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8. SAFER SCOTLAND

ALCOHOL USE AND ASSOCIATED HARMS

Introduction

1. This paper sets out some of the key health inequalities in relation to alcohol use and associated harms in Scotland.

2. There is now a greater awareness of the problems caused by alcohol misuse, from the short and long-term physical and mental health harms to anti-social and offending behaviour, and the negative impact this has on Scotland. As a result, the negative effects of excessive alcohol consumption continue to dominate the debate on health improvement.

3. Although many people in Scotland do drink sensibly, alcohol misuse is responsible for significant levels of harm to individuals' health, to families and to our communities. For example, in 2005-06, there were over 40,000 alcohol-related discharges from Scottish hospitals and currently one Scot dies every six hours as a direct result of alcohol misuse. The problems associated with the misuse of alcohol are particularly acute in Scotland compared to the rest of the UK and can often disproportionately affect those living in our poorest communities (see Annex A). This is why Ministers have recognised the need for a long-term strategic approach to tackle alcohol misuse in Scotland.

Health inequalities in alcohol-related health harms

4. The relationship between excessive drinking and socio-economic factors is not straightforward. However, while statistics show that consumption levels probably vary little across socio-economic groups, alcohol-related harms are strongly correlated with deprivation. ¹⁶ These include health harms as well as wider social harms, for instance:

• In 2005-06, people resident in the most deprived areas (as measured by the Scottish Index of Multiple Deprivation) were six times more likely to be admitted to a general hospital and almost eight times more likely to be admitted to a psychiatric unit with an alcohol-related diagnosis than those in the least deprived areas.

• The alcohol-related death rate in Scotland among the most deprived members of society is six times higher than among the most affluent (see figure in Annex A). This pattern holds for both men and women.

• Following adjustments for socio-economic circumstances, male mortality from chronic liver disease is significantly higher in West Central Scotland than the rest of Scotland. The increase in liver cirrhosis rates in Scotland over the last 10-15 years are amongst the highest in the world.

• At least 70% of all assaults presenting to A&E may be alcohol-related, with the vast majority involving young men.

• Leyland et al. Report (2007) found that relative inequalities in mortality are increasing and are greatest at younger ages for particular causes, such as alcohol, drugs and suicide, in the most deprived neighbourhoods (although absolute numbers for younger age groups are small).

• Homicide in Scotland 2006-07 shows that nearly half (47%) of the total of 167 persons accused in homicide cases in 2006-07 were reported to have been drunk or under the influence of drugs at the time. Of these, 30% were drunk, 8% were on drugs and 9% were both drunk and on drugs. In 41% of homicide cases it was not known if the accused was drunk or under the influence of drugs.

• 11,257 drink driving offences were recorded by the police in Scotland in 2005-06. There were a total of 990 casualties in Scotland as a result of accidents involving illegal alcohol levels. Of those casualties, an estimated 30 people were killed and 170 seriously injured. This suggests that around 1 in 9 road deaths in Scotland occur in an alcohol related incident. "Drinking and Driving 2007: Prevalence, Decision Making and Attitudes", published by the Scottish Executive, shows that the prevalence of driving after drinking is higher in social grades AB than in lower grades.

Statement of current policy and action in this area (with an impact on health inequalities)

5. A large a proportion of adults are drinking too much, across all sections of Scottish society. For instance, the Scottish Health Survey ( SHeS) 2003 reported that 63% of men and 57% of women who drank alcohol in the previous 7 days exceeded daily recommended limits (and these figures are considered an under-estimate). Alcohol misuse (in terms of consumption levels) cannot, therefore, be regarded as a minority issue.

6. Given that harmful and hazardous drinking are prevalent across the population, Scottish Ministers have confirmed that they wish to develop a long term strategic approach to tackle alcohol misuse, appropriate to the scale of the problem in Scotland and focusing on the long term objectives of reducing harm and achieving sustainable change. This approach, currently under development, is likely to take as its starting point a series of interventions which will impact on the whole population. There is considerable evidence to show that policies which affect the whole population can have a protective effect on deprived populations and reduce the overall level of alcohol problems.

7. However, a balance will require to be struck, as current trends and policy drivers also suggest that there are some groups (for instance, offenders and dependent drinkers) who will still require more targeted interventions. In addition, communication work currently under way around population segmentation will help support our understanding of the issues of particular concern to specific segments of the population enabling us to be more effective in our social marketing activity.

Resources devoted in this area directly or indirectly to reducing health inequalities

8. A key outcome of the Spending Review is the commitment of an additional £85.3 million over three years to tackle alcohol misuse in Scotland. This is in addition to the current annual alcohol misuse budget of £12.3 million, and to the larger sums from mainstream budgets spent by the NHS and other bodies in preventing and dealing with the consequences of alcohol misuse.

