Themes that emerged from participants’ narratives were merged into overarching categories in Figure 2, to describe key findings within the data. Table 2 contains anonymised quotes from participants to further support findings and illuminate their experiences.
The public health response
Formative interviewees reported that a Humanitarian Assistance Steering Group (HASG) was convened by Southwark Council in the immediate aftermath of the incident. The HASG brought together multiple stakeholders from the borough and wider region to develop a humanitarian response. An early, and unusual, decision of the HASG was to set up a Mental Health and Wellbeing Sub-Group (MHWSG) co-chaired by the local Director of Public Health and the chief executive of the local mental healthcare organization.
At the direction of the Director of Public Health, in the days immediately following the incident, the public health team undertook in parallel a rapid literature review which drew on expert opinion and experience from the recent Manchester Arena attacks, and a health needs assessment. Their review identified limited and contradictory guidance regarding best practice in such situations. In the most important response frameworks, terror attacks are treated as a humanitarian emergency that are indistinguishable from natural disasters. Although exposure to natural disasters also increases risk of adverse mental and behavioural outcomes, this overlooks the fact that terror attacks sui generis aim to cause long-term harm to mental health and wellbeing of communities.
The health needs assessment drew on opinion and perspectives from around the council, wider stakeholders and the community. The circumstances meant that the needs assessment itself required a dynamic approach with the Council’s public health team describing it as a “live document”. Three principal areas of interest were identified: mental health and wellbeing of those affected by the incident (with varying degrees of direct or indirect involvement), economic activity (that is the businesses affected), and broader community cohesion.
Needs were identified within hours of beginning the needs assessment. In the absence of any existing guidance, Southwark Council’s Public Health team coordinated a variety of initiatives aimed at protecting and promoting the mental health and wellbeing of people affected by the attack (quote 1). An early and very practical need was to review the evidence around risk communication so that social media messaging could be safe and effective. A compendium of social media messages drawing on the evidence base was pulled together.
Other activities included signposting people to pre-existing services and producing a wellbeing factsheet. They also arranged mental health workshops that were positively received by attendees from the local community and businesses (quote 2). From our evaluation there is evidence that the techniques used in these workshops had a broader positive impact. For example, a local schoolteacher used some of the techniques taught at the workshop with her pupils.
The MHWSG oversaw the design and response of all public health activities, whilst providing an interface with the NHS and other community partners such as business leaders and faith groups. This sub-group met approximately weekly for the first month and then on a reducing frequency thereafter, advocating upwards to the HASG for parity between physical and mental health response. It also laid the groundwork for the subsequent Outreach and Screen Programme, deploying trauma-focused cognitive behavioural therapy and other interventions. The MHWSG stood down almost four months after the incident. However, the Director of Public Health continued to provide advice and leadership around mental health and wellbeing within the HASG for the following two years, until that group was stood down.
Southwark Council also made efforts to protect potentially vulnerable communities at a time when police resources were stretched. For example, the Council supported and reassured the Muslim community by providing CCTV surveillance around mosques at their request (quote 3).
The impact on mental health and wellbeing
Interviewees highlighted numerous ways in which the London Bridge and Borough Market attack negatively impacted the mental health and wellbeing of people living and/or working in the area. Overall, the attacks resulted in a general sense of sadness, anxiety and fear in the local community (quote 4).
A number of contextual issues were raised. Firstly, the attacks took place in an area where lots of people from all over the city – and the world – come to socialise. The fact that it occurred near a major central London railway terminus appeared to have exacerbated the feeling that “it could have been me”. Conversely, it also meant that the impacts extended well beyond the geographical confines of the borough of Southwark. For example, none of the dead were residing within Southwark. Reflecting the global nature of London, only one of the eight victims and one of the three attackers were British nationals. Secondly, the London Bridge and Borough Market attacks came very soon after several other terror incidents in London (Westminster Bridge attack, three months prior) and the UK (Manchester Arena bombing a fortnight prior). It is possible, if not likely, that the cumulative effect of these attacks led to a heightened sense of anxiety and fear in the general population, as well as placing additional pressure on response resources. Third, this particular incident received a great deal of media attention because it occurred in a location proximal to many UK media offices and in the middle of a global city. Council employees and partners reported that intrusive press coverage impacted on their ability to respond to the attack (quotes 5 & 6).
Interviews were conducted around the first anniversary of the attack and negative impacts on this community’s mental health and wellbeing were still apparent. For example, several workers in Borough Market did not attend work on 3 June 2018 so they were not reminded of the incident.
Minority groups appeared particularly negatively affected. As the attackers had referred to Islam in order to legitimise their actions, the local Muslim community was fearful that they might become a more salient target of hate crimes. A local Muslim community leader expressed concern that female Muslims were especially vulnerable because their hijabs made them easily identifiable (quote 7). Two factors heightened the fears of the local Muslim community. First, the attack occurred during Ramadan, when the community would gather together far more often than usual. Second, there were a number of recent terror attacks carried out by British Muslims who had been inspired by the so-called Islamic State (in Syria and Iraq) and came less than a month after the Manchester Arena attack. However, it was noted that the longstanding and strong relationship between the Muslim community and other faith communities in Southwark did help quell these concerns and issues of community cohesion.
