3Services to support people vulnerable to suicide
41.In our interim report, we described the three groups for whom tailored support should be targeted. We were told that approximately one third of people who end their lives by suicide are in each category:36 those who have not been in contact with health services in the year before their death; those who were in contact with their GP preceding their death but were not receiving specialist mental health services; and those who are under the care of specialist mental health services.
People not in contact with any health services
42.Witnesses to our inquiry told us of the importance of whole community public involvement in suicide reduction and noted that the Government’s progress report on the strategy does not include recommendations about mobilising the public.37 They told us of the importance of “information, education, awareness and public understanding of suicidal behaviour”. Ruth Sutherland commented on the belief that one in six of the population experience suicidal thoughts and explained that
If upstream we are all more aware that life is difficult and sometimes you need someone to interrupt your dark thoughts, and if people are better able and equipped to do that, we are likely to have more success.38
43.For many people who experience suicidal thoughts, certain challenges may push them towards a crisis. These challenges might include bereavement, poverty, unemployment, relationship breakdown, gambling, housing issues, alcohol and drug misuse, financial problems or any one of a number of other issues. In many of these situations, the development of suicidal thoughts could have been avoided if appropriate support had been provided for an individual’s particular situation. Dr Peter Aitken explained it like this:
Citizens advice bureaux and the nextday housing accommodation officer used to be two of the mainstays of practice in the mid-1990s. You would have somewhere to send people who were in debt and somewhere to send people who needed re-homing urgently. That is not available any longer. That is putting a terrific pressure on health services to try to find ways to support basic life before you can do any medicine.39
44.In many areas, there are voluntary organisations providing practical support in some of these spheres. But many local authority funded support services are being cut due to local authority funding reductions. Dr Liz England of the Royal College of General Practitioners told us about her local authority:
Unfortunately, our local authority has now cut 50% of everything, so we do not have the capacity. We cannot refer into it now because it is not there. That is happening in many areas. We had an organisation supporting people and 50% of their resources were cut.40
45.This is concerning, and reinforces the need for funding to be allocated in a way which ensures that it will be used to maintain support services and public health activities in local authorities, to help prevent people reaching the point of suicide.
46.However another key barrier to these services providing an alternative option for support for people who could be vulnerable to a suicidal crisis is the lack of coordination. GPs cannot refer an individual to a support service or organisation if they do not know what is available of an appropriate standard.
47.We recommend that local authorities keep and maintain a record of services of a suitable standard (both in the voluntary sector and commissioned services) to which individuals can be signposted for both practical and emotional support. Part of the work of health overview and scrutiny committees in scrutinising local authorities’ suicide prevention plans should be ensuring that these records are created and maintained. There should also be an annual review of the impact of any loss of these services.
48.There is also a key role for organisations and services at high risk locations, including the police and the rail industry. These organisations are in a crucial position to be able to put in place measures to prevent suicide. We heard from Network Rail about their action on suicide prevention, including ‘hard’ prevention methods such as fencing on disused platforms and ‘soft’ measures including signage and training of staff. In particular high-risk locations, they also “train the local community to look out for those who are vulnerable to suicide”.41
49.The College of Policing outlined the importance of its role in identifying and responding to those who are vulnerable to suicidal thoughts and might decide to take their own life:
As the police service is often the first to respond to calls from the public and people contemplating suicide, the College has an important role in providing officers and staff with the best possible knowledge and advice on how to respond.42
50.We were pleased to hear from the Royal National Lifeboat Institution the steps it is taking to work out what role it can play in suicide prevention. While suicide prevention is currently not a key objective of the RNLI (unlike Network Rail, for example) the RNLI recognised that approximately 11% of their activity, and 44% of their activity on the Thames, is in relation to suicide, and is therefore seeking to explore how their role as first responders to incidents on the water fits into a wider multi-agency collaborative approach to suicide prevention.43
51.Local authorities should promote a joined-up, multi-agency collaborative approach to suicide prevention to improve data sharing and knowledge between different sectors which will ultimately lead to more efficient and effective action on preventing suicide.
52.We recommend that organisations and services at high risk locations, including the police and Network Rail (as well as other organisations such as the RNLI where appropriate), should be involved in the development and implementation of local authorities’ suicide prevention plans.