9. The additional £85.3 million is by far the single largest increase ever provided for tackling alcohol misuse in Scotland. As announced to Parliament, the main focus for this additional funding will be to ensure increased access to early intervention and treatment, and for prevention activity, which will form a key component of our long-term strategic approach. Given that harms from alcohol misuse correlate closely with levels of deprivation and inequality, the majority of this funding (which will identify and respond to harm) will therefore by definition be targeting inequalities. This will be particularly true of the delivery of brief interventions in acute, ante-natal and Keep Well settings.

10. The majority of the additional funding has been allocated directly to NHS Boards. The allocation formula takes into account levels of deprivation as well as the prevalence of excessive drinking. While strategic priorities will be set nationally, service commissioning decisions will be for NHS Boards and ADATs in line with locally identified need. We have asked Boards to consider health inequalities when determining local priorities.

What is known to work in reducing health inequalities

11. Although there is little specific evidence available on what works in reducing alcohol-related health inequalities, more generally, it is known that regulatory or structural interventions (e.g. seat belt legislation, banning smoking in public places) appear to reduce health inequalities more than information based approaches (e.g. nutrition labelling, drink drive campaigns). This is because more advantaged groups in society find it easier to avail themselves of, and therefore benefit from, health promotion advice.

12. Analysis of the effectiveness of brief interventions, of various forms and delivered in a variety of settings, show that interventions lead to a reduction in alcohol consumption among harmful and hazardous drinkers. A recent Cochrane Review found that brief interventions in primary care lead to a reduction in consumption by an average of four standard drinks. The Review found that the effect of the brief intervention was clear in men at one year follow up, although less clear for women. Little analysis on the effectiveness of brief interventions across socio-economic groups has been carried but it is assumed brief interventions are equally successfully across all groups.

What current action may the Task Force endorse or seek to extend

13. The work on developing a strategic approach for alcohol misuse recognises that the current updated Plan for Action on Alcohol Problems does not meet the scale of the problem in Scotland. The final strategy will be cross-government and bring all elements of alcohol policy into a coherent framework. The interventions proposed will contribute towards achieving the overall Purpose of the Scottish Government and its strategic objectives of a Healthier, Wealthier and Fairer, Safer and Stronger and Smarter Scotland. The interventions are likely to be a mixture of whole population and targeted measures. Work is currently ongoing and proposals for action on alcohol misuse are scheduled to be published for full public consultation before Summer 2008. An equality impact assessment of proposed outcomes and interventions will be carried out.

14. A new HEAT target on alcohol screening and brief interventions is being introduced in 2008-09. NHS Boards will be expected to monitor activity on delivering brief interventions in line with Sign Guideline 74, establish delivery arrangements, build capacity and develop monitoring systems. NHS Boards will be required to demonstrate how they will target efforts in A&E, primary care and ante-natal care, and amongst deprived populations. As noted in para 9 above, the new funding package will support Health Boards to roll out screening and brief interventions and to build workforce capacity.

15. The longer-term aim is for SIGN 74 to become part of the routine offer of the NHS. Given the strong relationship between alcohol-related harm and deprivation, the roll out of brief interventions may be expected to have the greatest impact on groups experiencing higher levels of harm.

16. Funding is being provided to support the Coal Industry Social Welfare Organisation ( CISWO) tackle smoking, alcohol misuse and associated health issues in the traditional coalfield communities across Central Scotland. The project will target some of the most disadvantaged communities in Scotland who suffer most from health inequality and social privation. The project will enable the local communities to develop their own networks of support via "Buddy Systems" and similar mechanisms so that the key objectives of smoking cessation and alcohol consumption moderation become embedded in the local culture as core values.

17. A Social Marketing review in Health Improvement has developed an over-arching strategy for Health Improvement consumer communications. This strategy aims to join up messages and targeting across a range of health topics, including alcohol, and recognises the need to address health inequalities by focusing on lower socio-economic groups as target audiences. The key target group will therefore be adults aged 25-50 and primarily C1C2DE.

18. Measures are already in place and planned under the Licensing (Scotland) Act 2005 to tackle under-age sales and irresponsible promotions, including removal of incentives to bulk buy.

19. The Scottish Alcohol Research Framework, compiled by NHS Health Scotland and the Scottish Government with advice from the Alcohol Evidence Group, sets out existing and planned work, together with priority areas for new research. The Framework identifies a number of studies that will help us better understand drinking patterns across population sub-groups, as well as, for example, links between patterns of alcohol consumption, serious alcohol-attributable disease and deprivation.

20. In addition, the Chief Scientist Office ( CSO) is currently funding a project (being delivered by Health Scotland and the Information Services Division) looking at the relationship between a) alcohol deaths and b) alcohol hospitalisations to risk factors such as age and deprivation. While the project is still at an exploratory stage, the analysis plan includes deprivation based analysis for a range of alcohol related and alcohol attributable conditions.

