April 08 2015

Violence intervention through hospital A&E

Yael Ilan-Clarke is a Research Assistant at the Centre for Abuse and Trauma Studies (CATS) based at Middlesex University, which has been working with A&E patients to reduce cycles of violence.

An innovative approach to tackling interpersonal violence in the UK has been the move towards using hospital accident & emergency (A&E) departments as the setting for intervention efforts. Recently there has been such support for this approach that in 2015 over £600,000 has been invested in placing specialist youth work services in all the Major Trauma Centres (MTC) in Central London boroughs.

The first two such projects in the UK have been longstanding in the capital and have demonstrated sufficient effectiveness to encourage further investment in the same vein. The first was set up in King’s College Hospital in 2006 (one of the London MTCs) with the voluntary agency Red Thread pioneering the service. The second one launched in 2010 in St Thomas’ Hospital, delivered by the Oasis UK charity.

Both projects serve two inner-city London boroughs characterised by diversity and high levels of deprivation. Multidisciplinary teams form the backbone of the projects, whereby a youth-work service is embedded into the referral pathways of the hospital following clinical assessment/treatment at an A&E (or in the case of King’s, also later on the wards). Professionals from a range of services act as advisors to the projects’ steering, with specific contributions from paediatric clinical teams, public health, police and youth offending. The CATS research group became involved as evaluators of the intervention at St Thomas’ when it was launched as a pilot, and continues to assess its effectiveness and progress to this date.

Reducing risk

It is the nature of these interventions and their location which represents the unique vantage point for  violence reduction. Most important is the move towards support and care, and away from judgement and punishment. Rather than just patching up the wounds and sending young people back to the streets to face the same threats, the projects aim to identify those at risk and work with them to reduce the level of risk in their personal, social and emotional lives. Such projects facilitate access to a population which too often slips through the net in terms of help-seeking behaviour. The population are typically young people with multiple risk factors who are on a continuum of risk on the brink of, or already embroiled in, a cycle of violence.

So what can such projects contribute to violence reduction efforts?

• Access – a large majority of violent incidents don’t reach the attention of services, are not reported to police and may go unattended, paving the way for further risk and potentially leaving vulnerability exposed and unattended. A&Es have unique access in that they are not stigmatised by society as being out of bounds in terms of help-seeking behaviour (unlike police and social services); therefore they see a large proportion of people who do not seek help elsewhere. In one seminal study, a team in Cardiff led by Professor Jonathan Shepperd (2007), found that up to 70 per cent of violent assaults reaching the hospital A&E were not reported to police. Conversely, the level of risk is apparent when you look at lifetime statutory service use. In the sample of young people in the St Thomas’ project (12-20 years old), approximately two-thirds had previously, or were currently involved with at least one of the following services: social services, mental health support or youth offending teams. This testifies to the complexity of circumstances surrounding these incidents and the vulnerabilities experienced by many young people along different facets of their lives.

• Opportunity – the A&E visit presents itself as a window of opportunity, or what is known as a ‘teachable moment’ (McBride et al, 2003). The heightened emotion caused by the event, may give rise to scrutiny of the situation and the result is an opportunity in which the individual may be more amenable to changing attitudes and behaviours. This aspect is seized upon in A&E interventions, with a drive to reduce risky and dangerous behaviours. Research findings and qualitative data from the St Thomas’ project suggest that the period following the A&E visit is one of confusion, evaluation and openness to change. The youth worker’s presence and direction can make the difference between taking strides in a positive direction or at best, maintaining the status quo, and at worse, falling into more destructive and dangerous patterns of behaviour.

• Scope – The relationship built between the youth worker and young person offers a unique opportunity to influence their choices and actions on issues that can have far-reaching effects. The youth worker can take on a role of companion to support the young person to act responsibly on matters that count, by undertaking tasks daunting or threatening to the young person, together. For example the St Thomas’ project has reported attending court hearings which otherwise would have been missed, supporting young people to attend appointments with mental health professionals, liaising with social and housing services on their behalf and encouraging the uptake of educational and employment opportunities. By devoting time and attention to the individuals, the youth worker is in a unique position to influence young people to make positive choices and to help them reach their potential.

These are just a few of the unique facets that hospital-based violence interventions for young people are able to contribute to the reduction in interpersonal injury. The CATS team will be holding a one day seminar in the summer for existing and emerging A&E-based violence interventions in the UK, with a view to forming a national network to facilitate sharing best practice between these innovative projects. It is hoped that by working with a shared agenda, more can be done to change the lives of individuals and communities in the effort to heal the wounds of violence.

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Tags: A&E, Centre for Abuse and Trauma Studies, crime, hospitals, NHS, offending, risk reduction, violence, youth work