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The BMJ VIOLENCE PREVENTION [email protected] Cite this as: BMJ 2020;371:m2987 http://dx.doi.org/10.1136/bmj.m2987 The surgeon solving violent crime with data sharing Sharing data to prevent violence is a revelation that came to Jonathan Shepherd 30 years ago—and is now significantly cutting violent injuries worldwide, writes Shivali Fulchand Shivali Fulchand It was a busy morning in 1982 in the operating theatre local government, frontline hospital staff, and the at Pinderfields Hospital, Wakefield. Jonathan police to discuss the idea. Initially, the police were Shepherd, a specialist surgical trainee in Leeds, was sceptical: they didn’t think that so much crime could attending to a surgical list involving head and neck be missed. But a snapshot police audit prompted by injuries. “There are always more assaults during the that first meeting showed that three quarters of miners’ strikes,” his colleague said. The conversation violent crime recorded by emergency departments moved on, but the comment stuck with Shepherd: was unknown to police in the city. The police were are there really more assaults during a strike, he convinced enough to at least try some of Shepherd’s wondered? ideas, and the Cardiff model was born. Violence is the cause of 1.4 million deaths a year and The Cardiff model is considered a global health issue by the World The model involves continuous collection of Health Organization.1 Although homicide causes less particular information by reception staff when a than 1% of deaths, it can be as high as 10% and, in patient checks into a hospital emergency department, some countries, is the leading cause of death in 15-49 including where the violence took place, the weapon year olds.2 Hospitals in England and Wales recorded used, the date and time of the attack, and the number 190 747 emergency department attendances related of assailants. After data entry the information is to violent crime in 2017. anonymised by an analytics team and is then sent to That off-the-cuff comment in 1982 turned into a PhD the police service’s multi-agency violence reduction for Shepherd and a model that would be adopted by units, made up of senior leaders from the police, the cities around the world, dramatically lowering the county council, and the hospital board, to identify rates of violence in each and championing a public violence “hotspots” in the community and to develop health approach to violent crime. specific prevention strategies. Beginnings After initial trials Cardiff introduced the model formally in 2001. Shepherd says, “We were seeing 80 Shepherd initially wanted to explore whether police people being injured from violence every week. Now, data on violent crime matched the data from hospital it’s around 35.” emergency departments. In 1983 his PhD at Bristol University revealed that only 25% of violent crimes He and his colleagues published a landmark study noted by Bristol Royal Infirmary’s emergency in The BMJ in 2011 showing the impact of the Cardiff department were recorded by Bristol’s police force.3 model on reducing violence. From 2003 to 2007, “That was the biggest shock in my career,” he says. violence related admissions in Cardiff dropped from Data from Denmark later echoed this, finding that seven to five in every 100 000 people a month—while, police were aware of only 26-31% of violent crimes in contrast, comparison cities rose from five to eight from 1991 to 2002.4 a month per 100 000. The number of wounding crimes committed in Cardiff fell by 42%, and it was the safest Shepherd’s research found three recurring reasons of 14 UK cities studied in 2007.5 why people weren’t reporting assaults to the police. First, patients didn’t want their own conduct St Mary Street in Cardiff was one of the hotspots scrutinised. Second, people were afraid of reprisals. identified by the model. As the entertainment centre And third, they doubted whether the police could do of the city it was infamous for frequent outbursts of anything. drunken violence, but little evidence existed to back any change. The data captured by the emergency Despite these findings it took a further eight years to department at the University Hospital of Wales turn this evidence into practice. In that time Shepherd showed that many violent crimes were committed on moved to Cardiff to set up a new department of oral this street, particularly at night. Further investigation surgery. However, he remained committed to the by the police showed that these were usually cause because, he says, it was “barn door obvious” “spontaneous eruptions” of violence, often started that regular dialogue between hospitals and the by hungry, alcohol intoxicated individuals who police could drastically reduce violent injuries—or bumped into each other on pavements congested at least give the police better insight into what was with people waiting for taxis or takeaway food after happening in the community. a night out. In July 1997 he convened the first meeting of the Cardiff Violence Prevention Board, bringing together the bmj | BMJ 2020;371:m2987 | doi: 10.1136/bmj.m2987 1 FEATURE