What gaps in action should be filled and what new activities put in place

21. Given the scale of the problem of alcohol misuse across the whole population, it is argued that tackling health inequalities should be mainstreamed throughout the long term strategic approach to alcohol misuse. As a result, there will be a need to ensure that there is appropriate (and where necessary enhanced) access to information and services in order to tackle health inequalities. In addition, as noted above, targeted interventions for particular groups (e.g. offenders and dependent drinkers) will be necessary together with measures affecting the whole population. Consideration will also be given to possible measures around supporting children affected by parental alcohol misuse.

What measures of success are or could be available

22. Progress in tackling Scotland's alcohol misuse problems will primarily be monitored through existing indicators, including alcohol-related hospital admissions and deaths (both of which allow from analysis by deprivation category, Health Board, gender, age, etc). A recording and monitoring system will be put in place as part of the proposed HEAT brief interventions target. Survey data will be used to monitor 'softer' measures of success (such as perceptions of alcohol misuse in communities).

Workforce implications, e.g. training and skills required

23. There may be a substantial training need for GP practice teams (and staff in acute settings) in developing skills both in screening patients for harmful and hazardous drinking and in delivering brief interventions. This is likely to be procured via NHS National Education Scotland and/or NHS Health Scotland. Training needs will be informed by research currently being undertaken by Health Scotland to consider barriers to implementation of the SIGN 74 guideline.

What relevant external experts, interests and reference groups say

24. The expert group of stakeholders (which included a range of interests such as public health, medical, voluntary and industry), convened to consider what the desirable outcomes of a new strategic approach to alcohol might be, was clear in its view that whilst tackling health inequalities should not be seen as an outcome in itself, it is a vital component in ensuring delivery of our long-term outcomes.

January 2008

ANNEX A

Figure 1: Alcohol-related death rate by Scottish Index of Multiple Deprivation, 2005

Source: ISD Scotland based on GROS data

Figure 2: Alcohol-related mortality, UK countries, 1991-2005

Figure 3: Deaths from liver cirrhosis (rate per 100,000) in 45-64 year olds, 1950 to 2002

ACTION PROGRAMME FOR TACKLING DRUGS MISUSE

Introduction

1. This paper:

• describes the health inequalities dimension to Scotland's drug misuse problem.

• describes current action to develop the Scottish Government's new Programme of Action for tackling drug misuse.

• identifies the key aspects of that developing strategy that could specifically address health inequalities.

The health inequalities dimension to Scotland's drug misuse problem

2. According to the latest research, an estimated 51,582 people in Scotland were misusing opiates and/or benzodiazepines in 2003. This corresponds to 1.84% of the population aged between 15 and 54. It represents a decline in the number of problematic drug misusers since 2000.

3. There are strong and very clear links between poverty, deprivation, inequalities and problematic drug use; but the situation is complex. Not all marginalised people will develop a drug problem, but those at the margins of society, such as the homeless and those in care, are most at risk. The pattern of who develops a drug problem and encounters other problems shows a close link with aspects of social exclusion.

4. A study by Dr Laurence Gruer of some 3,715 drug related emergency hospital admissions in Greater Glasgow from 1991 to 1996 plotted them by postcode using a standard index of deprivation. The admission rate from the most deprived areas exceeded that from the least deprived areas by a factor of 30. In other words, if the admission rate for the least deprived area had applied across the city, the number of admissions would have been only 8% of that which actually obtained. It was noted in this study that the relationship between deprivation and drug misuse was higher than any other health variable they had studied.

5. In a recent Scottish population based study Leyland and colleagues (2007) examined age, sex, and cause specific mortality rates for social groups to understand the patterning of inequalities and the causes contributing to these inequalities. Using a comprehensive assessment of deprivation, they illustrate that there have been general reductions in mortality in the major causes of death (ischaemic heart disease, malignant neoplasms), however such reductions have been socially patterned. Relative inequalities in mortality have increased and are greatest among younger adults where deaths are attributable to increases in suicides and deaths related to the use of alcohol and drugs.

6. Indeed, Professor Neil McKeganey and colleagues have gone as far as to suggest that just a single risk factor - problem drug use - may be responsible for a large part of the observed, deprivation-adjusted, cross-national differences in mortality rates between England and Scotland. The findings are far from conclusive - nearly half of the sample cited is drawn from the prison population for example - and there has not yet been independent data to cross-check it.

7. Changing housing markets and policies have had a clustering effect resulting in a concentration of multiple social problems including drug markets within deprived areas. Drug markets occur in fragmented local areas, but also within highly deprived areas with strong networks. Drug users face a range of employability barriers including a fear of drug relapse linked to having to renegotiate welfare benefits, and restrictive pharmacy dispensing of prescription drugs.

8. Problematic drug users come from all sections of society, all parts of the country and all socio-economic classes. However, the statistics suggest that they are twice as likely to be men and more likely to be out of work than in a job - in 2006-07 67% of new clients in drug treatment services reported that they were unemployed. For both males and females accessing treatment, 25-29 was the most common age group for new clients reporting to the Scottish Drug Misuse Database in 2007 closely followed by 30-34.

