damage has been fixed, the patient can be referred to a VRU. They can then be put in touch with social services, and receive advice and counselling on how they can avoid violence in the future. Under a conventional method of policing, the patient would likely be discharged from hospital, and would likely be back with further wounds.

To do this the VRU in Glasgow partnered with agencies in the fields of health, education and social work. According to the unit, the aim was to create long-term attitudinal change in society rather than a quick fix. The VRU also focused on enforcement seeking to contain and manage individuals who carry weapons or who were involved in violent behaviour.

‘Despite policing’s best efforts, the problem was getting worse. The recommendations that policing could not change the problem,’ said Will Linden, deputy director of the VRU.

‘The drivers behind the violence couldn’t be solved by policing alone. We were lucky at the time with the chief constable, Sir Willie Rae, who gave us carte blanche to think differently about something, so we tried to gather people together to look at the problem in a different way. That was how we started basically. We looked at all the possible solutions and all the different areas. We decide to focus on intervention.

In April 2006, the unit’s remit was extended nationwide, creating a Scottish centre of expertise on tackling violent crime. Funded by the Scottish Government, the unit’s job was to treat violence in all its forms – from gang fighting to domestic abuse and bullying in schools and the work place.

The approach in Scotland has achieved some remarkable results, with Glasgow going from being one of the most dangerous cities in Europe, to a relatively safe one.

‘We thought if you can tackle the problem in Glasgow, it will work anywhere. What we saw was a 60% reduction in homicide levels, over 50% reduction in assaults since the programme began. A priority was knife crimeare was, with young people in particular. It has seen an 80% reduction,’ said Will Linden, deputy director of the VRU.

‘We managed to reduce the number of people going into gangs, through partnership delivery. We were only there as a focal point, but we have seen a social change. Knife crime in particular. Now it is no longer cool to carry a knife. It’s no longer seen as the norm, whereas previously everyone was carrying them.’

The nurse’s role

While nurses working in primary care are unlikely to be treating stab wounds, they still have a role to play in the public health approach to tackling violence. As they are often the first contact in a health consultation, nurses may notice the physical and mental strain inflicted by involvement in gangs or violent behaviour, or the co-morbidities of substance abuse or a chaotic home life, before anyone else.

The announcement of a VRU is a laudable initiative, and hopefully the first on the path to a safer London. However, despite the noble intentions of the London Mayor’s office, it may take ten years for London’s streets to become safer. But if the experience of Glasgow is anything to go by, it is undoubtedly a step in the right direction.

‘The police for years have been experts at detection and enforcement. I’d much rather be top of the cliff putting a fence up, stopping somebody jumping over, as at the bottom of the cliff waiting until they’ve jumped,’ said Iain Murray, a police officer who worked for the VRU. ‘That’s the public health approach as far as I’m concerned.’