In response, Cardiff Council moved the taxi pick-up points and The reasons are not clear, but the effects of austerity on public pedestrianised the street, creating more space for walking. In 2003 services, rising exclusions from school, a growing drug trade, and the violent offences in St Mary Street were running at around 360 social media are thought to be factors. a year; by 2013 they were around 220. Lucie Russell, chief executive of StreetDoctors—a charity that works Shepherd’s team also calculated that the model’s implementation to empower and educate young people at risk of violence—says that had brought an overall £6.9m (€7.6m; $9.0m) economic and social more investment in prevention is needed. “It is absolutely key and cost saving, including £1.25m in healthcare and £1.62m to the more effective than dealing with the crisis. Enforcement alone will criminal justice system.6 Matt Jukes, chief constable of South Wales not change youth violence,” she told The BMJ. “We must see Police, says, “We are ahead by decades through the work that has violence as an epidemic and use the same methods to control been done.” violence as we do an infection.” Replication Shepherd believes that using the Cardiff model is still one of the most effective ways to do this. Implementation is still patchy, but Word of Cardiff’s success spread. Merseyside adopted the model in new multi-agency violence reduction units are now funded by the 2002, going on to record a 36% reduction in violence related hospital Home Office. And, after the improvement in emergency department admissions in a six year period from 2004 to 2010.7 And in 2010 data collection in England in 2017,13 Shepherd believes that “there London launched the Information Sharing to Tackle Violence is every facility, and every reason, [for NHS trusts] to implement initiative—also based on the Cardiff model—linking all 29 of this.” London’s emergency departments with the Greater London Authority and data from Transport for London and the London Ambulance Cardiff Model Timeline Service, eventually informing local Community Safety Partnerships and the Metropolitan Police. 1997: First violence prevention board meets in Cardiff, UK 2001: Model is formally introduced in Cardiff The implementation in London has served as a model for large cities 2007: Universities’ Police Science Institute opens in Cardiff with multiple emergency departments. In the US, for instance, a 2009: Queen’s Anniversary Prize and 2008 Stockholm Prize in Criminology city the size of Cardiff has six to eight emergency departments, 2010: Coalition government adopts model as strategy compared with Cardiff’s one, said Stephen Hargarten, chair of emergency medicine at the Medical College of Wisconsin’s 2013: Number of victims of violence treated in Cardiff emergency departments halves in 2002-13 Comprehensive Injury Center. London has helped to show how data 2014: Cardiff model dataset is codified and published by NHS Digital can be brought together from more than one hospital. 2016: US Centers for Disease Control (CDC) adopts the Cardiff model; UK This helped when, in 2016, the US Centers for Disease Control government commits to the approach in its modern crime prevention developed a guide to rolling out the model throughout the US: it strategy has since been implemented in Atlanta, Milwaukee, and 2017: CDC toolkit is published; standard NHS contract in England Philadelphia. This followed a US Department of Justice report,8 mandates Cardiff model data collection by trusts with emergency which found that over half of violent crimes were not reported to departments the police. And a recent study looking to replicate the model in the 2018: Jamaica adopts Cardiff model southeastern US found that, for every $1 (78p; €0.85) spent, the 2019: Cardiff model is officially implemented at 29 emergency Cardiff model would save $15 in the health system and $19 in departments in London criminal justice.9 I have read and understood BMJ policy on declaration of interests and have no relevant interests to The model has also been introduced to cities in Australia, Canada, declare. Colombia, Jamaica, the Netherlands, and South Africa and is now endorsed by WHO. And, although Shepherd says that it has faced Provenance and peer review: Commissioned; not externally peer reviewed. cultural clashes in some countries—in Amsterdam, for instance, 1 World Health Organization. 