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Public Health

a public health approach to…..knife crime.

Brief notes:-

Some of the below IS specific to knife crime, but relatively little. Most of this if adaptable to other stuff

·         Starting with specific’ what is learning from “a PH approach” to other issues I’d have a think about – price, advertising, availability, education, treatment (ie not just treatment, not just one of the above, but all). Number carrying, address the why I need to carry issue, positive alternatives. Reporting, really getting a handle on the data. Legislation, point of sale checks. Sentencing guidelines – careful re setting right messages vs over criminalising. Social norms. Gangs, culture. Use of peers, mothers of those victims. Housing, reloctation. Training, education, opportunities for employment.

General issues that might apply to this or other areas.

·         Worry a little bit about “medicalising” it. I wont, but some by calling it a “public health” issue may inadvertently medicalise a social problem. See this by Lynch on our tendency to reduce and simplify complex social things into something that’s about identifiable individuals. This was about health inequalities, but arguably same principle applies beyond. There’s nothing inherently wrong with the biomedical paradigm. It has served us well, it might not be appropriate for complex social contexts.

·         Going beyond labels I feel we have to be exceptionally careful to think of this in an upstream way and shifting population norms / providing the right environment so as the thing (in this case knife crime) less likely rather than directly addressing the visible thing – by arresting (then criminalising, with all the downstream consequences of that) individuals who commit the crime.

·         Im NOT saying we shouldn’t arrest folk who have done bad stuff – I AM saying that we should also address the wider context and social issues surrounding.

·         I guess also a “public health approach to” would also mean focusing on population problem not a sector (crim justice) or a service (it’s a police) issue. Joint ownership of problems across sectors.

·         Worth a longer chat on lessons from how we manage other public health issues – mix of “treatment” (secondary prevention) of the thing, and continual push upstream.

·         Care re the “evidence base”. The “evidence base” is massively over weighted to interventions focused on individuals and downstream “treatment”, and biomedical paradigm stuff. This drives what we prioritise for implementation, at the expense of upstream stuff. So danger is if we went with “evidence base” here we would focus all our effort in “treating individuals” (methadone, alcohol etc) and not foucs on upstream determinants (poverty, no hope, no job)

·         On the Evidence paradigm, I’ve previously written a bit on getting the right evidence paradigm.

It’s worth a read Harry Rutter and others’s amazing article – The need for a complex systems model of evidence for public health. This has immense implications for our approach to evidence development and use of evidence

A practical “call to action” framework for this sort of thinking was developed my Miranda Wolpert in the context of mental health. Rethinking public mental health: learning from obesity

·         Upstream / downstream problem – In any model, low level operational stuff tends to dominate and system. Interventions that affect individuals are often the default, tend to focus on specific interventions (often for “high risk” identifiable individuals). Results in rarely a focus in paradigms shifting. To identify the paradigm shifting stuff……..What are the Policy opinions – track back the logic model. What are the structural things that slow down the ambition, big landscape changing things. This is a beautiful articulation from the world of workplace health and safety. We issue PPE and often don’t try to eliminate the hazard. In the knife crime context, what is PPE, what is hazard elimination or substitution.

·         Focusing on “high risk” wont solve the problem. In this context I guess “high risk” will be known repeat offenders…?  We know in policy area after policy area that “the high risk approach” doesn’t solve the issue – need population wide approach focusing as much on services for individuals as much as upstream structural policy stuff, places where people live. But – the “must focus on high risk” is VERY deeply rooted mindset.

·         In geeky terms known as the prevention paradox –  seemingly contradictory situation where the majority of cases of a disease come from a population at low or moderate risk of that disease, and only a minority of cases come from the high risk population. Most strokes happen in people with normal blood pressure etc…. same principle applies in social phenomena. So we need to know about / address issues in “low risk” – basically moving the population dial AS WELL as the high risk stuff.

·         Of course there’s the must pay now, return on investment will be sometime in the future (and maybe to another agency?

·         What is the 1yr plan,  5 year strategy, 20 year vision. Reaffirm mission. Reaffirm mission in context of complex system and looking upstream. In 25 years’ time – what is it that we want to achieve. What is the ask the city at different levels

·         Is there and Emblematic target.

·         Whats the upward / national ask. National rules and processes – how do we influence these to effect how programmes get developed and prioritised – Home Office, DH, DfE, HMT, DCMS etc. Regulators and inspectors OFSTEAD, CQC

·         What is the System map and logic model. Process matters – who is in the room matters…Get critics in the room. A diversity of opinions matters. Back stage v Front of house (the 4 min elevator pitch, can you clearly articulate the vision). What is front of house = knife crime number. Back of house = the complexity of stuff that contributes

·         What is stopping us – structural – resourcing – cultural. I liked an alalogy of Draughts or chess – think 15 moves ahead, What is the end game – keep the strategy, focus on the end game

·         What are the targets & mechanisms of change – Cohorts (big pop segments in whom intervention would help), environments, policies and rules by which city works, narrative. Have we got the right mechanisms to do the right stuff in place

·         Have we got the right capacity in terms of expertise in the back room to orchestrate the band? Have we got anchor individuals not just anchor institutions – identify both

Fortunately cleverer people than me have already written on it

These two pieces are worth a read

Description in Scotland

Met Commissioner says we need PH approach to knife crime

Key points

·         Everyone agrees prevention better than enforcement.