9. In 2005-06, 45% of treatment clients reported that they had previously been to prison and studies estimate that a high number (as much as 80-90%) of all Scottish prisoners taken into custody have been misusing drugs and/or alcohol (Scottish Consortium on Crime and Criminal Justice ( SCCCJ) 2002) and that significantly high rates of prisoners come from the most deprived council ward areas (Houchin, 2005).

10. There is no suggestion that ethnic minorities are more likely to be affected - in 2006-07, 96% of new clients in treatment services reported their ethnicity as white. There is, however, some evidence that ethnic minorities are less likely to access health services (and therefore to be included in the statistics). Drug addicts can face many barriers to service, born out of others' moral condemnation, a chaotic lifestyle that acts as an impediment to, for example, keeping appointments, or inadequacies of local service provision (as evidenced, for example, by excessive waiting times for assessment in certain local authorities).

11. Among women drug users, there is a 'fear' that professionals working with them will view drug use as an 'automatic indicator of their unfitness as a mother'. This is one of the most important barriers to drug-using mothers seeking help and treatment. In addition, many abused women who are drug users lack access to social and economic resources which would help get them out of abusive and chaotic situations.

12. There is also an expanding population of individuals who have used drugs in the past, who are maintained on long-term substitute prescriptions (such as methadone) or are using drugs at a later stage in their lives than ever before. Studies are showing that the problematic drug using population has an ageing profile and that such drug use is associated with poor physical and psychological health and longer hospital stays. Some commentators suggest that the characteristics and health needs of older people need further investigation as the future cost of ageing drug users may be considerable.

The development of the Scottish Government's new Action Programme for Tackling Drugs Misuse

13. The high levels of problematic drug misuse in Scotland are not acceptable. The economic and social costs are estimated at £2.3bn a year, making drugs misuse an obstacle to achieving the Government's Purpose of achieving higher sustainable economic growth. There are also wider health and social costs that potentially undermine our capacity to deliver other national outcomes. The Government is determined to address this and, as a first step, is to publish a new Programme of Action for tackling drugs misuse before the Summer of 2008.

14. It is intended that the Action Programme will be a high-level, ambitious document. It aims to present a snapshot of the drug misuse problem in Scotland in 2008 and set out a set of priorities for tackling it in the context of the Government's overarching objectives and the reforms of governance, including the Concordat and introduction of outcomes. It will feature a clear programme of activity and reform - for Government and local partners - that will be drawn up in partnership with the Government's advisory committees on drugs ( SACDM) and alcohol ( SMACAP). It will be underpinned by the best available evidence, drawing on national and international research and practice. It will, however, also concede that there are gaps in that evidence, and commit the Government to setting up a National Evidence Group to ensure future policy remains evidence-based. The Programme will also highlight the major contribution of work to tackle drugs in tackling health inequalities. It will stress the importance of local delivery partners in providing access to services for hard to reach groups, and signal a review of the methodology for funding allocations that takes this more into account as part of wider reform of delivery.

15. A key theme of the Programme will be to promote recovery. This reflects the fact that too many people on opiate substitute prescriptions do not have access to the integrated, "wrap-around" services in housing, training or education that would allow them to recover from their addiction. Put another way, services and treatment need to deliver sustainable outcomes with an impact on health inequalities that endures. It also reflects the Government's view that it is important to get beyond some of the sterile debates of the past - in particular, about whether an approach based on abstinence or aiming at harm reduction is the most likely to yield results. Our aim is to build a new approach on consensus and evidence, with an objective of "recovery" seeking to unite practitioners and academics in the field.

16. The Strategy is also likely to cover:

• the crucial importance of prevention - widely defined - including policies to grow the economy, reduce poverty, and deliver better outcomes for children in their early years and later teenage years.

• better outcomes for children affected by substance misuse by focusing on prevention, early intervention and support for families and highlighting the moral obligation of the local communities in identifying children at risk.

• better enforcement to reduce the available of drugs by continuing to support the police and Scottish Crime and Drug Enforcement Agency.

• importantly, more effective delivery structures, so that Alcohol and Drug Action Teams (or, possibly, successor partnerships) deliver the services that are needed and can account for the money that they spend and the quality of the services they commission.

17. To complement the new Programme, the Spending Review proposes a 14% increase in the funding provided to Health Boards for drug treatment services over the next 3 years. In addition, local authorities also provide funding for services which, in the past, has been at least comparable to that provided through the ring-fenced funding, and the NHS also provides funding from its unified budget. Together these resources will provide funding for local partnerships to plan and commission services at the local level.

Addressing health inequalities through the Programme for Action

18. Key implications for the Task Force:

• the high degree of inequality associated with problematic drug misuse means that realising the drugs programme outcomes would in and of itself have a significant impact on health inequalities in Scotland - albeit that the degree of impact is difficult to quantify precisely.