53.In our interim report, we emphasised the need to “embrace innovative approaches that reach out to those in distress in order to offer an alternative before an avoidable loss of life to suicide”.44 We noted the importance of tackling the stigma that persists in talking about emotional health (particularly for men) and of offering non-traditional routes to help for people who are unlikely to access mainstream services.
54.We are pleased that the Government strategy, and the progress report on the strategy, recognise that men are a high risk group. We have seen and heard of examples of good work being done in this area, including by Everton in the Community and State of Mind (organisations that we visited),45 CALM (Campaign Against Living Miserably) and Men’s Sheds.
55.It is encouraging that the Government’s third progress report acknowledges that
We must look at more innovative ways of targeting men, especially middle-aged men, to address the barriers that prevent them from seeking help. We also need to consider what interventions and services would be most effective to meet their needs.46
56.However the report does not include any detail on how progress will be made. We recommend that local authorities should include in suicide prevention plans a strategy for how those who are at risk of suicide but are unlikely to access traditional services will be reached. This should include up-to-date knowledge about what services are available in the voluntary sector.
57.We repeat our concern about funding of these initiatives. A successful strategy in this area will allow public health teams within local authorities to identify those at risk and intervene early. If vulnerable people who need help are not accessing the services currently on offer, then the services must be adapted. The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) recommends that online services and help in non-clinical settings should be widely available, but that aim cannot be achieved unless local authorities have access to funding to enable it.47
58.We recognise the importance of promoting emotional wellbeing in order to tackle mental health problems in young people. We also note the importance of taking the opportunity to provide support for young people in distress, and at times of particular vulnerability, including in further and higher education settings. We are looking in further detail at children and young people’s mental health and education in our current joint inquiry with the Education Committee.
People in contact with primary care services
59.As we explained in our interim report, approximately one third of people who end their lives by suicide are in contact with their GP preceding their death, but are not receiving specialist mental health services. We concluded that GPs need better training in suicide risk.48
60.Dr Liz England (Royal College of GPs) raised concerns about the lack of training in mental health in medical schools. She said that “we have to start right at the beginning of medical school to introduce mental health alongside the physical health aspects”.49 She also noted the importance of psychiatry placements for GPs in training and the fact that there is no mandatory psychiatry or mental health within GP rotations.
61.We recommend that the GMC should ensure that all undergraduate medical students receive training in the assessment of suicide risk as well as depression. We also recommend that the Royal College of General Practitioners and Health Education England should include the assessment of depression and suicide risk in the training and examinations for GPs. The Government should monitor progress on the addition of these competencies to medical school and Royal College exams.
62.We noted in our interim report that tools already exist to support GPs in identifying mental health problems, including NICE guidelines on identifying and treating depression, and training programmes to assist professionals in detecting and supporting people who may be at risk of suicide.50 However, as we observed in that report, it is far too easy for these resources to go unused amidst GPs’ workloads and competing priorities.
63.It is promising that the Government has acknowledged the need for training for GPs and GP surgery staff:
Training for GPs and GP surgery staff in awareness of suicidality and safety planning can play a crucial role in suicide prevention, and Health Education England has been working with Public Health England to review materials such as e-learning tools and is considering how best to support this nationally.
Awareness training should encourage the implementation of NICE guidelines to improve the identification, treatment and management of depression in primary care.51
64.We are pleased that training on awareness of depression and suicide risk already exists and that Health Education England and PHE are reviewing e-learning and other materials. It would be valuable for PHE to use its oversight of how many clinicians have taken these training courses to ensure that there is appropriate follow-up in areas where this training is not prioritised.
65.Strong and coordinated national leadership is required to ensure that GPs and primary care nurses receive adequate ongoing training in detecting suicide risk. We recommend that NICE guidelines and other training resources should be promoted and made readily available for practitioners by Public Health England and Health Education England. There should be national oversight by Public Health England to ensure that all practitioners involved in the assessment of those who could be at risk of suicide are accessing this training.
Drug treatments and suicide
66.We concluded in our interim report that, whilst we heard concerns in some written submissions about the role of drug treatments and suicide, expert witnesses to our inquiry told us that there is greater risk from not using medication where appropriate, provided that it is following evidence-based guidelines.52 The Government did not address this issue at all in its progress report. We urge the Government to ensure that NICE guidelines on the appropriate use of drug treatments for depression are promoted and implemented by clinicians.
