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THE CARDIFF MODEL FOR VIOLENCE PREVENTION

Jonathan Shepherd

Professor of Oral & Maxillofacial SurgeryDirector, Violence Research Group

Rank 5-14 years 15-29 years 30-44 years

1Childhood cluster

200 139

HIV / AIDS

855 406

HIV / AIDS

855 406

2Road traffic injuries

118 212

Road traffic injuries

354 692

Tuberculosis

368 501

3Drowning

113 614

Tuberculosis

238 021

Road traffic injuries

354 692

4Respiratory infections

112 739

Self-inflicted injuries216 661

Ischaemic heart disease

224 986

5Diarrhoeal diseases

88 430

Interpersonal violence188 451

Self-inflicted injuries215 263

6Malaria

76 257

War injuries95 015

Interpersonal violence146 751

7HIV / AIDS

46 022

Drowning

78 639

Cerebrovascular disease

145 965

8War injuries

43 671Respiratory infections

65 153

Cirrhosis of the liver

135 072

TOP EIGHT GLOBAL CAUSES OF DEATH 2008 SOURCE: WHO

RECORDING OF VIOLENCE BY THE POLICE AND IN EDs

Police recording varies by victim age and gender and violence location

Only 23% of people injured in violence who attend EDs are known to the police

Crime surveys in UK, Sweden and US demonstrate similar police recording rates

LOW POLICE ACSERTAINMENT OF SERIOUS VIOLENCE IS AN INTERNATIONAL PROBLEM

869 (62%) victims

327 (23%) victims

207 (15%) victims

ODENSE UNIVERSITY HOSPITAL

POLICE

(Faergemann 2006)

1403 (100%) victims

Police recording is not closely related to injury severity

13% of firearm violence recorded in Atlanta EDs was not recorded by police (Kellerman el al 2003)

REASONS WHY VIOLENCE IS NOT KNOWN TO THE POLICE

• Non reporting reflects fear of reprisals, inability of injured people to identify assailant(s), unwillingness to have own conduct scrutinised and need for emergency treatment

• Non recording of reported incidents

National / Regional violence measurement

Emergency Department data

Local surveillance/prevention

INJURY-BASED APPROACH:

INDEPENDENT NATIONAL CORRELATES WITH ED TREATMENT AFTER VIOLENCE

Unemployment / Deprivation Ethnic minority population Alcohol expenditure Alcohol price Season

PROTOTYPE COMMUNITY SAFETY PARTNERSHIP

PROTOTYPE CRIME REDUCTION PARTNERSHIP: CARDIFF VIOLENCE

PREVENTION GROUP

Statutory in UK: 373 crime reduction partnerships Crime and Disorder Act 1998 Police Reform Act 2002

SUSTAINABLE ED DATA COLLECTION AND USE

Step One: 24 hour electronic data collection (precise violence location, time and weapon) by ED clerical

staff when patients first attendStep Two: Monthly anonymisation and data sharing by hospital

IT staff with crime analystStep Three: Monthly combination of police and ED data by analystStep Four: Summary of violence times, locations and weapons

– for police deployment and license regulationStep Five: Continuous implementation and updating of

prevention action plan

Licensed premises traffic light scheme. Effective policing, situational and environmental interventions:

VIOLENCE PREVENTION

Targeted street patrols, CCTV, redeployment of police from suburbs into city centre at night

Plastic glassware, fast food outlet relocation Pedestrianisation of entertainment streets Identification of people injured in domestic

violence

VIOLENCE HOTSPOTS IN 21st

CENTURY CARDIFF

CHOLERA HOTSPOTS IN VICTORIAN LONDON

VIOLENCE RELATED ATTENDANCES – CARDIFF A&E

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Case Studies

• ED information identified a source of blunt weapons – a construction site next to a night club with skips containing bricks, concrete blocks and pieces of wood. Skips were secured and violence fell

• ED information identified series of attacks on cyclists in a neighbourhood. Police targeted this area and violence fell

• ED information identified several violence hotspot pubs/night clubs. Alcohol licence conditions imposed and some licences revoked. Violence fell

Source: Dines 2011

CHANGES IN VIOLENCE RELATED HOSPITAL ADMISSIONS AND WOUNDINGS

RECORDED BY THE POLICE• Hospital Admissions:

down 24/year/100,000 population in Cardiff up 36/year/100,000 in comparison cities• Woundings recorded by police: up 336/year/100,000 population in Cardiff up 720/year/100,000 in comparison cities Florence et al BMJ 2011

ANNUAL COSTS AND BENEFITS

Annual cost of Intervention: £5,176 Annual cost of recorded woundings avoided (benefits):

£789k Cost/Benefit Ratio - total costs avoided = 1:152 Cost/Benefit Ratio - criminal justice costs avoided = 1:31

Analyses carried out by Curtis Florence at the US Centres for Disease prevention and Control, Atlanta, using 2008 costs

How does the Cardiff Model work?

The Cardiff Model works by facilitating earlier and more frequent police intervention through the use of information from EDs – and keeps people out of hospital and out of prison

Targeted policing prevents violence Eg Braga 2007

and has violence prevention diffusion effects Eg Weisburd et al 2007

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2 years before CCTV

Control towns (n=5)

CCTV towns (n=5)

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2 years after CCTV

EFFECT OF CCTV ON POLICE VIOLENCE DETECTION

Sivarajasingam et al, 2003

EFFECT OF CCTV ON ASSAULTED ATTENDANCE

Control towns

CCTV towns-4

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2 years before 2 years after CCTV

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CCTV towns

Control towns

OTHER MECHANISMS OF EFFECTIVENESS

• Identification and support of people injured in domestic violence – prevents repeat victimisation

• Identification of weapon trends – informs weapon-orientated prevention strategies

• Identifies violence hotspots, park locations and walkways for example, which can be targeted by city government officials

PREVENTION INGREDIENTS

Emergency physician/surgeon contributions to local community safety partnerships: advocacy from health makes a difference

PITFALLS

• Lack of leadership and management• Low data quality• Poor analysis• Information not used• Purpose of information not explained• Too much strategy, not enough tactics• Complicating a simple process

A NEW WEAPON STRATEGY: PREVENTING GLASS INJURY

Toughened glass

Non-toughened glass

All violence Domestic Stranger Acquaintance(%) (%) (%) (%)

NATIONAL EFFECT: USE OF WEAPONS IN VIOLENCE

British Crime Survey

1998 2000 1998 2000 1998 2000 1998 2000

Glass / 5 2 <1 <1 12 4 6 3bottle weapon

No 80 82 88 93 72 81 81 78weapon

HIGH PROFILE HOMICIDES CAN GALVANISE PREVENTION

UK IMPLEMENTATION Profession guidelines

Government Policy Wales: Welsh Government

England: Department of HealthScotland: Violence Reduction Unit

INTERNATIONAL IMPLEMENTATIONUS (CDC), Western Cape, Holland

WHO IMPLEMENTATIONImplementation of the recommendations of the World Report on Violence and Health