The Scottish Government

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chapter 9 violence in scotland

Violence in Scotland is a chronic problem. Levels of violent incidents have not changed for at least 30 years and have probably remained static since the 1930s. Glasgow has the highest homicide rate in Europe per head of population: the rate of murder committed with a knife is 3.5 times higher than that of England and Wales. Economically, the impact on Scotland is substantial - treating those affected by violence costs an estimated 3-6% of the NHS budget ⁸⁹. This equates to almost £400 million. Each murder investigation costs the justice system an estimated £1.3 million, while each serious assault costs an average £19k. With over 90 murders and 6000 serious assaults in 2006, violence poses a significant threat to Scotland's health - and wealth.

The World Health Organisation ⁹⁰ ( WHO) report on violence (2002) highlights Scotland as having a homicide rate of 5.3 per 100,000 population in males aged between 10-29, with an overall rate of 3.1. This is similar to Argentina, Costa Rica and Lithuania. The rate in England and Wales for the same age group is 1.0 per 100,000. However, murders in Scotland are the tip of an iceberg, beneath which lies an increasing volume of attempted murders, serious and simple assaults and a culture of knife carrying. Police figures tell an incomplete story; surveys in A&E departments in Scotland and in England and Wales indicate that on average only 30% of violence presenting to emergency departments is reported to the police ⁹¹.

The impact of violence on victims is incalculable, not only from the initial offence but long term. High rates of injury and illness are related to assaults, and violence leaves permanent scars, both physical and psychological. A deprived young urban male may suffer 60 years of physical incapacity as a result of injury and associated decline in quality of life and self esteem ⁹².

Until recently, violence in Scotland fell almost solely within the remit of police, courts and prisons. Yet despite the highest ever prison population in Scotland, with over 42% of the prison population incarcerated for serious interpersonal violence and huge investment in apprehending, sentencing and imprisoning offenders, violence rates have continued unabated. Over 50% of murders are committed within the home and it is difficult to see how policing alone could prevent them ⁹³. It is clear that although the police have a significant role in prevention and dealing with offenders, sole reliance on the ability of the justice system to stem the tide of victims and violent individuals is misplaced.

Yet violence is not an inevitable part of the human condition. The WHO highlights that "in much the same way as infectious diseases and other threats to public health have been in the past, violence can be prevented and its impact reduced".

Scotland has come to a crossroads over the past three years in relation to tackling violence, with a range of policy makers across health, education, police and other areas recognising that there are opportunities to change our culture by changing our methods. It is the public health approach to violence prevention which offers Scotland the best opportunity to shrug off its past and provide a safer, healthier environment for its people.

Table: Serious Violence in Scotland 1996-2006

Includes: Murder, Attempted Murder and Serious Assault
Source: Scottish Executive Statistics

Figure 9.1: The Public Health Approach to Violence Reduction

Tackling violence using a public health approach

Surveillance - understanding the problem

The under reporting of violence in Scotland may be down to a number of factors, e.g. lack of access to phones to report, victims on the fringes of criminality themselves or victims with the intention to perpetrate retaliatory violence. The result of this under reporting is that an incomplete picture of violence exists, limiting the ability of agencies including the police to prevent victimisation, target offenders and impact on environments that enable violence to occur.

Further, existing interventions targeted at reducing violence cannot be accurately evaluated to establish their effectiveness. A true measure of their success will be in reducing the number of patients presenting to A&E, GPs and dentists as a consequence of violence. For this to occur, injury surveillance must be the cornerstone of violence reduction in Scotland.

Data from the Scottish Trauma Audit Group ( STAG) indicates that over the 6 week period in March 2006, 3281 individuals reported to A&Es in Scotland as victims of violence. Yearly, this equates to an estimated 28,400 presentations. When one considers that only 7000 crimes of serious assault are reported to Scottish Forces in a year, the disparity is significant and much effort needs to be expended to narrow the gap ⁹¹.

Cooperation with the police and the NHS in Scotland, and in particular with Accident and Emergency Departments, is well developed. A data set of questions was developed (see text box) which enable in depth analysis of the problem and tasking of different agencies to tackle it. An initial paper based pilot by Glasgow Royal Infirmary of anonymised injury surveillance indicated that it was feasible and did not impact negatively on hospital time. Recommendations for further roll out of the system were dependent on an electronic solution to capture data to aid compliance and the dissemination of timely information.

As a result Lanarkshire NHS Board and Glasgow Royal Infirmary are about to embark on electronic injury surveillance project. Similar projects are being developed in Aberdeen, Edinburgh and Fife, with the aim of introducing a national surveillance system.

Injury surveillance

Injury surveillance questions are designed to gather information that can be acted upon by agencies such as the police and councils to prevent further injuries occurring.

Questions are asked about:

• Location and address of the assault, e.g. licensed premises, home or street.
• Weapons used, e.g. knife, glass, blunt objects.
• Was assailant known? e.g. acquaintance, stranger.
• Reason for assault, e.g. gangs, drugs, racial, religion.From the data other agencies can examine licensing of premises, improving lighting and services in assaults hot spots, improving transport services and taxis to disperse people from potential flashpoints, to better direct policing to areas where intelligence suggests that injuries are likely to occur.

