Oral evidence: Gangs and youth crime, HC 798Tuesday 25 November 2014
Oral evidence, 25 November 2014.
Witnesses
John Poyton, Chief Executive, Redthread Youth Limited, and Dr Emer Sutherland, Consultant Emergency Physician, Clinical lead for Emergency Medicine, King’s College Hospital, gave evidence.
Lorraine Fullbrook (in the Chair)
We welcome Dr Emer Sutherland and John Poyton to the Committee, specifically to talk about gangs and gang-related crime. First, can I ask Dr Sutherland about St Mary’s Hospital in Paddington that says it is treating children as young as 11 in hospital for injuries including shootings and stabbings?
Dr Sutherland
Good afternoon, Madam Chair. I am actually representing King’s College Hospital, which has been working in partnership with Redthread Youth for 10 years, but they have recently expanded our project in St Mary’s Hospital, and I am familiar with the work that is going to be rolling out there. May I talk about our experience at King’s College Hospital?
Lorraine Fullbrook (in the Chair)
Yes, please do.
Dr Sutherland
Thank you. King’s College Hospital, where I work as a paediatric and adult A&E consultant, has been aware for many years of youth violence and we have regarded it as a child safeguarding issue. In my department, child safeguarding is not just an issue of the young babies, it is an issue of adolescents and to recognise the many stressors that are placed upon adolescents growing up in the boroughs that we serve at King’s College Hospital. You are absolutely right: we have seen victims of assaults, going down to very young adolescents, who have come from the locality around our hospital but also from wider parts of south-east London since we are now a major trauma centre.
Lorraine Fullbrook (in the Chair)
How much evidence do you have from around the country with your work that this is happening elsewhere outside London?
Dr Sutherland
I think that, much as our colleague from Manchester has described, as with so many other aspects of life, this is not a pattern that is applied mutually across the country. There are hotspots for urban youth violence as there are hotspots for other issues. What is particularly interesting at the moment is that my department is involved in a research project looking at problem drinking in young people, and we are involved in a cluster collecting information from London, comparing ourselves with clusters from other parts of the country. It has confirmed my clinical feeling, which is that acute alcohol intoxication is not a significant issue for my local young people.
Lorraine Fullbrook (in the Chair)
It is not?
Dr Sutherland
It is not for the local young people in Lambeth and Southwark who attend my department, but I know that it is a significant issue in emergency departments in other parts of the country. So the one-size-fits-all does not apply, which I guess is how my hospital came to start the funding for our project, working in partnership with a local youth work group who were already embedded within the local community so that we could look at best serving this particular group of young people.
Dr Huppert
It is good to have you both here. Mr Poyton, I have been quite excited about the work that Redthread has been doing from what I have heard of it, so it is very good to have you here.
John Poyton
Thank you.
Dr Huppert
Could you say a little bit more about the sort of opportunities that you have in the NHS context, how you have driven them and what can be done to make that a better option for people?
John Poyton
I think it is particularly appropriate at a Committee when we are talking about gangs to recognise that young people often do not recognise themselves in this way and that a lot of hard to reach and vulnerable young people are already known to services but not choosing to engage. For Redthread and for my colleagues and friends at King’s College Hospital, and now at St Mary’s in Paddington, we recognise what we call a teachable moment when young people are in pain and, pain being a great catalyst, they may be bored waiting to be treated in a very busy A&E. We know that they may be close to death, or an injury does not necessarily equal the trauma that someone feels. It is a very teachable moment for young people to be engaged, both by the clinical team and by youth workers. As I said, they may have been known to services for a long time but not choosing to engage, they may be completely unknown, but the key is—and I think what the young people would say if they were sitting here—that they choose to engage with the youth work team that is embedded because they are treated as the victim or they are treated by looking at a solution for that young person. My medical colleagues have to look at the problem. They have to stop the bleeding and stitch the young person up. The youth work team are able to then immediately start working with that young person while they are still being treated, or while they are in a bed, and start looking to where the young person wants to make some differences in the future.
Dr Huppert
I spoke quite a bit about Redthread’s work and we had a debate about whether to have compulsory sentencing for possession of knives as a second offence. I do not want necessarily to go into that whole debate, but one of the concerns I had was that you were not getting sufficient support from the Government. There was a lot more that could be done from that sort of angle to reduce knife crime as well as gang violence. What level have you reached in terms of evaluation—that is a question for either of you—of the project so that there would be a strong evidence base to roll it out to the rest of the country where needed or to say, “It just does not work. It sounds like a good idea”.
