Evaluating a hospital-based youth violence intervention programme

Knife crime and other serious injuries among young people have been rising. This isn’t just an issue for the criminal justice system but affects the health of young people and the health services they rely on.  

Office for National Statistics figures show that violence-related crime offences involving a knife or sharp object rose by 53% to 51,891 offences between 2010/11 and 2019/20 in England and Wales. While the number of offences dropped in 2020/21 (to 41,563) – almost certainly related to Covid-19 and, in particular, measures introduced to combat the pandemic such as lockdowns and school closures – it rose in 2021/22 to 45,285.

Meanwhile, for the NHS in England and Wales, the number of inpatient admissions with a classification of assault by a sharp object (including, but not limited to, knives) fluctuated between 4,000 to 5,000 a year between 2010 and 2022. Around a quarter of these admissions were for children and young people aged between 10 and 19.

However, the numbers treated in the NHS will be an underestimate as – apart from likely under-reporting – they only relate to inpatients, and exclude treatment in accident and emergency departments.

A public health approach

Over the last decade the NHS, working with specialist charities, has tried to adopt a multi-agency approach to tackle the problem of serious injury among young people due to violence in the community.  

Scotland, for example, has pioneered a public health approach to violence as advocated by the World Health Organization (WHO), including knife crime. This has included educational programmes, as well as youth violence intervention programmes (YVIPs) which have developed to engage children and young people at their point of contact in emergency departments. And in London for example, around 15 trusts have YVIPs embedded in emergency departments, with NHS nurses and clinicians working alongside charity youth workers to support young victims of violence.

These programmes show the growing policy attention on taking a broader approach to preventing youth violence across the UK, with NHS guidance now available to support implementation of in-hospital violence reduction services.

But do these interventions have an impact and are they cost effective? While there is evidence of success, evaluating these programmes has proved difficult, partly due to the complex nature of YVIPs, which may influence a young person’s life in many different ways based on their needs.

Redthread at University College Hospital

As part of a wider NIHR-funded project to evaluate health and social care interventions, the Rapid Service Evaluation Team (RSET) – a collaboration between the Nuffield Trust and colleagues at University College London – undertook an evaluation of a YVIP run by the charity Redthread in collaboration with clinicians at University College London Hospital (UCLH).

Redthread has been implementing YVIPs in hospitals since 2006, and in 2020 they started a service at UCLH. The programme embeds specialist youth workers into the Trust's emergency departments, capitalising on the concept of 'teachable moments' to engage young people who attend following violent injury and trauma, and encourage a positive change in behaviour.

Our aim was to evaluate the implementation and impact of the Redthread intervention at UCLH to assess the feasibility of identifying the benefits of the intervention for patients and staff.

We found that within UCLH’s adolescent and paediatric services, the Redthread service was viewed positively by staff as filling a gap in service provision. Youth workers helped young people to better engage in their medical care and treatment by building trusted relationships and providing tailored support.

In practice, youth workers embedded within UCLH provided assistance to young people affected by a range of issues extending beyond knife violence. Reasons for referral not only included physical assault, but also substance misuse, sexual assault, suicidal thoughts, mental health crises and concerns about safeguarding.

Youth workers also linked with non-health care services within the community and thus enabled front-line clinicians to better support vulnerable young people following discharge from hospital.

Although there was severe disruption to the service due to the pandemic, by last winter Redthread was perceived to be well embedded in the paediatric emergency department and adolescent services, and there was increasing awareness of the service in outpatient departments.

Despite fewer than expected numbers of children and young people engaging with the longer-term programme due to Covid (59 over the period of the study), we also found that based on Redthread’s initial and final assessments, the “risk of experiencing further harm” and the “risk of not maintaining a positive relationship with their family” showed statistically significant reductions.

And in terms of resources, we estimated that the costs of the Redthread service at UCLH would be offset by savings if around a third of the engagements with Redthread led to at least one avoided emergency inpatient admission.

Our evaluation, which will be published by NIHR in the next few months, has shown that there are indications of benefits to those who engage with the Redthread programme and that the service is appreciated by NHS staff. However, small numbers, the disruption of Covid and problems linking data between the hospital’s patient administrative system and Redthread’s own data meant that we could not conclusively establish its effectiveness or cost effectiveness.

Nevertheless, we highlighted lessons for the NHS and YVIPs in terms of linking data and establishing continuous monitoring and evaluation to better understand the shorter and longer-term impacts of such interventions and help inform how best to deliver such programmes.

*The Rapid Service Evaluation Team (‘RSET’) comprises health service researchers, health economists and other colleagues from University College London and the Nuffield Trust who have come together to rapidly evaluate new ways of providing and organising care. For more information about the team’s work and projects, please visit the main RSET page.