Figure 9.2: Factors Increasing the risk of violence

Understanding the risks and protective factors of violence is key to developing strategies that will bring about the sustainable change required. However, there is no single cure - violence is a multi-faceted problem with complex causality.

Violence risk factors such as alcohol, drugs, deprivation and exclusion from school have been well documented. However, despite the plethora of work required on aspects such as swift visible justice for offenders, gangs and territorialism, it is the focus on the skills delivered in the early years of life, such as communication, empathy and problem solving, which research suggests will deliver the most significant impact on levels of violence ⁹⁴. A noticeable lack of these skills is evident amongst those with poor behavioural control. Efforts to address these issues when individuals enter the criminal justice system prove to be expensive and often unsuccessful, whereas targeted support of parents and children in early years has shown significant results in terms of equipping youngsters with the skills that enable them to lead lives where violence is not an inevitability.

Interventions and implementation

To truly act to reduce violence in Scotland, we must address through treatment and police enforcement not only violence as it occurs, but also before it occurs by working with communities throughout Scotland to prevent violence before it starts. To do this we must consider three tiers of intervention:

• PRIMARY PREVENTION - seeking to prevent the onset of violence, or to change behaviour so that violence is prevented from developing.
• SECONDARY PREVENTION - to halt the progression of violence once it is established or for those at risk - this is achieved by early detection followed by prompt, effective treatment.
• TERTIARY PREVENTION - the rehabilitation of people with an established violent behaviour or affected as a victim.

There are some extremely promising, evaluated interventions designed to deal with violence already in place in Scotland, aimed at preventing the onset of violence, tackling those at risk and dealing with those who have already perpetrated violence or have been victimised: Triple P (Positive Parenting Programme), PALS (Parents Altogether Lending Support), violence and alcohol counselling within hospital clinics and innovative enforcement will all deliver reductions.

Control of Violence for Angry Impulsive Drinkers ( COVAID)

Maxillo Facial Surgeons in Glasgow deal with a serious facial injury, on average, every 6 hours, 24 hours a day, 365 days a year. Over a third of victims will have been assaulted more than once in the previous year, and over half will have consumed alcohol prior to their assault. In an attempt to address the factors which led to the assault, three hospitals in Glasgow are involved in a trial where nurses deliver a brief motivational intervention ( COVAID) within hospital clinics to equip victims with skills to prevent further injury.

The Nurse Family Partnership

The Nurse Family Partnership is a programme designed by David Olds of the University of Colorado. Over the past 27 years it has been implemented in various parts of America. Evaluation shows reduced child abuse and neglect and less parental alcohol and drug abuse. It targets predominately young, poor, single mothers as early on in pregnancy as possible and has three aims: to improve the outcomes of the pregnancy by helping women improve their prenatal health; to improve the child's health by providing more sensitive and competent care; and to improve parental life by helping parents plan future pregnancies, complete their education and find work.

In three, large-scale, randomised controlled trials the programme has been tested and evaluated with different populations living in different contexts. It has been demonstrated that parental care of children has improved with fewer injuries associated with child abuse and neglect and better emotional and language development. Over a longer period the mothers have fewer subsequent pregnancies, greater workforce participation and reduced dependency on welfare. In late 2006, the welcome news was announced that Child Family Partnership projects would be trialled in the UK.

Table 1 - Interventions to prevent and tackle violence

However, scaling up of such initiatives and the delivery of a Scottish-wide parenting policy and early years support is the greatest challenge. The report by the Work Foundation in 2006, states that "Investing in early years is as close as it gets to magic without being magic". Parenting support and enriched day care, and preferably both together, create children with better behaviour and attitudes who will arrive at school with a capacity to learn. Programmes that continue into primary school have the most sustained long-term effects ⁹⁵.

Triple P - Positive Parenting Programme

Is a multi-level, prevention-orientated parenting and family support strategy. It incorporates five levels of intervention, from birth to age 16. Evaluation of Triple P shows consistent findings of decreases in child behaviour problems and meaningful outcomes for both parents and children. Running in Glasgow since 2003, the programme has demonstrated increasing self esteem and confidence in parents.

Operation Blade

In the early nineties, Strathclyde Police launched Operation Blade, designed to crack down on violent crimes involving knives. Operation Blade was prompted by a wave of media publicity about knife crime and resulted in more than 5,000 weapons being handed in to the police.

Some time later, Glasgow Royal Infirmary conducted a detailed analysis of the impact of Operation Blade. The report read: "There were no significant differences in the nature or number of assault victims attending this hospital one year after Operation Blade compared with the month before its implementation." The report concluded: "Operation Blade reduced the number of serious stabbings for a period of ten months, but subsequently numbers surpassed those prevailing before its implementation."

Operations similar to Blade have been carried out across Scotland over 2006 and 2007. Although successful in the short term, the reductions and activity were not sustainable.Setting up of many of these programmes will be financially onerous with few benefits in the short term; but if Scotland is committed to reducing the burden of violence in the long term then such programmes are key.

Conclusion

A Public health approach is best placed to deliver many of the long-term solutions to violence, and Scotland is one of the few countries to commit to reducing violence long term by examining opportunities to prevent the development of violent individuals. By looking after our children and developing our early years provision, the possible future benefits stretch far beyond that of violence prevention and will help to deliver the Scottish Government's promise of a healthier, wealthier and safer Scotland.

"Investing in early years is as close as it gets to magic without being magic"

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