Victim services in the National Health Service (NHS): combining treatment with violence prevention

Trends in violence in England and Wales 2010-2014

BACKGROUND

The National Violence Surveillance Network (NVSN) of emergency departments (ED), minor injuries units and walk-in-centres in England and Wales has brought clarity to contradictory violence trends derived from crime survey and police data. Gender, age-specific and regional trends in violence-related injury in England and Wales since 2010 have not been studied.

METHODS

Data on violence-related injury were collected from a structured sample of 151 EDs in England and Wales. ED attendance date and age and gender of patients who reported injury in violence from 1 January 2010 to 31 December 2014 were identified from attendance codes, specified at the local level. Time series statistical methods were used to detect both regional and national trends.

RESULTS

In total, 247 016 (178 709 males: 72.3%) violence-related attendances were identified. Estimated annual injury rate across England and Wales was 4.4/1000 population (95% CI 3.9 to 4.9); males 6.5/1000 (95% CI 5.6 to 7.2) and females 2.4/1000 (95% CI 2.1 to 2.6). On average, overall attendances decreased by 13.8% per year over the 5 years (95% CI -14.8 to -12.1). Attendances decreased significantly for both genders and all age groups (0-10, 11-17, 18-30, 31-50, 51+ years); declines were greatest among children and adolescents. Significant decreases in violence-related injury were found in all but two regions. Violence peaked in May and July.

CONCLUSIONS

From an ED perspective, violence in England and Wales decreased substantially between 2010 and 2014, especially among children and adolescents. Violence prevention efforts should focus on regions with the highest injury rates and during the period May-July.

All-Wales Licensed Premises Intervention (AWLPI): a randomised controlled trial of an intervention to reduce alcohol-related violence

Background

Violence in and around premises licensed for the on-site sale and consumption of alcohol continues to burden the NHS with assault-related injuries.

Trial design

A randomised controlled trial with licensed premises as the unit of allocation, with additional process and cost-effectiveness evaluations.

Methods

Premises were eligible (n = 837) if they were licensed for on-site sale and consumption of alcohol, were within 1 of the 22 local authorities (LAs) in Wales and had previously experienced violence. Data were analysed using Andersen–Gill recurrent event models in an intention-to-treat analysis. An embedded process evaluation examined intervention implementation, reach, fidelity, dose and receipt. An economic evaluation compared costs of the intervention with benefits.

Intervention

Premises were randomised to receive a violence-reduction intervention, Safety Management in Licensed Environments (SMILE), which was delivered by an environmental health practitioner (EHP; the agent). SMILE consisted of an initial risk audit to identify known risks of violence, a follow-up audit scheduled to enforce change for premises in which serious risks had been identified, structured advice from EHPs on how risks could be addressed in premises and online materials that provided educational videos and related material.

Objective

To develop intervention materials that are acceptable and consistent with EHPs’ statutory remit; to determine the effectiveness of the SMILE intervention in reducing violence; to determine reach, fidelity, dose and receipt of the intervention; and to consider intervention cost-effectiveness.

Outcome

Difference in police-recorded violence between intervention and control premises over a 455-day follow-up period.

Randomisation

A minimum sample size of 274 licensed premises per arm was required, rounded up to 300 and randomly selected from the eligible population. Licensed premises were randomly assigned by computer to intervention and control arms in a 1 : 1 ratio. Optimal allocation was used, stratified by LA. Premises opening hours, volume of previous violence and LA EHP capacity were used to balance the randomisation. Premises were dropped from the study if they were closed at the time of audit.

Results

SMILE was delivered with high levels of reach and fidelity but similar levels of dose to all premises, regardless of risk level. Intervention premises (n = 208) showed an increase in police-recorded violence compared with control premises (n = 245), although results are underpowered. An initial risk audit was less effective than normal practice (hazard ratio = 1.34, 95% confidence interval 1.20 to 1.51) and not cost-effective. Almost all eligible intervention premises (98.6%) received the initial risk audit; nearly 40% of intervention practices should have received follow-up visits but fewer than 10% received one. The intervention was acceptable to EHPs and to some premises staff, but less so for smaller independent premises.

Conclusions

SMILE was associated with an increase in police-recorded violence in intervention premises, compared with control premises. A lack of follow-up enforcement visits suggests implementation failure for what was seen as a key mechanism of action. There are also concerns as to the robustness of police data for targeting and assessing outcome effectiveness, while intervention premises may have received greater attention from statutory agencies and, therefore, the identification of more violence than control premises. Although SMILE had high reach and was feasible and acceptable to EHPs, it was found to be ineffective and associated with increased levels of violence, compared with normal practice and it requires additional work to promote the implementation of follow-up enforcement visits. Future work will aim to better understand the role of intervention dose on outcomes and seek more objective measures of violence for use in similar trials.

Trial registration

Current Controlled Trials ISRCTN78924818.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 3, No. 10. See the NIHR Journals Library website for further project information.

Preventing violence — caring for victims

Part of the great tradition of surgery, exemplified by the Royal College precept, 'From Here Health', is that surgeons are committed to prevention as well as cure. King James IV and his able contemporary in China, where this lecture was delivered, Emperor Hongzhi, would have approved of it. This tradition has, perhaps, been neglected since the emergence of public health as a medical specialty. However, opportunities and reasons for surgeons to contribute to prevention have never been greater. Community violence prevention--increasing public safety in the towns and cities in which surgeons work--is an example. Primary prevention of injury achieved by collecting and sharing unique information about weapons and the locations of assault, secondary prevention achieved by combining wound care with motivational interviewing to reduce alcohol misuse, and tertiary prevention achieved by early referral to mental health professionals for treatment of post-traumatic stress, have been integrated into a new care pathway which combines prevention with surgical care. Individuals and communities would benefit substantially if every surgical specialty incorporated prevention--a professionally highly-rewarding activity--into its training curriculum.

Preventing alcohol-related violence: a public health approach

BACKGROUND

Studies of the relationship between alcohol and violent injury confirm that while there is some evidence of a direct pharmacological association, many other factors are relevant to the frequency and severity of both violent perpetration and being a victim of violence. It is now widely recognized that official police statistics are a poor indicator of the nature and extent of public violence.

AIMS

Accident and emergency departments and trauma surgeons are not only in a position to provide more accurate information on the nature and extent of clinically significant injury, but they can contribute substantially to violence prevention. This can be achieved through individually targeted interventions in conjunction with other clinicians on the one hand, and on the other through public health and community initiatives, in conjunction with other community agencies, including the police and local authorities. This article describes some of those initiatives and the evidence underpinning them.