There are many variations on what “a public health approach to” violent crime actually means. For me there is nothing inherently wrong in the words, but a lot of misconception and baggage with it + people see “public health approach to” in different ways
This is a LONG blog. Sorry. Sets out 8 issues from the essence of “a public health approach to” to evaluation and evidential models.
It is hopefully the last time I will blog on it (famous last words)
1 What is essence of “PH approach to” …..
The essence of a “PH approach to”, or the core design principles, are (for me)
relentless focus on whole pops not high risk individual (Focus on whole of risk continuum not just those at the peak),
Focus on victims of AND perpetrators of violent crime
ever pressing upstream – at every decision point, what are the things upstream and the big structural policy interventions,
focus on whole systems not individual actions (though they remain important),
all the well trod stuff re partnerships (a city based approach, not one agency within that), data, evidence led etc. Taking feeds from evidence in multiple areas and sources, lived experience being weighted appropriately (not ignored as opinion as is often the case), nuanced approach to monitoring and evaluation
The danger of mis-framing “a public health approach to”……
Violence can be “cured”…. (Like an infection).
It’s alliuring to those outside a space to think that the “cure” is neat and simple, but the range of actions and actors that go into a public health approach to measles is also quite complicated.
In the context of violence, the “cure” might well be jobs, hope, aspiration, alternatives and all the things that lead to those things. It’s a complicated world, perhaps more so than a standard public health response to say measles. If we say that “we will treat it like and infection” then the answer is better sanitation system and drains, not better treatment for cholera.
Not loosing faith in “a PH model” will matter. We have PH approach to lung cancer for the last 40 years– it’s called tobacco control. Just as there will still be 45 yr old people who have lung cancer, there will still be people who get shot.
A Public Health approach to anything doesn’t obviate a need for an acute response, in this cotntext policing and locking up folk who have committed crimes.
increasingly I have antibodies to violent crime being framed as “a public health approach to” …. Mathew Ryder QC one of Sadiq Khan deputies did excellent blog on that – basically drawing parallel between “treating as a disease” risks medicalisation at expense of social policy. The blog makes the case that “a public health approach” to violent crime borrows medical techniques to tackle a social problem. I disagree. It takes “public health techniques”.
2 crime oriented vs people and community oriented.
can you reference how any coherent response to violent crime is community and people oriented, not (only) crime oriented.
An alternative approach to developing a response following the chicken box story was a very interesting exercise in engagement. Dozens of Londoners stopped to share their thoughts as the movement gained some social media traction; over 100 ideas were submitted in total, such as more investment in youth services and greater financial assistance for single parent homes. Such a method can provide alternative perspectives on real and authentic insight about how communities really feel.
3 There is always something upstream
There IS a legitimate issue of how far upstream you stick as stake in the ground, how big a slice of policy you take on, what the organising principle is
All that difficult upstream stuff is (from the perspective of those downstream of it) more amorphous, harder to get your fingers on.
I don’t know what all of the answers are to the interventions, policies, systems and processes that will lead to addressing issues like poverty, hope, aspiration, training and skills. None of these may have quick or measurable pay offs in the violence space. And because of this we tend to be diverted to simipler more downstream approaches, like putting messages on on chicken boxes
Rather than emphasising fear as a deterrent of crime, investments in policing should focus on the restorative task of building trust in communities and working collaboratively to create safer environments by tackling the root causes of crime. See here and here for helpful articulations.
“No causal relationship proved with austerity, but evidence is pointing in direction of stripping our a whole range of services, alongside the effects of inequality, competitive individualism, and insecurity. We all like and seek a neat simple answer. There isn’t one. We often “individualise” our thinking, this can be helpful for helping convey the stories and narrative that lie beneath the statistics, but individualization is not a helpful approach in terms of the policy response, as that belies the complexity of the social, political and economic context.”
Danny Dorling helpfully reminds us that murder rates are a ‘social marker’ that tell us ‘the story of the connected consequences to our collective actions’.
the man wielding the knife
the man who sold him the knife,
the man who did not give him a job,
the man who decided that his school did not need funding,
the man who closed down the branch plant where he could have worked,
the man who decided to reduce benefit levels so that a black economy grew.
There are “consequences of economic changes and political decisions gradually rendered considerable numbers of the British working class economically obsolete”. Further – “this is exacerbated by people remaining attached to the appeal of consumerism, material wealth, and their ability signify prestige. Consumerism, individualsism and competition has become merged with traditional masculine prerogatives around mental and physical toughness that were once economically functional to an economy that relied on heavy industrial production”.
five main points:
(a) the social determinants of health (SDH) are broadly similar to the social determinants of criminal behavior;
(b) poverty, socioeconomic status, abuse, violence, housing, mental health, access to healthcare, education, environmental health, & nutrition as key determinants;
(c) we should adopt a broad public health approach, focused on prevention and social justice, for identifying and taking action on these shared social determinants
(d) introduce and sketch a non-retributive alternative for addressing criminal behavior, the public health-quarantine model;
(e) recommend eight broad public policy proposals for moving forward. If what I have argued is correct, we cannot successfully address concerns over public health and safety without simultaneously addressing issues of social justice—
- Increase funding for mental health services with a focus on the early and active treatment of mental illness
- Invest in programs and policies aimed at reducing poverty, homelessness, abuse, and domestic violence
- Secure universal access to affordable and consistent healthcare for all
- Reject retributivism and purely punitive approaches to criminal justice and shift the focus to prevention, rehabilitation, and reintegration. Such excessively punitive punishment not only causes severe suffering and serious psychological problems, it does nothing to rehabilitate prisoners, nor does it reduce the rate of recidivism. Norwegian system prioritizes rehabilitation and reintegration (providing prisoners with educational programs, work training, etc.)
