Tackling violence

Violence is now on the public health agenda in Britain largely because of increases in injury and homicide rates, particularly among men, and an increase in reports of domestic violence. In the absence of a national system of violence surveillance in accident and emergency departments, surveys such as the British Crime Survey are a starting point for understanding the circumstances and extent of assault, and one lesson that emerges is that health professionals need to do more to help prevent violence.

In 1995 the British Crime Survey data showed that the most common type of violence was that by acquaintances (40% of violent offences), followed by domestic violence (25%), violence by strangers (25%) and during robberies (10%) and that men were most at risk (6.7% of men; 3.8% of women).¹ Importantly in a medical context, repeat victimisation is more common for violence than for other crimes: 30% of victims in the 1995 survey (and 43% in a 1989 accident and emergency department survey²) had been assaulted before. Fear of reprisals and a continuing relationship with the assailant prevents men as well as women from reporting offences.³ The incidence of all categories of violence has increased since 1981, particularly domestic violence (240%) and that by acquaintances (120%).

Overall, England and Wales has risen in the crime prevalence league table from 6th out of 15 in 1989 to 2nd out of 11 in 1995.⁴ Victimisation rates for violence are now highest in England and Wales (3.6% adults in 1995) and the United States (3.5%) but lower in Scotland (2.7%) and much lower in Northern Ireland (1.5%). These international comparisons accentuate the effectiveness of firearm control in Britain: 30 000 Americans have been killed with guns every year in the past 30 years.⁵

Since its inception in 1985 the British Crime Survey has consistently shown substantial amounts of crime which are not recorded by the police. In 1995, for example, only 30% of domestic violence, 60% of robberies, 40% of violence by strangers, and 37% of violence by acquaintances was reported. Nevertheless, crime surveys also underestimate domestic violence and male violence in bars. Despite more proactive community policing, it is now widely acknowledged that the police cannot fight crime alone.⁶ Following research in accident and emergency departments on unrecorded violence the Home Office has recently identified health authorities as potential partners.⁶

How can doctors contribute to this new interagency approach? Putting violence on the public health agenda has undoubtedly begun to pay dividends in America: homicide rates have fallen, legislation such as the Brady bill has made it harder to buy firearms, laws have been enacted to protect children in the home by requiring that firearms are kept in locked cupboards.⁷ In Britain a medical perspective on violence has shown that many more of those injured in violence have criminal records than those injured in accidents.⁸ Clearly, delinquent behaviour increases the risk of injury by assault, and primary prevention should focus on preschool education and early family support.⁹,¹⁰ A key starting point, however, is the establishment of violence surveillance in accident and emergency departments, both to provide national data on morbidity and to inform local community violence prevention.

Recent research has highlighted the need for the injured to have increased access both to the police and victim support services immediately after injury and to screening for alcohol and substance misuse and the acute stress reactions which predict serious psychological sequelae. Collaboration between licensing authorities and accident and emergency departments would help to make drinks licensing sensitive to local injury rates as well as to unreliable crime rates. It is too early to assess the effectiveness of these initiatives but the principles which have emerged include the importance of dealing with the many offenders not currently being investigated, giving all those injured by violence an opportunity to report offences, and integrating accident and emergency departments into community policing without dissuading those who may be on the edge of the law from seeking treatment.

Although all assaults causing injury are criminal offences, there is more to providing a comprehensive service to the injured than finding out if the police are involved.¹¹ Other agencies also have an important role, including victim support schemes, community alcohol teams, and women’s refuges. Ethical issues relating to confidentiality and data protection are important: clear interagency procedures agreed by doctors, the police, mental health and support services, and local authorities are as necessary in dealing with crime directed against adults as they are for child protection. Drawing on existing guidance and educational material produced by many groups, they would help provide not just better services for patients but also increased security and staff protection from one of the scourges of our time.