Criminal neglect: no justice beyond criminal justice - The rights of victims of crime - Health

Victim Support believes that

healthcare professionals must be equipped to provide an appropriate response to victims of crime
crime victims must have access to free healthcare services geared to meet their needs
the government must adopt an integrated approach to meeting the healthcare needs of victims of crime. National standards are needed to tackle this major health issue

Healthcare professionals must be equipped to provide an appropriate response to victims of crime

The British Crime Survey (13) reveals that less than half of all crime is reported to the police, including many crimes of serious violence. Victims of crime are more likely to contact healthcare workers than any other professional. Healthcare workers are therefore likely to meet victims of crime who are not seen by any other agency. So, it is crucial, that the healthcare system responds effectively, including knowledge about the on the individual, an explanation of any proposed treatment and some information about other sources of help available.

Victims of crime make up a substantial proportion of health service users. They rely on hospital services such as accident and emergency (A&E) units, acute care, outpatient treatment, primary care services and mental health, psychological and counselling services. But Victim Support is seriously concerned that their specific needs are being overlooked.

Family doctors in Glasgow are treating more women and children for domestic violence than for cancer, heart disease or diabetes."(14) This finding comes from a study by the Greater Glasgow Health Board, which goes on to note that many doctors are unaware that domestic violence is the underlying reason for a high proportion of consultations, and that few GPs have received any previous training or information on domestic violence. "They also appeared isolated from services for abused women, being largely unfamiliar with the work and effectiveness of these.(15)

Victim Support's experience shows that despite some examples of good practice, common problems still persist. For example, most of the victims of violent crimes who are treated in A&E units are young men (outnumbering women by six to one).(17) This group of people frequently find it extremely difficult to admit that they have been attacked - partly because young men are frequently blamed for the crimes they have experienced. It is therefore essential that healthcare professionals remain non-judgemental and encourage their patients to talk about what has happened by offering support and understanding. However, evidence from staff at A&E units gives a different picture; "Research has found some astonishingly judgemental attitudes; for example, that the injured are largely responsible for their own injuries, and that anyone hurt after drinking alcohol should be made to pay for their treatment."(18)

Casualty departments are largely black holes into which victims are drawn, to be regurgitated back to their homes and communities without any attempt at prevention, protection, or support, or the apprehension and conviction of their assailants, who remain at liberty to inflict further physical and psychological harm.(16)

Healthcare professionals need sufficient awareness to ensure the health and safety of their patients. Victims of domestic violence may try to hide evidence of abuse or claim that injuries are the result of accidents. They may be particularly reluctant to discuss domestic violence if their partner is present or is a patient of the same GP. In 2000, the Department of Health published Domestic violence: a resource manual for health care professionals (19) aimed at increasing the knowledge, understanding and response of healthcare workers. It calls for clear policies and protocols backed up by appropriate training, supervision and support, recognising that it is; "not acceptable to simply assume that someone else - such as social services or the police - will be doing something." Victim Support has welcomed this initiative and is keen to see it implemented. But similar initiatives are needed to include all crime victims.

It is also essential that healthcare professionals are equipped to provide a co-ordinated response to the criminal justice process. Victims of crime need to be assured that medical professionals will do all in their power to collect and safeguard evidence as well as providing treatment.

Crime victims must have access to free healthcare services, geared to meet their needs

It is probable, however, that at least a substantial minority of victims of assault who attend A&E departments will suffer some degree of psychiatric disorder, and will need specialist assessment and care.(20)

Our experience suggests that most people find it extremely helpful to talk about feelings arising as a result of crime. Victim Support volunteers are trained to listen in a constructive way and to provide reassurance that these feelings are normal, and even healthy. This emotional support is coupled with information and practical assistance. But Victim Support does not describe its services as counselling. One reason is that the word may suggest that the problem lies with the victim's personality, lifestyle etc rather than the fact that they need help and support to deal with understandable reactions to an external situation. All Victim Support volunteers are trained to recognise when an individual might be in need of more specialist help including, where necessary, counselling and psychiatric services.

But access to, and availability of these services varies greatly across the country. And there is little research available as to the effectiveness of the many different forms of treatment offered.(21) There are also concerns that some counsellors based in GP practices cannot provide satisfactory help to people who have been victims of crime because of inadequate training on issues specific to crime victimisation.

My downstairs neighbour had been harassing me for months - loud music and being abusive and threatening. I was in a permanent state of anxiety and got so as I couldn't even stand being at home. I was not sleeping either so I went to see my doctor. He said I should have counselling to help me cope, but I'd be waiting months on the NHS, so why didn't I go private. I went to see a psychotherapist he recommended, but it didn't help one bit. After talking to him for 10 minutes, he only seemed interested in the fact that I was gay. I felt like something out of a textbook rather than a normal person being driven crazy by an aggressive neighbour - he didn't understand at all.