- Prioritize and properly fund education, especially in low-income areas, and support educational programs in prison.
- End all policies that disenfranchise ex-offenders, making it more difficult for them to reintegrate back into society.
- Adopt policies that protect the environmental health of our communities by combating climate change, protecting air and water, and reducing/ eliminating harmful toxins.
- Research more effective interventions and rehabilitation strategies for psychopathy.
4 It cant all be local. And it MUST be across the WHOLE of govt
It is worth thinking though our local ask on national agencies, both regulator, Home Office & other govt depts. This includes being up front about the way that govt policy operates, either explicitly or unintended consequence. Eg unintended consequence of what is happening re underfunding of schools AND the OFSTED regime and culture is leading to greater exclusions
The ask of local agencies is obviously important, but it can’t only be local. Be good to see something on
The interaction between police and criminal justice policy and operation. Police is one part of CJ sytem. How does the model interface with other parts.
What’s the ask on sentencing, prison, bail, probation policy and operation?? I don’t know where the Home Office are for example on sentencing policy, that may have a bearing on future life course and trajectory. Getting balance between punishment, rehab, protecting society not further harming the life chances have done something bad etc. tricky.
As might the role of employers around ensuring people have alternatives to what might be a set course.
My sense is that the civil service “get” the right approach on this. The views of ministers unknown, maybe deeply held ideological beleifs about many of the upstream cultural and policy drivers of violent crime.
5 The money
The elephant in the room is the money
Whatever approach taken must be up front about the significant cuts to services along way upstream from violent crime that may well then have downstream consequences. Thinking well beyond youth work here. We know there’s been a massive asset stripping of young people early intervention and prevention services – obviously the elephant in the room.
The massive cuts to youth services (notwithstanding difficulties in defining what is “in” youth services) might well have had an impact, one can only wonder!. Recent YMCA report highlighted a shift of £1.36bn (20/21) to £398m (in 18/19), a cut of c£1bn.
It is worth noting that we all want more prevention, as long as someone else is investing!
If only we had the money. Of course the long term shrinking of funding in local government hasn’t helped. We know we have asset stripped many services, and this has had a massive impact on preventive oriented services in many spaces.
However, one might argue it needn’t ALL be about the money. The big gain is bending existing resources and professional practice to better focus on a shared goal, rather than chasing after new £
Admittedly investment helps. A lot!
The real elephant in the room is if we really want to address the determinants of crime then the 10 year cuts to local government are the deal deal. Small pots of money help, but they don’t touch the £billions we have removed from services. This HAS had an impact on all aspects of our economies – public private and social. We know austerity has had a disproportionate impact on the most vulnerable (individual, family, community, city, region).
This point is completely unacknowledged.
So if we are REALLY taking a PH approach, there is a legit ask of Govt on this one? The way that govt policy operates, either explicitly or unintended consequence
6 language matters. Whose issue is it?
Violence is seen as a police issue, but no more a police issue than “health” is a “NHS issue”.
Health ≠ “NHS” just as violence ≠ “police”.
Violent crime could be seen as an outcome that is a result of positive or negative stuff that happened upstream.
We ought to be careful that we don’t end in a position where police – who are considered lead agency, maybe appropriately so – don’t have to single handedly sort it all out, the prevention, equality all other local agencies are just as asset stripped as the police.
is the issue a “a public health issue”, or is it something to take a “public health response to”. These are subtly different.
Some things are an issue that massively impacts on a relatively small number of individuals. The issue itself may not be on the same scale as say air quality, poverty, or smoking. However the upstream factors may affect tens of thousands It IS nonetheless important! Is it a “PH issue” (plenty say maybe not given incidence of violence compared to air pollution… but some tricky stuff re upstream risk exposure prevalence vs actual violent crime)
I am clear this is an issue that massively impacts on a relatively small number of individuals. It isn’t something of the same scale as say air quality, poverty, or smoking. It IS nonetheless important! Is it a “PH issue” (plenty say maybe not given incidence of violence compared to air pollution… but some tricky stuff re upstream risk exposure prevalence vs actual violent crime)
6 A big plan, or a true strategy
population coverage of the right interventions vs context in which the delivery happens
the paradigm of complex adaptive system matters. All three of those words matter.
of course delivery of the right mix interventions, at the right scale is massively important
Some of this wont be written down in a “big plan” up front. It will develop over time. It may not be best done by command and control mechanisms.