·         Almost all prosecuted had troubled upbringing

·         Brings me very quickly back to adverse childhood experiences. Going up my radar very quickly. Also going up police radar I’m told (by the police)

·         Cites the Glasgow story – see below.

·         Investing in young people (of note, all local authorities being forced to strip services out – see recent data (EIF??) that demonstrated was early intervention and prevention type services that bore brunt as we try to protect the statutory)

·         Don’t think there is a “public health” budget to go at however, its been slashed as much as every other budget. Its also fully committed to other stuff. More about a “function” / way of approaching the world rather than a bag of cash to do some stuff.

·         Set up specific violence reduction unit

·         Work across sectors, not just within a single sector. (This does require infrastructure staff to do that job – tricky as we’ve slashed funding for all those type of staff as we try to protect frontline)

·         Seems to have paid off in Glasgow

·         “Beyond the blade” – looks interesting

·         Good results reported. Might be worth a trip??

·         Youthwork / positive prevention. Would police be investing in this?

·         3 key lessons 1) efficiently tackle gang culture, targeting leaders and isolating them from followers, 2) understand the culture of violence – immediate and spur of the moment / escalation of drunk argument vs gang / criminal thing 3) police trust issue.

·         Describe the thing, impact and the downstream consequences, upstream risk factors,

·         What are the local and national interventions to address the issue, comminity and city level. National ask of govt.

There is DH document on a “public health approach to preventing violence”. Its pretty good. Most of key points in above tho.

Lastly – I saw this on twitter…. Its good. From a police inspector, not a PH person

UPDATE

I had a read through a number of reviews of evidence on what works. I posted key points here

As I feared there is relatively little by way of volume and what there is available is concentrated on downstream interventions. This has the effect of concentrating minds on implementing downstream stuff when it seems we should focus upstream.

It’s a bit rough and ready & not much more than a simple lift of key points of a number of systematic reviews.

UPDATE 2

EIF. intervening early to prevent gang and youth violence. Primary schools

excellent report

Key points from exec summary:

This report explores the extent to which young children at risk of gang involvement or youth violence are supported through evidence-based early intervention, particularly within primary schools. It draws on qualitative interviews with schools, local government officials, police and voluntary sector organisations within the London boroughs of Lambeth and Wandsworth, and builds on earlier EIF research which indicates that risk factors for gang involvement and youth violence can be spotted as early as age seven.

Our research paints a picture of primary school staff who know their children and local families well, and who go above and beyond to try to provide strong, positive role models and to support children’s emotional wellbeing. However, there is also a strong sense that some school staff are intensely frustrated and feel unsupported in their efforts to work with vulnerable children. Some staff expressed anger and sadness as they told us that they feel unable to change children’s outcomes in spite of their best efforts.

The school staff and stakeholders we spoke to identified a range of concerns, including:

·       the lack of a clear or shared understanding of the level of risk within a school

·       a lack of clarity or confidence in identifying and accessing statutory and other services beyond the school walls

·       a limited awareness of the range and quality of external support that is available to schools, and little evaluation of the external support that is commissioned

·       the pressure on schools to focus on academic performance to the exclusion of children’s wellbeing, a challenge which is often exacerbated in schools located in areas where the risk of gang and youth violence is likely to be higher.

Our recommendations concentrate on four areas:

·       improving the use of evidence in commissioning in-school support and programmes, including by providing improved information to schools and by calling on funders and commissioners at the national or regional level to make evidence-based decisions

·       increasing the emphasis on and time available for developing children’s social and emotional skills in primary schools, including by making PSHE compulsory in all schools and by requiring Ofsted to consider how well schools are supporting children’s wellbeing alongside the academic performance

·       improving the links between schools and the wider early help system in their area, so that school staff are clear about the options that are open to them and confident that referrals will result in support for children and families

·       examining how the police can most effectively work within primary schools to help prevent gang and youth violence.

This report is the first output of a three-year project that will explore and support the testing of evidence-informed approaches to early intervention to prevent gang involvement and youth violence. We will be working with the local authorities, police, participating schools and providers in Lambeth and Wandsworth over the next two years, with a view to co-designing, implementing and testing new approaches to preventing gang and youth violence through effective early intervention.

UPDATE 3

See this from the Lancet- Insights from population health science to inform research on firearms

Excellent articulation of the essential components of “a public health approach to ……..”

Substitute firearm for knife and …….

  • See event as part of a continuum. Need to change whole continuum, not just events at the very sharp end
  • Don’t just focus on “high risk” – small changes in ubiquitous causes of harm can result in more substantial changes in the health of populations than larger changes in rarer causes of harm
  • Things happen in the context of a Complex adaptive system. Hard to predict x to y in a linear fashion
  • broaden the scope of inquiry to include non-fatal injuries and the social and economic effects of firearms
  • Consider both Upstream and downstream of event / issue of consideration Upstream normally matters a lot more impact wise
  • Social, behavioural, economic, political approach is needed, as well as Medical
  •  the magnitude of an effect of risk to human harm is dependent on the prevalence of the factors that interact with that exposure.

UPDATE 4

Also see this excellent view from Suffolk

3 replies on “a public health approach to…..knife crime.”

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