People under the care of specialist mental health services
67.Approximately one third of people who end their lives by suicide are under the care of specialist mental health services.53 The Government’s progress report acknowledges that “the number of people who die by suicide whilst in contact with crisis resolution home treatment teams remains worryingly high”. However, it does not address the recommendation we made in our interim report that all patients being discharged from inpatient care should receive high quality follow up support within three days of discharge, rather than the current standard of seven days. This is disappointing: that recommendation was aimed precisely at reducing suicide risk in people being treated by crisis resolution home treatment teams.
68.The Royal College of Psychiatrists agreed with our recommendation and told us in written evidence that they were “disappointed that the Government did not include this in their report”.54 They told us that ideally this should be in addition to some other follow-up in the first week:
We believe that the safest way to prevent suicides would be for two contacts to be made by the crisis team within seven days, with the first happening within the first three days. This would allow someone to provide support, when most suicides happen, and then slightly later to see if any other issues emerge. It is also important that the guidance is clear that this follow up needs to be done for all people with concerns leaving all acute care not just those leaving A&E.55
69.Dr Peter Aitken told us that the key issue in being able to implement this follow-up is a lack of workforce resource:
Many hard-pressed crisis response teams at the moment are barely able to make a telephone call check in that first week, so you can see the implication for resource immediately. If we are already dealing with a limited resource pool, it proves quite challenging to think a bit about how that commitment can be kept.56
70.We recognise Dr Aitken’s concern about the lack of workforce resource for this follow up. We are concerned that there are some crisis resolution home treatment teams who are so under-resourced that they are barely able to make a telephone call check in with vulnerable people who have only recently been discharged from inpatient care. We do not consider a text message alone to be an adequate follow up in those circumstances.
71.We repeat our recommendation that all patients being discharged from inpatient care should receive high quality follow up support within three days of discharge. We recommend that this should be in addition to a further instance of follow up support within the first week post-discharge. The Government must ensure sufficient funding for crisis resolution home treatment teams to ensure that they have enough resource to provide adequate support.
72.The Government set out its target for liaison psychiatry services in the progress report:
By 2020/21 all acute hospitals will have all-age liaison mental health services in place with at least 50 per cent meeting the ‘Core 24’ standard for adults and older adults.57
73.The Royal College of Psychiatrists was cautious about the feasibility of our recommendation to bring forward the deadline for establishing liaison psychiatry services in every acute hospital to 2017:
The College welcomes plans in the Five Year Forward View to extend liaison mental health services and was also pleased to see the Committee encourage the Government to go further and bring forward the deadline for establishing liaison psychiatry services in every hospital from 2020 to 2017. The two main barriers to achieving this appear to be both finances and recruitment. While it may be possible for the Government to commit additional funds it would be difficult to recruit enough psychiatrists and other staff to be able to provide a liaison psychiatry service in every hospital this year.58
74.We reluctantly acknowledge the fact that recruitment is a barrier to meeting a 2017 deadline. We are concerned that RCPsych considers that “even in the longer term recruitment will continue to be a significant challenge”59 and that the College suggests that workforce issues may be a barrier to implementing the Mental Health Taskforce. We note with concern that Core Psychiatry training currently has the lowest fill rate of any higher specialty training.60
75.We urge the Government to ensure that there are enough trained staff to establish and sustain liaison psychiatry services in every acute hospital.
76.More broadly, the Health Education England Mental Health workforce strategy must set out what the Government is going to do to ensure that there are enough trained staff to implement the Mental Health Taskforce recommendations.
77.We welcome the expansion of the Improving Access to Psychological Therapies (IAPT) programme, as set out in the progress report, which will considerably increase the availability of support for people with common mental health problems, including depression and anxiety. However, as Dr Peter Aitken explained, IAPT is not sufficiently integrated into mental health teams and is therefore ill suited to suicide risk assessment:
The IAPT investment, while it can help to manage and treat depression and anxiety, does not in itself help the general practitioner re-equip with suicide risk assessment skills or management. If an IAPT service finds somebody to be suicidal in the context of their work treating them for depression and anxiety, they will in most instances refer them back to the GP or make an onward referral to specialist mental health services.61
This causes avoidable delays.
