When it comes to the blunt force injury, Monday is peak time in Scotland's emergency departments. "Stuff happens over the weekend and it can take until then to realise you need help," says James Toner, a charity worker who covers busy emergency department shifts at Wishaw General Hospital in North Lanarkshire, offering victims of violence on-the-spot support. "People in crisis present in all sorts of ways; many are affected by drink and drugs and mental health problems, but there's always violence of some form involved."
Dressed in pink scrubs and based in the charge nurses’ office, Toner tracks patients whose injuries and medical history indicate they may need help, making contact at the bedside. “I ask how they ended up here and there’s generally a lot going on their lives – homelessness, prison, benefits, care experience, domestic abuse,” says Toner. “We are able to provide a wee space for them. Just saying, ‘Come on and we’ll go for a coffee’ can sometimes be enough to get someone started on the road to recovery.”
Aged 56, Toner knows what he is talking about. From Castlemilk, the housing estate where he still lives, he lost his father young and drifted into the then-prevalent gang culture, followed by addiction to drink and drugs. Brutalised by violence and imprisoned four times, Toner finally entered recovery in 2018 and is now a passionate peer mentor. "I've been a drain on A&E throughout my life and I've got the scars to prove it," he says. "If I can help someone break their violence cycle it'll help the person and the NHS, their family and the community as a whole."
Toner is one of 14 navigators working in hospitals across Scotland employed by the charity, Medics Against Violence (MAV). Its approach to prevention, inspired by the Glasgow-based Violence Reduction Unit (VRU), views the impact of violence as a symptom of deeper problems that need addressing. It works with people to resolve their challenges and thereby reduce emergency department attendance. "When we started the charity in 2008 we were literally falling over people presenting with injuries caused by violence, in the operating theatre overnight and all weekend," says Dr Christine Goodall, maxillofacial surgeon at the Glasgow Dental School and MAV founder. "It was obvious something different had to be done."
Precisely what made the difference in Glasgow is not known, but between 2009 and 2013 there was a 50 per cent reduction in blunt force and knife injuries requiring maxillofacial surgery in hospitals across the city, a trend that has been maintained. “Something’s been working,” says Dr Goodall. “The Violence Reduction Unit has certainly played a part in that.”
The VRU was set up by Strathclyde Police in 2003 to explore public health approaches to tackling an underlying culture of violence that was killing people. That year, there were 137 murders recorded in and around Glasgow and knife crime involving young men was a headline-grabbing issue, earning Scotland’s largest city the unenviable soubriquet “Violence capital of Europe”.
Following US experience, the VRU started the community initiative to reduce violence to crack the gang culture behind many attacks, and at the same time Strathclyde Police operated targeted stop-and-search campaigns. Rates of knife crime fell fast – last year there were 64 murders recorded in Glasgow – and word of the work of the VRU spread.
"Its reputation is based on the notion that the VRU has been very successful, but there's surprisingly little hard evaluation of its impact on violence," says Dr Alistair Fraser, criminologist at the University of Glasgow. "There have been global reductions in violence across the same timeline, for instance Sweden and there's no VRU there."
In an attempt to identify what might have been the drivers for improvement, Dr Fraser has started the first large-scale study into public health approaches to violence so that international best practice can be identified and shared. “There’s no question that the VRU has had a positive impact but it may be as much about changing the narrative – society refusing to normalise violence – and promoting prevention, or it could be down to shifts in youth culture, or even a bit of luck,” says Dr Fraser. “Whatever the reasons, we need to know. It’s difficult to quantify right now, but the VRU principles has to be a good way to proceed, starting with the children.”
The VRU, described as “a think tank that does stuff”, initiates research and projects that are taken up by other agencies and it fosters awareness across the public sector in Scotland of the impact of adverse childhood experiences and how to mitigate them.
Violence reduction projects modelled on Glasgow's are now running in London and 17 other areas of England and Wales, and the Republic of Ireland is being urged to follow the VRU lead to stem its rising tide of knife crime.
But Niven Rennie, VRU director, warns that setting up such a unit is not in itself a silver bullet: indeed, taking knives off the streets and diverting young people from gang culture may be the easy bit. “There is growing recognition in Scotland that poverty is the real issue, and that all agencies need to be working together to tackle that,” he says. “It’s clear that prevention must come first, that the justice system isn’t the answer. Political decisions have an impact, and I am optimistic for the future here.”
VRU founder Dr Karyn McCluskey, now chief executive of Community Justice Scotland and a member of Scotland’s drugs deaths taskforce, agrees that poverty and inequality must be addressed if all violence – including drugs deaths and domestic abuse – is to be stemmed.
“We have to address it in the round and getting that right will take thematic action,” she says. “But if you ask me,what would make a massive difference would be the introduction of universal basic income and supporting parents.That would show real political bravery and commitment.”
Until then, emergency department presentations will continue to act as a guide to the prevalence of violence in society, and according to Toner in Wishaw the signs are not good. “I’m seeing fast-growing numbers of people turning up at hospital needing help for the effects of violence,” he says. “It’s still happening and it’s all to do with trauma and poverty. We really need to do something about that.”