A&E navigators – South Yorkshire Police

South Yorkshire Police is taking a public health approach to preventing and reducing homicide and serious violence.

Accident and emergency (A&E) navigators are a key part of this approach, working with partners to prevent the progression of violence and supporting those who have already become involved in violent behaviour.

The A&E navigator scheme has received positive anecdotal evidence supporting its impact including from partners who felt navigators were making appropriate referrals at an appropriate volume.

South Yorkshire Police was identified in 2019 as one of the 18 forces in need of a violence reduction unit (VRU) to tackle and prevent serious violence. The force identified the need to improve a joined-up homicide prevention approach in South Yorkshire.

South Yorkshire Police identified two key challenges relating to serious violence and homicide prevention. These were the need to:

• prevent the progression of violence for those already involved in violent behaviour
• improve a joined-up approach to homicide prevention across the force and partner agencies

There are several navigator programmes in South Yorkshire, including school navigators and custody navigators as well as the A&E navigators discussed here which launched in Dec 2019. The different navigator programmes all largely operate independently.

A&E navigators are based in the Major Trauma Centre at the Northern General Hospital in Sheffield, South Yorkshire. The navigators provide support to patients who enter A&E with a violence-related injury.

The aim of the navigators is to:

• access vulnerable individuals who may be otherwise unknown to the police
• intervene at a reachable and teachable moment
• encourage individuals to choose a different pathway in their lives
• prevent the escalation of violence to homicide

A&E navigators are recruited by Sheffield Teaching Hospitals NHS Foundation Trust on temporary contracts as non-clinical staff. They often come from community or youth worker backgrounds. They provide a point of contact, to both victims and offenders of violent offences, that is distinct from the police or medical experts. As they operate autonomously, they are not required to report crimes to the police – except in specific circumstances that are outlined by guidelines. Their independence encourages patient engagement.

A key part of the A&E navigator role is to signpost or refer clients to other support services. The navigators have access to a range of charities and support networks that promote a positive lifestyle. These networks include refuges, housing, and drug and alcohol services. Navigators are given access to the community directories of all four districts across South Yorkshire, which enables them to quickly locate a wide range of support services and contact details whenever needed.

The navigator role often also goes beyond referral to other services. Navigators may continue to act as a support network for their client once hospital treatment has finished and the client is back in their community.

Navigators deal with personal, emotive and complex caseloads daily as part of their role and as such, clinical support and supervision is key. Many navigator clients have suffered from domestic abuse and are identified as at an elevated risk of further violence if they are not provided with access to help. Some navigators have lived experience of similar circumstances to their clients.

All navigators require comprehensive support to understand what to do in specific scenarios, such as domestic violence and honour-based violence. Sheffield Teaching Hospitals NHS Foundation Trust has recently introduced clinical psychology sessions to support the navigators and other staff with secondary trauma from client cases.

A&E navigators logic model
 

A&E navigators are employed by Sheffield Teaching Hospitals NHS Foundation Trust and funded through the South Yorkshire VRU — a unit managed by the Police and Crime Commissioner (PCC) and in receipt of Home Office funding. The South Yorkshire VRU assists with the recruitment of navigators.

There are currently four A&E navigators who are located in one South Yorkshire hospital. The navigators travel to the other three districts in the region as required.

In the period between launch in December 2019 and July 2022, 347 patients were referred to the A&E navigators. (Navigator data shows slightly more male clients than female since launch (54% to 46%). The mean client age is 31 years old, but with ages ranging from 8 to 83 years old.)

Data shows the reasons for hospitalisation for these patients as:

• assault (31%)
• domestic abuse (28%)
• stabbings (12%)
• assault with a weapon (11%)
• alcohol and substance abuse (7%)
• other or unrecorded (6%)
• gunshot (3%)
• slavery and trafficking (2%)

Navigator data suggests that a third of approached individuals accept navigator support. Clients have typically been supported by a navigator for up to nine months.

While the navigators have found that a higher proportion of approached women tend to accept their support than men, the reasons for this have not yet been empirically explored.

How the A&E navigator programme works

• Patients are identified as eligible for a navigator if they enter hospital with a violence-related injury. The patients are either directly approached by a navigator, referred by hospital staff or (less frequently) self-refer themselves after seeing hospital posters.
• While the navigators can work a full-time role of 35 hours a week, their hours are focused on weekends covering from Friday overnight through to Sunday. Clients can leave messages for their navigator outside of their working hours.
• The hospital environment enables navigators to reach patients at a reachable and teachable moment – when they are in a safe environment and protected from their usual influences.
• Clients can stay in the navigator programme for as long as they wish. Of the 39 active clients in July 2022, 12 of these had engaged with the navigators for less than a month, 31 for less than 3 months, 5 for less than 6 months and 1 had re-engaged (they left the programme and then re-joined). However, a key part of the navigator role is to find appropriate services for clients alongside the navigator relationship.

Between launch and July 2022, navigator referrals were made to the following organisations, with housing and mental health services receiving the most referrals.

• Housing services.
• Domestic abuse services.
• Mental health services.
• Police.
• Social care services.
• Alcohol services.
• Probation services.
• Food banks.
• City Hearts charity (supports women with life controlling issues and survivors of modern slavery).
• Mind charity (provides advice and support to anyone experiencing a mental health problem).
• Together Women charity (works with women and girls across the North of England).
• Shelter charity (exists to defend the right to a safe home).

