Duncan Bew: Healing a Traumatised Society: A Shared Obligation to Care, a Shared Opportunity to Thrive
The development of national major trauma networks has led to significant improvements in the care of patients with major traumatic injury, yet the greatest opportunity to reduce the burden of the disease of trauma is in its prevention. Possibly the greatest change which has improved trauma care is a shared mindset and agreed operating procedures, working together to form a chain of survival. In a similar way, violence prevention and the safeguarding of those who are vulnerable requires the responsibility of us all, working together to provide a continuum of support.
Cofactors associated with violence are shared with many other public health challenges and addressing all of these is essential for population health, and the true wealth of our society. We have a moral obligation to safeguard those who are vulnerable, but there is also an economic imperative to invest in the sustainable social development of communities to enable them to thrive.
Public health approaches to violence can be effective but must have a true understanding of the local risks and deliver relevant, culturally credible interventions in partnership with families and communities, rather than being imposed upon them. Multi-agency collaboration is essential and it is crucial that partner organisations understand their shared strategy and use the same terminology and definitions. Organisations must view each other as mutually compatible partners rather than competing rivals in their coproduction and delivery and be prepared to share their information and insight which is so vital for swift, early and effective intervention. Violence is not inevitable and is preventable, but it is also not an inevitable product of social inclusion and wealth. Public health approaches must be supported by enforcement from a police force that is adequately resourced to be able to proactively engage with and protect communities with mutual respect.
Both victims and perpetrators of violence have often witnessed or suffered repeated physical and psychological trauma from violence as children. Potential solutions to reducing violence have so far been hampered by a misunderstanding of the diverse challenges individuals in different communities face, often determined by an assumed political narrative rather than fact and an impatience to be seen to produce results. Other than in a small number of Violence Reduction Units, this has resulted in a lack of long term coordinated strategy sustained beyond political cycles or which effectively addresses the reality of the structurally violent environments in which people live. Short term strategy has focused predominantly on enforcement and secondary prevention which offers a very recognisable (and potentially valuable) intervention but only after harm has already occurred. Primary prevention offers huge potential to safeguard, educate and inspire positive futures as well as civic and first aid preparedness, but significantly lacks the investment required to support a comprehensive public health approach.
Society has branded knives, gangs and young people as a cause of violence, when they are instead the most visible symptoms of violence as a much more complex endemic societal disease. Families on adjacent streets are living parallel lives with polarised aspirations and opportunities, and dedicated parents suffering in work poverty working multiple jobs struggle to support their children. Our most deprived communities face discriminatory criminalisation. For many of the most vulnerable children, emotional, physical and sexual violence can become normalised and for some an inevitability. The lack of safe spaces, the ability to make safe journeys and often the absence of a trusted adult in their lives is a true reflection that they are being failed by our society, rather than failing it themselves. Their perceived failure to make the right choice is often due to an absence of choices for them to make.
Healthcare has a pivotal role to play in the physical and psychological care of patients who are injured as a result of violence, the prevention of future harm and also as an inspirational employer in every community. Caring moments offer an opportunity to safeguard and a teachable moment for those at risk, but they are also teachable moments for us to listen, to understand and appreciate unmet needs, expectations and environments which place our most vulnerable at risk.
In a trauma-informed approach we can enable effective reachable moments of primary prevention. In identifying these risks, effective sharing of data across networks must strive to ensure systems of care provide continuing support and prevent unrealistic thresholds of access or gaps between professional silos into which the most vulnerable can fall. This understanding can also enable us to effectively target the allocation of limited resources to guide primary prevention and thereby always place those who are most vulnerable at the heart of our care. There is now significant potential for the government to make this a reality for violence prevention and in doing so the social development goals of the SDG2030 (UN Sustainable Development Goals 2030) agenda.
NHS networks of health care provide an incredible opportunity to work in partnership with violence and injury prevention networks to deliver and evaluate evidence-based prevention.
Every interaction we make is an intervention and we must make every encounter count.
Duncan Bew is a Consultant Trauma and Acute Surgeon at King’s College Hospital, London