• the programme will reflect actions to reform delivery of services at the local level. These should address the need for services to be capable of reaching the hardest to reach groups; and to provide equitable provision across the country; between men and women; and for ethnic minority groups.

• the programme will cite the potential contributions to tackling drug misuse of a range of other Government initiatives, including on early years, children affected by parental substance misuse, youth, curriculum reform, and the provision of "More Choices, More Chances" for potentially vulnerable young people. The more these strategies can contribute to reducing drug misuse in Scotland, the greater their contribution will be to reducing health inequalities. Tackling drug misuse should continue to be recognised as being an objective of these developing policy initiatives.

January 2008

VIOLENCE AND HEALTH INEQUALITIES

Introduction

1. Detective Chief Superintendent John Carnochan, head of the Violence Reduction Unit ( VRU), and Professor Peter Donnelly, Deputy Chief Medical Officer, will lead a discussion on the problem of violence in Scotland.

2. The Leyland et al. Report (2007) identifies violence as a serious source of health inequalities in Scotland in particular amongst young men. This assessment is supported by the World Health Organization ( WHO) which has identified Scotland as bucking the trend of Western European countries which typically have low rates of youth homicide. The WHO assessment is that young men (between 10-29 years of age) in Scotland are 7 times more likely to be the victim of homicide than their counterparts in France and 5 times more likely than even their counterparts in England and Wales.

3. The WHO data are historical. Current data, however, do not suggest significant improvement. The Scottish homicide statistics for 2006-07 were published on 18 December 2007. The statistics show a 27% increase in the number of victims of homicide. Homicide itself is rare - 119 victims equating to 23 victims per million - though the factors that contribute to it are not. The analysis of the statistics show the continued disproportionate impact on young men (62% of offenders; 42% of victims), the prevalence of knives (responsible for 3 times as many homicides as any other form of killing), the associated use of alcohol and drugs (47% of perpetrators reported to be on drink or drugs at the time of the offence), and a geographical focus in the West of Scotland (64% in Strathclyde Police force area with the homicide rate in Glasgow twice that of London and more than just about every other European city). The causal and associative factors in relation to violence - alcohol, drugs, deprivation - are all sources of significant health inequality.

4. The presentation to the Task Force will outline a case study involving a serious act of violence. The intention is to use this case to illuminate a much wider and deeper set of issues: profound levels of inequality across society, families with multiple and complex needs, the vulnerability of young people. Violence is perhaps the most serious symptom of these deeper issues, and discussing this symptom and its causes will in turn expose implications for a whole range of policy areas and agencies. The problem of violence and our response to it exemplifies much wider aspirations than just those for a Safer and Stronger Scotland; it gets to the heart of what we should mean by a Healthier, Smarter, Wealthier and Fairer, and even Greener Scotland.

The extent of the problem

5. Scotland has an unenviable international reputation as a violent country. The World Health Organization ( WHO) World report on violence and health (2002) highlighted the fact that the homicide rate in young men between 10 and 29 is 5.3 per 100,000; the equivalent rate in England and Wales is 1.0 per 100,000. On this very limited measure, Scotland is one of the most violent countries in Western Europe.

6. International comparisons are not always reliable. Domestic data, however, offer little comfort. Statistics on the Scottish homicide rate covering the most serious form of violence are set out above. In relation to violence more generally, the Scottish Crime and Victimisation Survey ( SCVS) 2006 indicates an estimated 4% of the adult population was the victim of an assault in 2005/06. Of all crime, violence can have the most pervasive and profound impact not only in relation to the victims and their families but also fear of violent attack and disorder can destabilise a much wider set of communities where violence is less of an issue. The SCVS 2006 indicates that 23% of respondents across Scotland thought assault was common in their area, with 37% of respondents indicating they were worried about being assaulted. DCS Carnochan will talk in his presentation of the "normalisation" of violence in certain communities, typically communities with high levels of deprivation - of different values and norms of what is and what is not acceptable, tolerable. In those communities the concept of "fear of crime" can have a deeper, more complex meaning.

7. The cost to Scotland of violence and the inequalities that underlie it goes beyond mere reputation. A Home Office analysis of the total cost to society of crime in England and Wales indicates that the total cost of violence against the person in 1999/2000 was £16.8 billion. (The equivalent cost in relation to Scotland would be between £1.5-£2 billion.) Within this there is the cost to public services. Traditional assessments in relation to violence focus on the cost to the police service and the wider criminal justice system; with violence accounting for 26% of all crime and 40% of the prison population, the "traditional" costs are considerable.

8. However, the impact is much wider. In his Annual Report 2006, the Chief Medical Officer for Scotland states that violence alone costs the NHS between 3-6% of its total budget, which equates to approximately £400 million per annum. The impact of violence, therefore, goes beyond our aspirations for a Safer and Stronger Scotland; as Dr Harry Burns puts it, "violence poses a significant threat to Scotland's health - and wealth".

