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What does a ‘Public Health’ approach to violence really mean?

Three professionals have a conversation together. Two are sat at a table, working on their laptops, while a third sits on the edge of the table holding a coffee cup. They are all smiling.

This week, the Home Secretary announced that the Government would take a ‘public health’ approach to tackle youth violence. Last month, the Mayor of London announced a Violence Reduction Unit based on the successful Scottish Violence Reduction Unit (VRU). Again, he announced it would have a ‘public health approach.’ It’s a term we hear a lot – and a term we hear misused a lot.

But what does a public health approach actually mean?

A public health approach is one which:

  • takes a population approach, not one which just focuses on high risk individuals,
  • is preventive: by tackling ‘upstream’ risk factors, it aims to lessen ‘downstream’ consequences,
  • takes a system wide multi-agency approach including involving business and volunteers,
  • takes brave decisions that require a long-term commitment, and
  • recognises the complexity of the issue, and seeks to build an evidence base that reflects that.

It’s an established approach outside of youth violence. Take the emergency services. Firefighters are now offering “Safe and Well” visits whilst installing smoke alarms in the homes of more vulnerable people in our communities. The approach includes fire safety advice, and how to reduce hoarding and clutter. Firefighters have worked out it is better to prevent a fire than to fight it later with inevitable and often tragic human costs. This type of upstream public health prevention is one we could learn from in addressing knife crime.

The VRU evidences the success of this approach. It sets out what they do in terms of primary, secondary and tertiary prevention. It considers which of these will be universal (aimed at the general population) and which will be targeted at those more at risk. This is a classic public health approach with primary prevention meaning preventing violence before it happens, secondary prevention being an immediate response to instances of violence and tertiary prevention focusing on long term care and rehabilitation.

The reality is that organisations such as Catch22 are largely commissioned to provide tertiary prevention, and occasionally secondary prevention both in a highly targeted way. Whilst these services are undoubtedly necessary, unfortunately we see all too often that these come too late for many, and to use a medical analogy are ‘treating the symptoms’ of youth violence, ‘rather than the disease’.

How do you commission a public health approach?

A public health approach focuses on the population, not the sector or the service. So the commissioning approach needs to look beyond the service or sector to the population and commission jointly. It is undoubtedly multiple ‘commissioners’ who need to be brave. No one agency or service can achieve these outcomes alone and a multi-disciplinary/multi-agency approach is certainly required to tackle these issues. We are currently commissioned by health, local authorities, police, Police and Crime Commissioners (PCCs), prisons, and work with employers to provide apprenticeships and other employment opportunities. We want to knit these services together to reduce youth violence.

It’s not easy. Commissioners need to be brave, and prepared to take risks, albeit calculated ones. These are not quick fix solutions. A public health approach will probably take at least the length of a school career if not a generation, and the return on investment is many years off and more than likely to another agency. It took the VRU over 10 years to make an impact. In 2004-05 there were 137 murders in Scotland but by 2016-17 the total had more than halved to 61.

What are we doing to move towards a public health model?

We are moving our delivery models upstream, where possible. Catch22’s Wolverhampton Violence Reduction service is an good example. We have adopted a three Tier approach:

  • Tier 1 is working with schools and young people to divert those at risk away from negative influences using intensive support and educational approaches.
  • Tier 2 provides interventions that work with those already active in gang lifestyles, providing one-to-one and group interventions that offer a range of positive alternatives and opportunities as part of our bespoke gang exit programme R.O.A.D.
  • Tier 3 services provide more tertiary interventions, working closely with statutory agencies supporting those heavily involved in gang lifestyles, known to Police, Youth Offending Team (YOT)and Integrated Offender Management (IOM) teams as an active gang member.

Whilst this approach attempts to prevent youth violence, at best it is a largely focused on those already at risk and has therefore misses prevention opportunities, particularly primary prevention ones. Whilst a focus on risk factors, such as school exclusion, and gang membership is welcome to create a paradigm shift across the population of London we need to track back from the downstream consequences and look at the environmental and social factors and what can really change the overall landscape. Just focusing on high risk individuals, won’t solve the problem. Presenting this another way, we can’t just focus on those individual with high concentrations of Adverse Childhood Experiences (ACEs) we need to aim to prevent these occurring as well as focus on where they already exist.

Primarily this approach is about shifting action ‘upstream’, but none of this takes away from the very real complexity of the way factors interact in society to produce violent crime (reference 2). Any theory of change needs to recognise the complexity of this interaction. There are recent lessons here too from public health where the limitations of evidence building to date have led to a focus on individual level interventions and a downstream approach. We require an approach that reflects real life complexity, a complexity we see every day at Catch22.

As the Firefighters have worked out, it is better to prevent a fire than to fight it later with inevitable and often tragic human costs.

– Peter Jones, Director of Justice Reform at Catch22, and Emma De Zoete, Director of Health and Public Health Consultant.
– With thanks to the thinking and writing of Greg Fell, Sheffield’s Director of Public Health.