John Poyton
It is fair to say that over the nine years—10 years next year—that Emer and I have been working together there has only been a very small amount of funding available for this intervention. It just so happens that nine or 10 years ago we stumbled upon this. We were not aware that it was innovative necessarily at the time. It just met the needs of the local population, and it has taken some time for the funding snowball to begin. In that sense, there was a feeling at King’s that the small pots that we received needed to be put into the intervention and there was never a nice large research evaluation pot to fish in. Now what is quite exciting is, in rolling out to St Mary’s, there is evaluation of the King’s and Redthread model happening with the St Mary’s programme over the next three years. Also the Mayor’s Office Policing and Crime Team are funding a pan-London rollout of the Redthread and King’s model over the next year, and that will give us funding to start to do some evaluation with their team.
Dr Huppert
Presumably the NHS has to be able to accommodate this sort of thing. Has it been an easy thing to get acceptance for?
Dr Sutherland
I think that it has been hugely welcomed by the shop-floor staff in the emergency department, because the atmosphere in which we work is one, especially in an emergency department, of time pressure on highly skilled individuals whose skills are in high demand. Our nurses particularly, our junior doctors as they come through, are very aware that they are not getting the whole story from young people who come through, that there is something else happening. The number of young people who fall on glass in the area surrounding my department is quite terrifying, but we have a resource available in the department that you can call upon to come down and sit with the young person and to engage with them while they are there. Young people are not daft. They know that with knife crime and gun crime we have a GMC obligation now to inform the police, hence the falling on glass. They find our approach much more threatening. They regard us as being part of the establishment, but they are very comfortable with the youth work model and we find that the story that we have been given will change as they speak to the youth worker, even within the one sitting. We particularly see the strength of the model when we start to look at issues like young women who are being sexually exploited within the gang environment. In those situations they are almost always not ready to tell us enough to reach a statutory threshold on their first attendance, but they want to be asked. We know from an SPCC document and the Children’s Commissioner document that they have wanted to be asked. Healthcare professionals cannot ask a question if they have nothing to offer the patient in return. But in my department you only have to suggest that you are a young person who is worried about something and we can contact our youth workers who can engage with you on a youth-friendly basis in terms that you can accept, and work with you to a point where you are willing to engage with statutory partners. So the staff on the ground have been very welcoming of it, and it forms one of the big parts of our major trauma centre and our injury prevention strategy.
Tim Loughton
I think your comments about youth workers appearing to be more empathetic are very interesting. What do you think it is about a youth worker that draws a more trusting revelation from some of these people appearing in a medical context?
Dr Sutherland
I do not know why John appears to be more trustworthy than I do, but I think there is something about—
Tim Loughton
We do not need to personalise it, just youth workers generally.
Dr Sutherland
I think there is something about the types of questions that you are forced to answer, by the information that you have to gain professionally and also about the pace at which you ask it. I do not have the luxury of sitting in the waiting room with my young person and chatting to them, “How is college going? How are things at home?” the things that I would like to ask. I do not have the luxury of that time because I may be going straight from one major trauma case to the next major trauma case, whereas the youth workers have that opportunity. As John said, there is something very powerful about not going on to the negative, “How big was the knife? When did it happen?” and very much going on to think about where the young person wants to move forward to.
Tim Loughton
Is it a matter of time or is it that you are effectively the uniformed service whereas a youth worker is not?
Dr Sutherland
I think we have been labelled as part of “the Feds”. When we have done user group engagement, they have told us in no uncertain terms that we are the Feds and that John is not.
Tim Loughton
Is that right, Mr Poyton?
John Poyton
I think one of the things that we feel has been successful over the nine or 10 years at King’s, and that we feel is working very well at St Mary’s now and will do so at St George’s next year, is that this is an important partnership between a major trauma centre and a voluntary sector agency. As major trauma centres, we have all looked at the numbers of young people who attend and where they attend from. We have very nice colourful bar charts that show the numbers of boroughs they come from. We have had many conversations with our colleagues and partners that we work very closely with in the local boroughs that there is no room in a busy A&E department to have a youth worker from Lambeth, Southwark, Lewisham, Bromley, and I think also that would mean that a youth worker, who may work in a similar way, would then come with that sort of statutory hat on. I think it is the voluntary sector element, the fact that Redthread is there as a voluntary engagement, there is no statutory agency. It is all carrot and no stick I suppose, and it does mean the young people pick up on that. It is a voluntary engagement. They can choose to say, “No, I am not ready to talk about this”, but it is a team approach in that very solution-focused way. They look at the future and also they have the time to start off the conversation with a glass of water or a Diet Coke. It is very old fashioned. It is almost biblical that a glass of water between a Good Samaritan and someone is actually a real breaker of barriers.
