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Can public health strategies tackle London’s rise in fatal violence?

BMJ 2018; 361 doi: (Published 06 April 2018) Cite this as: BMJ 2018;361:k1578

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Radical upgrade in Public Health investment is needed to tackle the knife violence epidemic

Dear Editor,

We read with interest your news analysis ‘Can Public Health strategies tackle rise in fatal violence?’ (BMJ 14th April p6). As Public Health practitioners we would like to share our views on this issue. Violence negatively impacts every aspect of our society. There are 2.5 million episodes of violence in England and Wales per year with an estimated annual cost to the NHS of £2.9 billion. In addition to resulting in physical harm and occasionally death, violence has an even wider impact on the health of society. For example, childhood exposure to violence increases the risk of obesity, substance abuse, cancer and heart disease. Violence and the fear of violence also impacts mental wellbeing, freedom to use outdoor spaces and public transport (1).

The cause of violent behaviour and its apparent recent escalation in fatal violence in London is multifactorial. A BBC news article (2) highlighted that ‘it is far too simplistic to draw a direct link between the number of killings and the number of Bobbies on the beat’. Violence is also strongly associated with inequality with A&E admissions due to violence being five times higher in deprived vs wealthy communities (1).

The role of Public Health is to enhance wellbeing, prevent disease and reduce health inequalities. It aims to address the wider determinants of health including poverty, mental ill health and homelessness to name a few. Since violence is strongly associated with the wider determinants of health and has a large influence on the welfare of society, it cannot be denied that violence is a Public Health issue.

The BMJ news item further adds that ‘the principles of treating knife crime like an epidemic of disease should apply’. Public Health measures have been responsible for the dramatic decline in infectious related deaths and why should similar tactics not be applied to managing violence (3). The World Health Organisation (4) states that ‘violence can be prevented, and its impact reduced, in the same way that Public Health efforts have prevented and reduced infectious diseases. The factors that contribute to violent responses – whether they are factors of attitude and behaviour or related to larger social, economic, political and cultural conditions – can be changed.’ The Public Health approach to addressing the issues that impact the health of society are as follows: After the problem is defined through research and data collection, the risk factors and protective factors for violence as well as the modifiability of these need to be identified. Prevention strategies then need to be developed and trialled before the effective strategies can be widely implemented (5). Scientific approaches such as this, highlight the significant role that the field of Public Health can have in response to the rise in fatal violence.

The UK Government document referenced earlier (1) has summarised the evidence to show that the implementation of Public Health strategies focusing on primary prevention and addressing risk factors can reduce the incidence and impact of violence.
• Parenting programmes such as the Australian ‘Triple P’ aim to improve parent-child relationships and parental skills. Programmes such as these have been shown to have an especially positive impact on children with conduct disorders with large reduction in crime-related costs.
• Preschool programmes such as the Chicago Child-Parent Center (CPC) which offers training and support to parents of children in deprived areas have led to ‘less violent offending by early adulthood’
• Gang-focused strategies in the USA which have delivered social support, health amenities and educational/ occupational opportunities to gang members have found a reduction in violence.
• Controlling alcohol sales times by restricting pub opening hours in Newcastle, Australia led to a 37% reduction in night-time assaults.

An outreach programme called ‘Safe Streets’ in Baltimore (6) engaged staff who have typically been previously involved in drugs and gangs reaching out to young people thought to be at increased risk of gun violence with the aim of being positive role models for change. An evaluation showed a 34-44% and 26-64% reduction in nonfatal shootings and homicides retrospectively in several areas.

The Scottish Government (7) has used a combination of law enforcement and early intervention to tackle violence and are seeing violent crime ‘at its lowest level for 41 years.’ Examples of their programmes include the ‘Violence Reduction Unit’ which focuses on changing attitudes as well as enforcement. Their ‘Mentors in Violence prevention’ programme encourages young people to safely speak out against violence.

Despite the evidence that these strategies are effective, Public Health has continued to see year on year reductions in Public Health grant allocations funded by the Government. The budget for Public Health in England was cut by £200 million in 2015-16 and according to the House of Lords Select Committee will fall by another £331 million 2021 (8). The Committee cautioned that ‘there is a grave risk that the burden of disease will increase if these cuts continue’. A recent systematic review showed Public Health Interventions offer good return on investment with a benefit of £14 for every £1 spent (9).

So why is the value of Public Health to our population not considered by those who decide on resource allocation? It could possibly be because the positive impact is mostly revealed in the medium to long term, thus not attracting much political interest and fitting with the election cycle. The British Medical Association emphasises that the ‘potential contribution of Public Health is being undermined by funding constraints’ (10).

Local Public Health Departments should focus on saving lives, primary prevention and population-wide interventions in alliance with the criminal justice system which gives us the best hope of dealing with violence. Unfortunately, this strategy is not compatible with the Government’s cuts to Public Health resources. This year is the 70th birthday of the NHS and Government should use this opportunity to invest in prevention and Public Health to tackle the wider determinants of health that impact significantly on health services and the society. This becomes even more critical with the moves to fund Public Health through business rate retention.

Laura Cattermole 1, Padmanabhan Badrinath 2, Abdul Razaq 3

1 Foundation Doctor in Public Health, 2 Consultant in Public Health Medicine, 3 Director of Public Health, Public Health Suffolk, Endeavour House, Suffolk County Council, IP1 2BX, Suffolk, United Kingdom.

This article reflects the personal opinions of its authors and does not in any way represent the opinion of Suffolk County Council.

1.Protecting People, Promoting Health - A public health approach to violence prevention in England 2012. [ (Last accessed 16th April 2018)
2.BBC News. London killings: No easy answers to gun and knife crime. 2018. Last accessed 16th April 2018.
3.Centers for Disease Control and Prevention. The History of Violence As A Public Health Issue. 2009. (Last accessed 16th April 2018)
4.World Health Organisation. Violence – a global public health problem. (Last accessed 16th of April 2018)
5.Centers for Disease Control and Prevention. The Public Health Approach to Violence Prevention 2015. (Last accessed 16th April 2018.
6.John Hopkins Center Bloomberg School of Public Health. Estimating the effects of law enforcement and public health interventions intended to reduce gun violence in Baltimore. 20918. (Last accessed 16th April 2018)
7.Scottish Government. Action to reduce Violence and knife crime. (Last accessed 16th April 2018)
8.House of Lords Select Committee on the Long-term Sustainability of the NHS. The Long-term Sustainability of the NHS and Adult Social Care 2017. (Last accessed 16th April)
9.Masters R, Anwar E, Collins B, Cookson R, Capewell S. Return on investment of public health interventions: a systematic review. J Epidemiol Community Health. 2017 Aug;71(8):827-834.
10. Feeling the squeeze: The local impact of cuts to public health budgets in England Britiah Medical association 2018. (Last accessed 16th April 2018.

Competing interests: No competing interests

17 April 2018
Padmanabhan Badrinath
Consultant in Public Health Medicine
Laura Cattermole, Abdul Razaq
Public Health Suffolk, Suffolk County Council
Endeavour House, Ipswich IP1 2BX