9. Violence affects all of Scotland but it does not do so equally. The chart below indicates distribution of non-sexual crimes of violence recorded by the police across local authority areas.

Figure 4: Number of non-sexual crimes of violence per 10,000 population 2006-07

10. The situation in Glasgow appears extreme, with a level of recorded violence 2.5 times that of the Scottish average. A relevant factor which helps explain the issue for Glasgow is deprivation. 30% of the Scottish Index of Multiple Deprivation ( SIMD) data zones in Glasgow City are in the 15% most deprived areas. The Leyland et al. Report (2007) into inequalities in mortality makes clear, violence is a significant source of health inequalities, stating (p.102): "Assault stands out as a cause of death that particularly affects those living in the most deprived areas; the death rate from assault in men under 65 was higher in 2001 than the Scottish mortality rate from cerebrovascular disease in this age group."

11. The table below sets out death rates per 100,000 for a range of causes of death. While overall the figures for assault are relatively low, the gradient between the least and most deprived is, along with drugs, the steepest of any of the causes. The death rate from assault in the most deprived communities is nearly four times that of even the Scottish average, and over ten times that of the least deprived communities. This confirms that in relation to violence where you live matters.

Age standardised mortality (per 100,000 population) from selected causes within each SIMD deprivation quintile. Men aged 0-64, Scotland 2000-02.

12. The point of this assessment, however, is not to single out violence. Violence sits within a well-defined but complex context of risk factors, influences, causes etc., many of which have been highlighted to the Task Force previously. In relation to the discussion at the last Task Force meeting, the complex links between low educational attainment and poor health outcomes were recognised as was the potential for educational interventions to have a protective effect. There are equally strong (and complex) links to offending, reoffending, victimisation, viz., poor justice outcomes; and no doubt effective justice interventions can have a protective effect, contributing to that of health and education.

The response to the problem

Background

13. In 1996 the 49th World Health Assembly declared violence to be a global public health issue. In 2002 the WHO published its World report on violence and health, which was the first systematic articulation of how governments and other agencies can use a public health model to understand and respond to the problem of violence.

14. The Scottish Government's response to this report and the endorsement of its approach is captured in the Strategy Unit's paper Violence in Scotland: trends and issues published in December 2003. Separately, Strathclyde Police established the VRU in 2005 explicitly to develop a public health approach to reducing the serious levels of violence in their area. The need to coordinate a national response meant that in April 2006, with the Scottish Government's support, the VRU became the national centre of expertise on violence reduction.

15. The primary focus for collaborative work since 2006 has been on building a consensus not only around the need for change but around the specific approach to change recommended by the WHO. The achievements of the VRU in establishing consensus on the implementation of the WHO's public health approach was recognised by the WHO at their Violence Prevention Global Milestones conference at Tulliallan in July.

The public health approach

16. The public health approach is interdisciplinary and evidence based, while not ignoring individuals its primary focus is on whole-population solutions, and, above all, it focuses on prevention rather than reaction. The basic model is set out below.

17. Work to address gaps and inadequacies in relation to each of the four stages is ongoing. In relation to surveillance, data collected by hospital emergency departments ( EDs) indicates that only about 30% of even serious violence is reported to the police. Before we can tackle the problem we need to understand what the problem is, where it is and who it affects - data collected by EDs can be used to assess levels of violence locally and when data on location of incident etc. is shared with partners this can be used to target resources much more effectively. Key to this is analysis and use of intelligence along with effective information sharing between agencies.

18. In relation to research, there is a considerable body of evidence from international and UK sources to enhance our understanding of causes, risks and what can mitigate those risks (i.e., practice). Through events such as the WHO Milestones conference and best practice seminars, the VRU and Government officials are working to ensure that this research is available to practitioners in Scotland. New research focused on some of the distinctive aspects of the Scottish context - on knives, gangs and alcohol - has been commissioned.

19. The work of colleagues such as Professor Jonathan Shepherd of the Wales College of Medicine show the clear benefits of leadership in relation to research in particular in translating scientific findings into effective practice. Prof. Shepherd is not only a leading maxillofacial surgeon with a recognised expertise in injury prevention but is also Chair of his local Community Safety Partnership. His efforts to implement his and colleagues' research findings in Cardiff have resulted in a 40% reduction in violence-related A&E admissions since 2002. There is leadership in Scotland in health and, separately, in community safety; there is very little leadership in the health/community safety interface.

20. In relation to developing interventions, the strategy has been based on two pillars:

• The need for increasingly effective and innovative enforcement practice primarily by the police, local authority and other criminal justice partners. The best example of this is in relation to knife crime where the police, prosecutors and judiciary have worked together to establish a much tougher regime built on the foundation of tougher legislation.

• The need to approach violence in terms of prevention and anticipatory action. This is beginning to show results in terms of new innovative work with partners in education and health.

