Jonathan Shepherd Lecture - 11 December 2002

Violence which results in medical treatment is substantially under-recorded by police forces: the British Crime Survey demonstrates that only about 25% of moderately serious offences are recorded by the police. From an A&E perspective only about 25-50% of assaults appear in police records and in the US, only 40% of aggravated assaults (assaults with a weapon or causing significant injury) appear in police records. Importantly, police recording cannot be predicted on the basis of injury severity. The most important implication of this under-recording is that health facilities, particularly A&E Departments are potentially very important sources of information about the circumstances (for example, location, time, weapon, etc) of assault which can be used by police and other crime prevention agencies better to target what are limited prevention resources. Another important implication is that substantial numbers of offenders are not being brought to book.

Alcohol misuse has been shown to be causally related to risk of injury in assault. In the population which matters, males and females aged 15-30 years, binge drinking (more than about seven units of alcohol in a six hour drinking session) is a major risk factor. Alcohol dependence only becomes a risk factor for males over the age of about 45. A significant relationship has been found between alcohol dose and severity of injury. The risk of repeat injury has been shown to be reduced following reduction in alcohol consumption. Nationally and regionally, the risk of assault injury has been shown to be significantly related to the price of lager, real expenditure on alcohol and proportion of household expenditure on alcohol.

An antisocial lifestyle has been found to predispose to a wide range of social problems and injury. Antisocial children, teenagers and young adults are prone to truancy, teenage pregnancy, drug misuse, offending and injury, particularly assault injury. There is substantial overlap between injury in assault and offending: a far greater proportion of assault patients have a criminal record compared to age and gender-matched victims of road accidents for example. The medical effects of an antisocial lifestyle characterise DATES syndrome comprising Drug Abuse, Assault, Trauma and Elective Surgery.

Significant links have been found between injury in assault, deprivation (Townsend scores) and unemployment. Susceptibility to assault injury in lower income groups relates to ability to pay for heavy binge drinking at the weekends.

Assault injury is seasonal with peaks in the summer/spring and troughs in the winter. In regional and capital cities however, periodic increases in city centre night-time population because of major public events like New Year celebrations - can mask overall seasonality.

There is a growing literature on evidence based violence prevention centred in the Campbell collaboration (the social science Cochrane). Medical contributions include evidence based primary prevention (toughened glass, plastic bottles, firearms legislation, permanent restriction orders to prevent repeat domestic violence); secondary prevention (preventing repeat injury through brief alcohol interventions; and tertiary prevention (limiting the effects of injury through interventions to improve wound healing and to limit the psychological effects of violence, including post traumatic stress disorder, anxiety and depression).

Knowledge of the substantial extent to which violence which results in treatment is not recorded by the police and of risk factors makes a multiagency, criminal justice system/police/accident and emergency/public health approach to violence an obvious way forward. Furthermore, effective multiple interventions usually act synergistically the combined prevention yield is greater than the sum of the efforts of individual agencies. The Cardiff Violence Prevention Group, comprising Cardiff County Council, South Wales Police, A&E Department, Psychiatry and Judiciary members, is an example which is cited in the 1998 Crime and Disorder Act as a model of good practice. The objectives of this Group are to prevent violence and provide integrated services for the injured which take account of mental health needs. From an organisational standpoint, medical staff are less likely to be transferred than personnel working in other agencies and can therefore provide stability.

Effective multiagency interventions include pooling data from police and A&E sources to improve targeted policing of violent hotspots such as licensed premises and schools. A&E data have proved an objective measure of assault injury and are being developed as a new police performance/crime prevention measure. Health professionals, particularly senior nurses and A&E and public health consultants can be powerful advocates for community violence prevention.

Effective interventions to increase the reporting of violent offences include the provision of free phone links to the police in A&E Department waiting areas combined with campaigns among trauma patients through leaflets to encourage police reporting. It has been shown that deterrence is best achieved not through increasing severity of punishment but through increasing the certainty of punishment.

1. Accident and Emergency Departments should be more than passive receivers of the injured: they need to develop as sentinel places in communities for violence prevention through appropriate data sharing and advocacy.
    
2. Violence is a public health issue because it causes widespread health problems (injuries and the psychological impacts of assault) and because much of it only comes to the attention of the NHS. The NHS now has as a statutory responsibility to work with Local Authorities and the Police to tackle violence. Furthermore, public health analytic expertise is, in contrast to police analytic expertise, both present locally and well practised in prioritisation on the basis of surveillance.
    
3. Since brief alcohol interventions combined with suture removal/dressing changes in trauma clinics have been shown to be an effective intervention, nurse training in trauma and maxillofacial clinics and in primary care is necessary to ensure that alcohol abusing patients with injuries are counselled about their alcohol misuse when they attend for treatment.
    
4. To achieve integrated services for victims which take account of mental health needs, a referral framework comprising the A&E Department, Laision Psychiatry, Victim Support and Primary Care is necessary.