10 facts about violence prevention. Updated May 2017. there was historical discomfort about sharing information with the https://www.who.int/features/factfiles/violence/en/. police, stemming from the second world war—he has taken pains 2 Roser M, Ritchie H. Homicides. Our World in Data 2013 Jul; updated 2019 Dec. https://ourworldin- to “firefight misconceptions.” He says that there hasn’t been one data.org/homicides. complaint about someone’s personal information being misused. 3 Shepherd J, Shapland M, Scully C. Recording by the police of violent offences; an Accident and Emergency Department perspective. Med Sci Law 1989;29:251-7. Knives out doi: 10.1177/002580248902900311. pmid: 2770477 4 Faergemann C, Lauritsen JM, Brink O, Skov O. [Development in violence in Odense City from The Cardiff model continues to deliver success. An April 2020 report 1991-2002]. Ugeskr Laeger 2007;169:2532-5.pmid: 17725901 from the Cardiff University Crime and Security Research Institute 5 Florence C, Shepherd J, Brennan I, Simon T. Effectiveness of anonymised information sharing showed a 45% drop in people treated at emergency departments and use in health service, police, and local government partnership for preventing violence related after a violent crime in England and Wales since 2010.10 The national injury: experimental study and time series analysis. BMJ 2011;342:d3313. cost of violence in the UK has dropped from an estimated £75bn in doi: 10.1136/bmj.d3313 pmid: 21680632 2004-05 to £44bn in 2015-16. 6 Florence C, Shepherd J, Brennan I, Simon TR. An economic evaluation of anonymised information sharing in a partnership between health services, police and local government for preventing But the battle is far from won. Recruiting a public health specialist violence-related injury. Inj Prev 2014;20:108-14. doi: 10.1136/injuryprev-2012-040622. https://pubmed.ncbi.nlm.nih.gov/24048916/. pmid: 24048916 to aid the Cardiff model initiative has proved surprisingly difficult, 7 Quigg Z, Hughes K, Bellis MA. Data sharing for prevention: a case study in the development of as “violence was not considered a public health issue,” says a comprehensive emergency department injury surveillance system and its use in preventing Shepherd. It was only in 2019 that the UK government announced violence and alcohol-related harms. Inj Prev 2012;18:315-20. a “public health duty” to tackle serious violence.11 doi: 10.1136/injuryprev-2011-040159. pmid: 22210640 8 Truman JL, Morgan RE. Criminal victimization, 2015. Bureau of Justice Statistics. Oct 2016. The past few years have seen a worrying rise in knife crime in the https://www.bjs.gov/content/pub/pdf/cv15.pdf. UK. A recent report by the Ministry of Justice showed that knife and offensive weapon crime rose from 2639 in 2013 to 4562 in 2019.12

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9 Mercer Kollar LM, Sumner SA, Bartholow B, etal. Building capacity for injury prevention: a process evaluation of a replication of the Cardiff Violence Prevention Programme in the Southeastern USA. Inj Prev 2020;26:221-8. https://pubmed.ncbi.nlm.nih.gov/30992331/. doi: 10.1136/injuryprev-2018-043127 pmid: 30992331 10 Cardiff University. Fewer people injured in serious violence in England and Wales in 2019—A&E data report. 21 Apr 2020. https://www.cardiff.ac.uk/news/view/2285628-fewer-people-injured- in-serious-violence-in-england-and-wales-in-2019-a-and-e-data-report/_nocache. 11 Home Office. Javid S. New public health duty to tackle serious violence. 14 Jul 2019. https://www.gov.uk/government/news/new-public-health-duty-to-tackle-serious-violence. 12 Ministry of Justice. Knife and offensive weapon sentencing statistics: July to September 2019. 16 Jan 2020. https://www.gov.uk/government/statistics/knife-and-offensive-weapon-sentencing- statistics-july-to-september-2019. 13 NHS England. Emergency Care Data Set (ECDS). https://www.england.nhs.uk/ourwork/tsd/ec- data-set/.

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