Tricky point re an approach based on “a single big plan” vs setting the right mission and enabling staff to achieve the goal within that, based on giving them freedom and flexibility
It’s a really difficult shift in culture away from command and control towards overseeing a complex adaptive system (or whatever the opposite of command and control is)
Organisational infrastructure to hold it together matters.
Need more nuanced approach to performance and regulation to enable us to deliver against the mission we have set. Re 4hr wait in A&E there was interesting discussion about median wait times and flex based on specific cohorts of patients with certain characteristics. A blanket MUST be 4hr drives perverse behaviour. We all know this
We know leaders like to focus on operational details. As above operational details do matter. But there are MANY things that happen every day in the name of “the big plan” that leaders may never get to know about.
Leaders obviously feel vulnerable to not being sighted on the micro stuff of delivery. No doubt it is important. That takes bandwidth away from the big system shifts and the rules of the game in which the micro detail is played. Donella Meadows stuff on leverage and inflection points in a system etc. System shifting inflection points.
Build the mechanics, rules, finance systems, performance, set exectations about behaviour and professional practice. All that stuff. Arguably far more important than what (amazing stuff) staff are doing
7 The delivery model – I’ve a lot of time for the VRU support each in Scotland.
The VRU model gets a lot of attention as basic model for delivery, but must be truly multi agency + truly upstream, as well as focused on the now issues. Also it shouldn’t be simply lifted from one context to another… and NEEDS to be funded properly (well funded in Glasgow etc!) Obviously no panacea, and not for straightforward import without contetualisation.
We need to be careful that we don’t end in a position where police – who are considered lead agency, maybe appropriately so – outsource the prevention to other agencies. We ALL need to be responsible for ensuring we invest in preventive model
The precise “answer” / policy or intervention mix will depend on the topic area (obviously!), and a complex set of interacting issues and interventions going on. It may not be possible to specify in advance what the answer will be. There may be merit in a small number of big things that get a ball rolling in a certain way, a 1, 5 and 10 year approach. There may NOT be a nice neat simple plan that we are all comfortable with
in violence and knife crime in particular, one set of recepie I have come across is thus:
Change culture upstream say around carrying
hope and aspiration – nothing stops a bullet like a job
navigators – focused on A&E and revolving door people
practical emotional and psychological support to exit violence
School, peer mentoring ACE informed and resilience approach
training and mentoring
ACE informed policing
tagging as an exit from crime with a badge of honour
There is a role of physical activity (basically get folk hooked on things that are alternatives to bad stuff, this would get traction in many different spaces) in this, I haven’t seen it played out much anywhere yet. It would be interesting to see which govt dept thinks physical activity is “theirs”.
making it stick
We should make this work through our CSP. That’s basically the partnership mechanism to make it work. For any of us the VRU isn’t the totality of our strategy. It WILL help with delivery os SOME elements of the strategy but needs a broader approach.
We know the VRU is underfunded (significantly) compared to the Glasgow model it is based on. Given it is Home Office short term funding there IS a danger of future passing of £ risk onto local gov directly, or indirectly through police budgets
8 A careful evaluation IN A wider context is needed. Evidence and evidence models
See this excellent set of thoughts on evaluation of an oft cited innovation – the VRU. Key points
stark differences in both levels and trends of violence in Greater Glasgow and its surrounding authorities compared to those in Greater and Central London.
all local authorities included in analysis experienced a downward trend in violence; however, the tide started to turn in Greater London on or before 2012/13, while it continued to fall across most of Strathclyde. This strongly suggests that whatever factors influenced a change in the trajectory of violence in London were not experienced in Glasgow, which is indicative of some degree of Scottish (or possibly London) exceptionalism.
speculation that the VRU was a key driver in this process. The potential impact of the VRU is somewhat confounded by the general similarities in falling violence across both study areas, although it is possible that the VRU played a role in keeping violence low in Greater Glasgow during the latter period, at the time it was starting to rise again in London. Without specific evaluation of the role that the VRU played in reducing crime in Greater Glasgow, however, this is difficult to prove.
This study highlights two key problems. Firstly, the lack of systematic long term analysis of crime trends and their causes; and secondly, the paucity of evaluation data for initiatives like the VRU. Both problems contribute to the type of speculation we have seen around the differential trends in violence north and south of the border.
While it may well be that the solution to London’s current violence problem is to set up a VRU of its own, it is by no means certain that this will be the panacea that Sadiq Khan, the Metropolitan police and the people of London so desperately desire.
There are legitimate demographic, social, economic differences between cities. So applying a VRU (or any other) model in Glasgow may yield different results to London, or South Yorkshire
Framing of evidence
There’s something in this about how the evidence question gets framed – whether “crime” oriented or broad “determinants of crime” oriented, or indeed people / place / community oriented. The framework in which any evidence review is set also matters, as does whether the evidence question is about specific interventions or broader systems / methodological approaches to a broad social problem. Finally the question of whether the evidence and evaluation paradigm is one that is again framed narrowly or broadly in a socio-political paradigm….matters. Matters a lot