Tim Loughton
Interesting.
Dr Sutherland
If I could add to that, I think particularly it is the young people who have had very complex journeys, who have perhaps had a lot of involvement with services, who are not sure whom they can trust. We certainly have several young women, in particular, who have not been able to tell their story until the second or third engagement with our specialist female youth workers in the team. We are not in the business of bringing people back for repeat attendances, so it is having someone who can take them away from the emergency department, meet them on neutral ground and allow them time to tell their story. We know that there is some testing that goes on in those first few conversations of implying that the story is to come and then they wait until they feel that they can trust before they share.
Tim Loughton
Turning to the centre, which was opened in 2011 I think, wasn’t it, between Herne Hill and Redthread?
John Poyton
Yes, it was.
Tim Loughton
Can you talk us through how it is effective in reducing inappropriate use of acute services and its proactive role in education as well?
John Poyton
Certainly. The Well Centre is a one-stop shop, a youth centre and a health centre rolled into one, set up by Redthread with the youth work team and with primary care. My co-founder is Dr Stephanie Lamb. We were looking at the fact that young people were often not engaging with mainstream services and also that there were not places for young people to go once they left the A&E department. They might meet up with the team in a cafe or in McDonald’s to continue to have a conversation, but often they were still not reaching the threshold to be referred on to the gangs units or to the Havens, the Rape Crisis Service or CAMHS for mental health issues. The young people were also not engaging with their local GPs and local GPs were not necessarily feeling they were resourced enough to engage young people in those very short seven to 10-minute appointment slots. So the Well Centre was set up in 2011 specifically to enable young people to come and engage on any issue whatsoever. We have young people who will come in, having engaged with the team in the A&E department at King’s, who may need their stitches removed. They probably are not at the point of realising that their anxiety, their paranoia and the fact that they now do not leave the house without their mum is possibly linked to post-traumatic stress, in a not dissimilar way to our soldiers coming home from warzones. It might be that end of the spectrum. It might be a young person who needs to have a sexual health check or who maybe is feeling paranoid because they are aware they are smoking substances. They could come in with their acne. Adolescents do not understand how services work. I can totally see, having worked with the NHS in partnership for 10 years, why health has to work in silos. But young people cannot understand how the system works and why—if they have perhaps an issue around their sexual health, because they are adolescents who are perhaps starting to experiment and to live life—they have to go on one bus to a sexual health clinic over here when at the same time they may be smoking, they may be experimenting with drugs, but they cannot deal with that over here. They have to go on another bus over there. At the same time, their substance misuse might be affecting them and causing some paranoia, but then they probably have to go on another bus to engage with CAMHS. At the same time, they might or might not reach the threshold. So the Well Centre enables young people to engage with a team dynamic for all the young people to come through. They are first and foremost engaged by the youth work team, again in a very voluntary sense. They can sit down and get a feeling of the service while having a hot chocolate and a slice of toast after school or after whatever they have been doing, and ask the questions that they might want to ask. They all get an opportunity to have a good long conversation with the GPs that run the sessions, and all the young people then are able to have a team health check, as we call it. That is a great opportunity for a young person who attends and maybe when they look in the mirror in the morning they are most bothered by spots. But when a GP is able to start to ask a few questions and to do a little bit of a health needs assessment, you start to pick up on the fact that their risky behaviour, related to perhaps their substance misuse or their sexual health, is actually of much more concern to us, and perhaps their self-harm and so on. It means that we are able to start to case find. We start to be able to do some good early intervention and prevention work. We have CAMHS services. Lambeth CAMHS second one of their experienced mental health nurses to us and she has been embedded with the team for the three years that we have been running. It creates perhaps a very unique opportunity for teenagers to engage with their health and to return and learn over time and in that relationship how to access mainstream services in future.
Paul Flynn
I have enjoyed very much what you have said. How rare is this collaboration between the two services and do you think it is applicable elsewhere?
Dr Sutherland
We are about to roll out to the four major trauma centres in London. We hope to start working in a more networked way. I think that some of the high profile things that raise headlines, such as urban street violence, are in many ways the tip of a pyramid and our youth workers are not single-issue youth workers. As John has described, thinking about children who do not meet the CAMHS threshold and who might be being sexually exploited or in dating violence, those children and young people are in all emergency departments and not just because of urban street violence. While you may not need a full extended hour’s presence in every department, I think most young people would benefit from a more integrated service.