21. The prevention pillar of any public health approach is vital and this is where a great deal of energy has gone in Scotland so as to ensure a comprehensive response to the problem. The prevention pillar of the approach is divided into 3 related strands, which can be understood (loosely) in terms of age groups:

• Primary prevention - preventing violence or other antisocial behaviour from occurring in the first place. Focused on children from pre-birth through to high school age and their parents. Activity may includes parenting initiatives, intensive pre- and post- natal support, early years enrichment etc.

• Secondary prevention - preventing the escalation of violence and antisocial behaviour toward serious criminality. Focused on children of high school age (11-18). Activity may include diversion and positive opportunities for young people through to more formal youth justice and anti-social behaviour measures.

• Tertiary prevention - preventing violent offenders re-offending, which typically means adults within the criminal justice system. Activity includes offender programmes within prison and in the community coordinated by Criminal Justice Authorities.

22. It is in the clear focus on prevention that the implications for a wider agenda - health inequalities, multiple and complex needs, etc. - become clear. In relation to criminal behaviour and offending, the traditional focus for police and criminal justice interventions has been after the "point of impact", viz., the criminal act. Better criminal procedure, adequate prison provision both in terms of physical capacity and programmes, more effective community sentences etc. Earlier intervention has traditionally (though not exclusively) fallen to other agencies, in particular those in the health and education sectors. Police and criminal justice partners, led by the VRU, are seeing the benefits and indeed the necessity of engagement with these other agencies to reduce supply. Whether it is brief interventions to victims of alcohol fuelled violence in maxillofacial clinics or the work of school-based community police officers, new cross-agency relationships and practices are emerging.

23. It is early days for much of this and perhaps the most significant challenge faced in introducing the public health approach has been in relation to the fourth stage, "implementation": our inability to scale up small scale evaluated interventions to impact on the wider population. While there is an issue about inadequate evaluation in relation to many local initiatives, there are clearly recognised evaluated interventions currently being delivered in Scotland on a small scale that could be helping achieve the Government's priorities if they were being delivered on a bigger scale. The challenge of lack of resources is no doubt a major factor but so is lack of leadership and the associated lack of understanding of the potential benefits of better, closer cross-agency, cross-sector working.

Implementation - challenges and opportunities

24. The WHO conference in July both the Cabinet Secretary for Justice and Cabinet Secretary for Health and Wellbeing confirmed that the vision for a new approach to violence reduction is now well established in Scotland and they committed the new Administration to this approach. The clear message was that the priority for the next phase is delivery - we need to realise the vision.

25. As mentioned above, there is a great deal going on at a local level. There are a significant number of local initiatives along with some regional and national programmes which are helping reduce and prevent violence, and which are addressing the wider problem of inequalities. The landscape is, however, fragmented with few of the potential benefits of a more systematic approach being realised. Government has a key role in addressing this and that is why our objectives are:

• Joining up - establishing, developing and enhancing primarily partnership delivery structures to ensure action on violence etc. is systematic, holistic and looks beyond the point of impact.

• Scaling up - ensuring that when good practice is recognised that the government directly and indirectly (through the VRU and others) supports local and regional efforts to widen and deepen that practice to cover more individuals or provide even more effective interventions for those already receiving them.

26. What is particularly hopeful at this time is that the Scottish Government is taking a fundamental look at its strategic aims in a way that fully supports the approach being outlined here. We see this in many of the underlying principles of the new strategic objective framework not just as part of Safer and Stronger but also Healthier, Smarter and even Greener and Wealthier and Fairer. These principles include:

• Earlier intervention.

• Recognising the value of early years support.

• "Prevention is better than treatment".

• Promoting positive opportunities for young people.

27. There are a number of specific strategies and initiatives emerging that should help this agenda; these include:

• New early years strategy.

• New approach to tackling health inequalities, overseen by the Ministerial Task Force.

• Revised youth justice strategy.

• Revised victims strategy.

• Revised alcohol strategy.

• New drugs strategy.

• Actions emerging from the National Domestic Abuse Delivery Group.

• New youth strategy incorporating work on promoting positive opportunities for young people including Inspiring Scotland and use of Proceeds of Crime Act ( POCA) funds.

28. One of the internal challenges is to ensure that the links to the violence agenda are recognised across these and the many other relevant strategies. This will help ensure that the agenda benefits appropriately - as it has not really done previously - from the delivery of more mainstream services. There is however a wider issue which is to identify and articulate the common threads between these approaches. In many cases the primary "client groups" in particular in relation to the "at risk" groups are the same: those most susceptible to poor health, education and justice outcomes. Are we satisfied that they rest on a consistent conceptual framework and that the practice being recommended is consistent? Are we maximising potential benefits from closer integration?

29. There is an external challenge, which is that with the loss of ring-fenced funding in many areas including community safety and antisocial behaviour, responsibility for delivery lies more clearly with local government and partners. There may be more of a challenge with both "joining up" and "scaling up" when decision making is more thoroughly devolved. This makes the task identified above of ensuring consistency across strategies all the more important.