Process

1. Patient admitted to A&E with violence-related injury.
2. Patient approached by navigator or referred by A&E staff.
3. Patient chooses to engage with navigator and becomes a client.
4. Navigator arranges support to referral services if required.
5. Navigator maintains ongoing relationship with client for as long as required.
6. Client leaves navigator programme.

Enablers for implementation

Organisational culture

Regular contact between the navigators and South Yorkshire Police is maintained and encouraged by the VRU. While the VRU is not directly part of South Yorkshire Police, it is formed through a collaboration of key duty providers in South Yorkshire, of which the police form a key part. Silver- and gold-level command in South Yorkshire Police are also engaged with the navigator programme.

Governance structure

The involvement of South Yorkshire VRU with A&E navigators helps give the programme a focus and standing in the force’s drive to prevent homicide. The role of the VRU also helps the navigator programme get buy-in from the PCC.

The PCC is very supportive of the navigator programme. The PCC particularly supports the partnership working of the navigators and the role the navigators play in South Yorkshire Police’s homicide prevention strategy.

Partnership working

The A&E navigator programme relies heavily on effective multi-agency arrangements. The navigators depend on effective working relationships with South Yorkshire Police, multiple referral agencies, and the staff in hospital A&E departments. The navigators encourage their clients to report crimes to the police, but no referral will be made to the police without the client’s permission (except in specific circumstances that are outlined by guidelines).

Evidence suggests that A&E navigator programmes can prevent further violence.

See evaluations from the:

• Crime reduction toolkit – A&E navigators
• Youth Endowment Fund – A&E navigators

Sheffield Hallam University conducted a process evaluation of the South Yorkshire A&E navigators. This study involved document reviews and interviews with staff. The findings provided insight into how the navigators successfully adapted during the COVID-19 pandemic – a period when they were excluded from hospitals and when key referral services were shut.

The South Yorkshire A&E navigators were further evaluated in 2021. A survey of navigator referral partners suggested that partners thought the referrals they received from Navigators were appropriate, and that they received the necessary information from navigators. The surveyed partners also believed that navigators were not referring too many individuals to their services, and that the navigator service had a positive impact on clients’ lives. The evaluation also found that A&E navigators were well embedded in their hospital and working well.

Navigators keep output data on the number of text conversations between themselves and clients. In the quarter leading up to July 2022, the navigators engaged in 400 separate text conversations. The navigators record linked texts (conversations) as one record, rather than measuring every individual message as a new record.

Sheffield Teaching Hospitals NHS Foundation Trust is working on a new database to show whether a navigator client is a returnee to A&E within a number of months or years.

Navigator recruitment, training, and support

South Yorkshire Police has identified the following learning and recommendations in relation to the recruitment, training and support requirements of their A&E navigators:

• Recruiting navigators with lived experience of similar circumstances to their clients can assist with forming connections between navigators and clients.
• When deciding on resource requirements for navigator programmes, forces should consider that some aspects of the navigator role can be very time consuming. For example, working with housing services to find suitable accommodation for a client.
• South Yorkshire’s navigators have fed back that they would like to be measured against performance indicators. This would provide them with more substantial directives. Sheffield Teaching Hospitals NHS Foundation Trust is currently working with the navigators to develop performance indicators.
• Navigators require comprehensive support to understand what to do in specific scenarios, such as domestic violence and honour-based violence.
• South Yorkshire’s navigators believe that the work they conduct for their clients when back in their communities can be more beneficial than their initial work in A&E. Therefore, having capacity for navigators to continue their work in community settings is suggested to be important.

Partnership working

South Yorkshire Police has identified the following learning and recommendations in relation to partnership working:

• Partner relationships are believed to be key to the success of A&E navigators. South Yorkshire Police highlights the particular importance of medical staff recognising the value of the navigator programme. Having a 'nurse champion' is suggested to help facilitate the relationship between hospital staff and navigators.
• Building relationships with any other navigator programmes in the region (for example, custody or school navigators) can help identify and utilise the most appropriate referral services for clients.
• Forces should consider how the work of their navigators feeds into other areas of policing (for example, neighbourhood policing teams) and the force’s wider homicide prevention strategy. This will help forces ensure a joined-up approach to homicide.

Other learning

• Forces should consider their funding streams for navigator programmes. Short-term funding may limit the number of good applicants to navigator positions due to the short-term nature of contracts. Relatedly, having navigators on short-term contracts may risk damaging relationships with clients.
• Forces should consider the specific needs of their local communities when setting up navigator programmes. For example, South Yorkshire has seen more older people require navigator services for domestic abuse situations than they anticipated.
• South Yorkshire recommend not being too restrictive about the severity of cases qualifying for a navigator. This approach will help ensure navigators do not turn away patients who are at risk of later coming back into the system in a worse situation. In South Yorkshire, any case that involves an injury from assault (either by hand or by weapon) can be referred to a navigator.
• Having a map (or similar system) of available referral services can be a key way to help navigators make the best use of regional resources. This may be especially helpful when navigators need to access out-of-hours support.
• Forces should consider how to minimise navigator client attrition issues. South Yorkshire has found this to be a particular challenge once a client has left the safety of hospital and is re-exposed to any negative influences back in their community.