Paul Flynn
You mentioned earlier about not raising issues where you do not have any solution, if I understood you correctly.
Dr Sutherland
Exactly.
Paul Flynn
We know that among the gang members, people in these categories have a very high degree of mental ill health problems, from anxiety to psychosis and usually a high use of alcohol and drugs, excepting Lambeth, which is a very temperate area.
Dr Sutherland
Substance is an issue but alcohol is not, in our local studies.
Paul Flynn
That is fascinating. But what can you do about that? Can you offer any solutions to those problems?
Dr Sutherland
In our hospital for many years now, as well as a very holistic child safeguarding assessment, every young person up to the age of 18 who is admitted after a serious assault will have a full CAMHS assessment. We do recognise going forward that there are serious mental health issues, but we also know that when we are discussing more of the walk in-walk out type assaults that we see, which we review weekly in our multidisciplinary meeting, that Redthread are engaged with that. We know that a number of them have been referred to CAMHS in their youth, often for issues around anger management, but as part of the issues that have brought them to that stage they have not been able to engage on those terms. That is where something like a drop-in service is much more youth friendly.
Paul Flynn
There was a survey conducted by Professor Coid last year of nearly 5,000 people between the ages of 18 and 34. They found that of the group of men identified as having a gang association, 66% of them were alcohol dependent and 57% were drug dependent. Apart from the alcohol point that you made earlier, are those other figures on drug dependency plausible, in your experience?
Dr Sutherland
Professor Coid’s paper was very interesting. There is a similar piece of work that has been done in our local population. I do not know if you are aware of the South East London Health Collaborative who have been looking at health inequalities in south-east London. They have published a paper, which I would be very happy to share with the Committee, looking at mental health, substance and alcohol use in people within Lambeth and Southwark who have either been victims of violence, perpetrators of violence or been exposed to violence. You are absolutely correct that substance and alcohol abuse are associated with both those groups—substance more so in our area than alcohol—and that there is a cumulative effect on their mental health, that being an exposed victim or a perpetrator cumulatively make you more likely to have features for mental health diagnoses. I would be happy to share that paper with the Committee if you want it.
Paul Flynn
These are problems that are very difficult to treat, the mental health problems and if the drug addiction is a serious one. Are you building up expectations that you cannot fulfil in suggesting that you can improve their lives?
Dr Sutherland
The primary prevention?
John Poyton
Yes. The youth work team embedded in the department is able to become a single point of contact, as the clinical teams cannot be bringing up issues if there are no services to link to. It is difficult for clinicians in a very busy department to have a relationship and partnership with every different agency that is out there, whether they are voluntary sector agencies who are commissioned by local boroughs to provide services or the boroughs themselves. So it is the youth work team that look to create those partnerships, which means that both Redthread and King’s are not then looking at reinventing the wheel. There are many good services out there, so we do try to make sure, if we cannot support those young people ourselves, that we signpost, handhold and relationally refer those young people into the most appropriate services. We are very aware, and when I was a youth worker on the ground 10 years ago in King’s, that with a lot of young people coming through with mental health issues and misuse issues, it was very difficult to do all that work and try to manage a caseload of 700 13-to-19 year-olds every year. So it was a lot of signposting, but if young people who start to build up a rapport in the teachable moment are then told, “We are going to make a referral” it is very much a sense of rejection for them. They have just started to build some trust, some rapport, and then that person is saying, “I can’t deal with you”. So what we recognise is a real need to blend that relationship into the community. The work cannot just happen in the A&E department. There needs to be youth workers as a single point of contact creating relationships with the other agencies, providing mental health services, substance misuse services. We can then take the young people and introduce them to our friends and colleagues so that the young people themselves can really sense that this is a relationship from John to Paul and not just a fax or an e-mail and a very cold referral. That seems to work very well, and it means that the hospital and Redthread do not have to try to recreate and outdo other colleagues who are already providing excellent services.
Paul Flynn
Thanks. I look forward very much to reading your paper and I think we can probably add to the knowledge of what is happening in Lambeth and Southwark, which has a large population of Members of Parliament who form a sort of gang who are not without their problems as well.
Lorraine Fullbrook (in the Chair)
Mr Poyton, Dr Sutherland, thank you for coming to the Committee today to give your evidence. We would be grateful for any evidence or reports that you would like to share with the Committee for the compilation of our report. Thank you very much. Gangs and youth crime, HC 199 2