The way ahead

30. The Task Force is asked to consider the following possible ways forward. These are framed in terms of the four stages of the public health model and build directly on the comments of the Chief Medical Officer in his 2006 Annual Report.

Surveillance, data collection, information sharing

31. Acknowledge the intention to establish an electronic injury surveillance pilot in three hospitals in NHS Lanarkshire and, subject to appropriate evaluation, consider the value of introducing this approach across Scotland. In particular note that the data collected from emergency departments - on time, location, cause of injury - will be shared with local partners to ensure more effective enforcement and prevention action. This is a proven tool in efforts to reduce levels of violence and will have an impact in reducing health inequalities.

32. In relation to John Carnochan and Peter Donnelly's presentation, note the problems highlighted in relation to information sharing between agencies. Inadequate information sharing is leading directly to poor health and justice outcomes. Steps have been taken to improve information sharing between agencies - an example includes the work undertaken recently by ACPOS and the NHS to agree information sharing protocols - but further action may be required.

Identify risk and protective factors - research

33. Ministers may wish to consider whether the evidence base on risk and protective factors is adequate. It may well be that the research etc. on individual strands - alcohol, violence, deprivation - is considered adequate (although this is not the case in relation to violence) so that what matters more is the interrelations between the strands and also the lack of leadership in translating the scientific findings into effective practice. Consider the example of Professor Shepherd in Cardiff and the impact he has made locally and regionally and whether similar leadership in Scotland would deliver similar benefits.

Interventions

34. Reflect on the current lack of effective interventions for young men who are already engaged in damaging behaviour such as violence, and who are thus susceptible to aggravating their already poor health outcomes. The Government has already committed to developing a programme of positive activities for young people, including activities funded through POCA. Some of this activity will impact on the "at risk" group we are referring to but not consistently and not perhaps enough to change behaviour. In addition the most serious young offenders receive "treatment" as part of custodial sentences and are provided with other forms of support in relation to drug and alcohol misuse etc. In particular consider whether there is a gap in provision in relation to higher volume, low tariff "offenders" - those involved in gang fighting, knife carrying, low level offending - who are a high risk in relation to later high tariff offending. In addition Ministers may wish to consider whether there is sufficient provision in relation to tackling victimisation among young people. Given that in many circumstances victims and perpetrators of crime are the same individuals, there may be merit in considering whether effort would be better focused on reducing levels of victimisation among young people rather than offending.

Implementation

35. Given the point made above about the importance of local government, NHS and other partners in delivering on this agenda, consider the value of facilitating early discussions with those partners on the actions they propose to take to address the issues identified in the presentation. John Carnochan and Peter Donnelly could be invited to help in this process and report back to the Task Force with any further insights or recommendations.

January 2008

Additional briefing provided by the Violence Reduction Unit:

VIOLENCE REDUCTION

Purpose

To provide further information on the way ahead in relation to violence reduction as requested at the Task Force meeting on 9 January 2008.

Introduction

Violence in Scotland is a chronic and pervasive problem that directly or indirectly affects everyone. The economic and social costs are a substantial drain on resources and significantly inhibit individuals and communities. This paper will not rehearse in any further detail the need for action to reduce violence but rather assume that the case for action has been made.

The recognition in Scotland of violence as a public health challenge and the application of public health models to develop sustainable strategies to reduce violence is a significant advance. Understanding of this shared agenda allows the development of cohesive cross sectoral policy development. It allows policy makers to consider long, medium and short term actions framed within a collaborative and inclusive national strategy.

In addition, the use of a common model to frame different problems and challenges allows the possibility of identifying solutions that will have a positive impact across several disparate problem areas this is turn removes or at least weakens the silo effect often cited as a barrier to co-ordinated and effective delivery of services.

At the heart of sustainable solutions will be the dedicated, robust and determined coordination of service delivery across the entire breadth of providers, public, private and voluntary sectors. There are several key National policies in place or intended that enhance the possibilities for success. Principal among these are The Curriculum for Excellence, The Early Years Framework, Getting It Right for Every Child and Better Health, Better Care.

Annex A provides prevention actions which could be adopted to address violence within the primary, secondary and tertiary approaches as detailed in the World Health Organisation Report recommendation, "Analysis to Action". The main high level recommendations are shown in bold text. It also categorises these approaches within the ecological public health model in relation to individual, relationship, community and society.

Annex B shows how actions will lead to improved outcomes in the medium and long-term, and how they will contribute to better health and reduced health inequalities.

Alcohol is the single largest driver of interpersonal violence in Scotland and as such any action that will limit supply or access will have a positive effect on reducing the levels of violence and the number of victims. The decision not to include actions relating to alcohol in this paper was made in the knowledge and understanding of the ongoing work in relation to alcohol being carried out by the Government. The VRU are fully supportive of this work.

Violence Reduction Unit
March 2008

Violence Reduction Unit

Note: Main high level recommendations are shown in bold text.

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