The impact of the police cordon on local residents and businesses was another regularly reported issue. In the aftermath of the attack, the needs of the police to secure a sterile crime scene took precedence over the mental health and wellbeing needs of the local population who were deprived of their accommodation, sustenance, income and systematic mental health support delivered by experts.
Local people who lived within the cordon were evacuated from their homes and prevented from returning while the investigations continued. In some cases, it was ten days before people were permitted to return home. At a time when many residents were already feeling anxious and upset, this uncertainty created additional stress (e.g. not being able to feed pets or access possessions needed for work). Several interviewees explained that this issue was worsened by a perceived lack of information from law enforcement. Even a year after the incident, resentment towards the police among local communities was observed (quote 8).
The closing down of Borough Market resulted in a negative economic impact on a variety of people in the area. Business owners reported they had lost “vast amounts of money” as they were prohibited from opening for up to ten days, including two weekends. This was particularly problematic for small business owners (who make up a large proportion of businesses in Borough Market). This problem was most apparent among market traders and others who held fresh foods in stock, as it perished while the cordon was up. Staff working within the cordon were also affected: with no workplace, some had no income.
Was the public health response successful?
Interviewees acknowledged that the Council was operating under extreme circumstances amid very little guidance. Moreover, they had limited human resources and members of the teams deployed had many other roles and responsibilities. For example, the Council’s Emergency Planning team which has statutory responsibility to undertake specific tasks under the Civil Contingencies Act 2004, comprises only three staff members. Like many other council departments, Southwark’s Public Health team re-tasked six members of staff immediately into supporting the response. There was also an array of other unexpected tasks that arose, for example providing information and reassurance to local community stakeholders.
There was an issue with lack of visibility of the response. Only a limited number of residents were aware of or accessed the Council signposted mental health and wellbeing initiatives. Most stakeholder interviewees said they did not attend the mental health workshops (quote 9). Many stakeholders reported hearing about the wellbeing information sheet, but very few actually saw it. Potential reasons for the low visibility include the physical barrier of the police cordon, staff not living in the area, and the difficulty in identifying those affected due to the transient nature of where the attack occurred.
Interviewees involved in the mental health outreach activity highlighted the challenge of contacting affected residents. Council workers did not have an immediately clear understanding of who was displaced and who had been affected. As a result, support ended up targeting the business community (specifically the Market) rather than residents (quote 9). A significant proportion of people present at London Bridge and in Borough Market on the night of the attack were not from the local area and this was a particularly challenging and heterogeneous community to target. This made it difficult for Southwark Council to trace individuals who required support and provide it in an appropriate manner (quote 10). Another reason for this lack of visibility is potentially tied to the ‘watchful waiting’ approach suggested by the evidence on trauma used by the MHWSG. Watchful waiting in the context of trauma exposure involves carefully monitoring people’s symptoms to see whether they improve or get worse. It is sometimes recommended because most people who develop problems after a traumatic experience get better within a few weeks without treatment. This approach was sometimes misconstrued as the absence of a response by the community. In the case of Southwark Council, the watchful waiting service was commissioned in October (post-incident), meaning only a proportion of the exposed population were screened. Despite NICE guidelines for PTSD  stating the importance of screening post major event, in reality the national health service ‘do not run a continuous service, the event takes place, then they are making a decision if they want the service or not. And then it takes a few months to book someone onto the service’. This limits ability for such commissioned services to effectively screen and monitor opopulations effectively.
Yet there were also several positively received measures that the Council took as part of their response. They appreciated the value and need for a bottom up approach to encouraging community cohesion based on the social capital and relationships already embedded in the local community. One particularly positively observed outcome was a series of organically developed events, led by the community and supported by the Council, which brought a diverse range of people together to reflect on the incident. A ceremonial clearing up of flowers was a notable example of this (quote 11). The Mayor and local religious leaders began to move the flowers and other participants at the event and formed a human chain to help. The Council were at the end of the chain to respectfully place the flowers into a van. This was interpreted by many as an act that allowed the process of moving these offerings in a respectful manner. It is critical to recognise that such events were meaningful because they were driven by a number of community leaders working together in a proactive way to bring their local populations together.
Some members of Southwark Council had longstanding and trusting relationships with various community groups and were sources of reassurance and practical support after the attack. However, such relationships were not systematically engaged to enrich the response. For example, the relationships with representative from the local Muslim community fostered by various Council departments were not drawn upon to maintain and nurture community cohesion between different religious groups who lived and worked in the Borough. These stakeholder narratives suggest that local authorities should focus on building resilience, particularly among vulnerable populations to mitigate subsequent terror incidents. When incidents do happen, they should draw on such networks of resilience when planning and delivering a response. These same networks of resilience could also function as a means of systematically and sensitively disseminating information (i.e. the mental health and wellbeing leaflet) to people in need.
Finally, as some interviewees pointed out, organic community-based responses to the attacks did result in the protection of wellbeing as they forged strong relationships between people who were affected by the harrowing and unique event. Again, it is important to think about how such relationships might be nurtured in the event of future responses.