Waiting times for counselling or psychiatric help are a frequent problem, especially when many would benefit from immediate intervention. We believe that people who have been victims of crime should not have to pay for the services they need simply to get help more quickly. We are also concerned that there is a two-tier system in operation. For example, it is common practice for civil actions for personal injury to include claims for private medical treatment (typically for counselling or physiotherapy). In such cases payment is frequently made in advance, as it is recognised that early treatment can lessen the long-term effects and so reduce the final amount of the claim. Obviously, such a system is only workable for claims against insurance companies; it is not an option open to the vast majority of victims of crime. It does, however, indicate the level of unmet need.

Victims of crime injured in violent attacks show a similar level of anxiety and depression to those patients injured in accidents, in the immediate aftermath. However, after three months, the levels of anxiety and depression experienced by victims of violent crime remained constant. This suggested that both victims of accidents and crime need a similar level of support immediately after an event, but that this support needs to be sustained over a longer period for victims of violent crime(22)

Rapid access to other healthcare services can also be a problem. For example, we believe victims of crime should not have to bear the cost of reconstructive surgical treatment (such as cosmetic surgery) resulting from a crime. The psychological, as well as the physical impact of the crime should be taken into account when assessing priority for treatment. The fact that scarring has been caused by a crime serves as a constant reminder to the individual and can delay their recovery. In addition, victims of crime should not have to pay for medical documentation or certificates (ie letters in support of re-housing, to take time off work, or to support claims for compensation).

Our experience shows that there is an absence of, and/or delay in providing, treatment for children seriously affected by crime. The most likely reasons are a lack of resources combined with a medical view of the problem as requiring a crossover between two specialities: expertise in treatment for post-traumatic stress disorder, and child/adolescent psychiatry. We believe this situation needs to be addressed as a matter of urgency.

I was the victim of an unprovoked attack that resulted in a serious facial injury. The scarring that this injury left me with affected me deeply. I felt that it was the first thing people saw when they looked at myself in the mirror.

The government must adopt an integrated approach to meeting the healthcare needs of victims of crime. National standards are needed to tackle this major health issue

A 1998 Victim Support survey of our local services (23) found the quality and availability of healthcare was often dependant on location.

It found:

widely varying levels of awareness of issues affecting victims of crime
services organised and accessed differently in different parts of the country
varying levels of service provision resulting in long waiting times in some areas when victims of crime are in need of immediate help

Although the survey highlighted a great deal of inconsistency, it also found examples of good practice and innovative projects. One health authority arranges medical student placements with their local Victim Support Schemes to increase awareness of issues affecting victims of crime. It also provides information about other sources of help available. Several initiatives bring services for victims of crime into hospital A&E units. The Cardiff Violence Prevention Group Inter- Agency Task Force was formed after it became clear that a great deal of violence resulting in hospital treatment was not recorded or investigated by the police. The project has devised a series of possible interventions including: providing assault victims with the opportunity to report to the police whilst in the A&E unit; establishing links between the local Victim Support Scheme and the A&E Unit; and assessing the risk of future harm.

Cases of children experiencing difficulty in accessing medical treatment for their psychological injuries:

a six year old seriously assaulted (being set on fire) and still on a waiting list some six months later
two boys aged eight and nine who saw a man having his throat cut
three children whose mother saw their father murdered. In this case, the local Victim Support Scheme obtained treatment for these children by asking a favour from a personal contact in the NHS.

These developments are encouraging, but they need to be built upon by setting central policy initiatives and implementing and co-ordinating them within an agreed national framework. The Department of Health sets and defines standards for specific NHS services or care groups through the National Service Framework. It supports implementation and measures performance. The National Service Framework for older people provides an obvious example of how this model could be applied to crime victims.

The sheer volume of specific health needs of people who have been victims of crime and the failure of the health service to meet their needs, are strong arguments for the need to establish a new National Service Framework. This would not only lead to improved services for crime victims, but would clearly demonstrate that the government has recognised the need for an integrated approach to tackle this major health issue.

References

13. Successive tranches of the survey have found that under 50% of all crime is reported.
14. Community care, 30 August - 5 September 2001
15. Munro, 2001
16. According to the journal 'Criminal behaviour and mental health', quoted in Shepherd, 1996
17. Shepherd, 1997
18. Shepherd, 1996
19. Department of Health, 2000
20. Shepherd et al, 1991
21. Department of Health, 2001
22. Shepherd et al, 1991
23. Victim Support, 1998