78.Dr Aitken explained that IAPT services are an “extremely robust evidence-based approach”62 to ensuring that an individual has the right care for diagnosed depression or anxiety. The therapy is delivered by a well-trained worker with specific skills, from “basic advice, help and treatment through to complex psychotherapy”.63 However, as he went on to explain,
The IAPT service does not have the front-end multidisciplinary biopsychosocial risk assessment machinery that community mental health teams or even general practice primary care teams do. They are very much a delivery mechanism for highly effective care interventions for somebody who has already been assessed as having depression or anxiety. Unfortunately, for people with depression, [ … ] the reality is that very many have intrusive thoughts of suicide; they have suicidal ideation. Sometimes that suicidal ideation will become intent, but at the point it becomes intent the IAPT service is not equipped to manage the risk, so the intentful person, or the person who is speaking about ideation, may very often find themselves being pushed back to the general practitioner or the community mental health service.64
79.We welcome the Government’s expansion of the Improving Access to Psychological Therapies (IAPT) programme. However we urge the Government to ensure that it is properly integrated into mental health teams supporting people with complex mental health conditions, to ensure that patients being supported by the IAPT programme who experience suicidal ideation can be supported effectively and quickly.
Other at risk groups
80.We also note with concern the levels of perinatal suicide and the rising levels of suicides in prisons. The latest Confidential Enquiry into Maternal Deaths, published in December 2016, reveals that between 2009 and 2014 111 women in the UK died by suicide during or up to a year after pregnancy.65 This is a matter of great concern and we will be following up on this issue as part of our regular reviews of the progress following the publication of the National Maternity Review report ‘Better Births’ in February 2016.
81.In January 2017, the Ministry of Justice published statistics on deaths in prison custody for 2016. These statistics demonstrated that there was a record high of 119 self-inflicted deaths in custody in England and Wales. As the bulletin reported,
The rate of self-inflicted deaths has doubled since 2012. The likelihood of death in custody is 1.7 times higher than in the general population, while self-inflicted death is 8.6 times more likely.66
82.The Royal College of Psychiatrists set out their views on how this issue was addressed in the Government’s strategy:
The report is right to flag concerns that there have been sharp increases over recent years in reported deaths by suicide following police custody and increases in the number of self-inflicted deaths in prisons.
The report however then goes on to suggest that these rates are rising because of a number of external reasons including that “Prisons contain a high proportion of vulnerable individuals, many of whom have experienced negative life events that increase the likelihood of self-harm or suicide”. It does not however explain why these rates are rising, as it has always been true that people in prisons are especially vulnerable, nor identify/recommend action for supporting this group.
Instead it would have been better if the strategy had acknowledged the impact of The National Offender Management Service having to make cuts of almost 25% in real terms in 2014–15 and the number of prison officers falling by around 2,500 since 2013.67
We note that a significantly greater number of prison officers have been lost since 2010.68
83.We agree that this is a hugely concerning issue and we are pleased that the Justice Committee and the Joint Committee on Human Rights have been scrutinising, and continue to scrutinise, the Government’s policy and action on this matter.69
36 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH), Suicide in Primary Care in England: 2002–2011, 2014
37 Q418 [Ruth Sutherland] , Royal College of Psychiatrists (SPR0174)
38 Q420 [Ruth Sutherland]
39 Q91 [Dr Peter Aitken]
40 Q90 [Dr Liz England, Royal College of General Practitioners]
41 Q139 [Ian Stevens, Suicide Prevention Programme Manager, Network Rail]
42 College of Policing (SPR0069)
43 Q137 [Melanie Hide, Head of Corporate Affairs, Royal National Lifeboat Institution]
44 Fourth Report of Session 2016–17, Suicide prevention: interim report, HC 300, paragraph 14
45 Annex, Visit to Liverpool and Salford
46 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, paragraph 17
47 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (SPR0087)
48 Fourth Report of Session 2016–17, Suicide prevention: interim report, HC 300, paragraphs 18 and 22
49 Q81 [Dr Liz England]
50 Fourth Report of Session 2016–17, Suicide prevention: interim report, HC 300, paragraph 18
51 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, paragraphs 27–28
52 Fourth Report of Session 2016–17, Suicide prevention: interim report, HC 300, paragraph 18
53 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Making Mental Health Care Safer, October 2016
54 Royal College of Psychiatrists (SPR0174)
55 Royal College of Psychiatrists (SPR0174)
56 Q426 [Dr Peter Aitken]
57 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, paragraph 32
58 Royal College of Psychiatrists (SPR0174)
59 Royal College of Psychiatrists (SPR0174)
60 Letter from Professor Ian Cumming, Chief Executive, Health Education England, to the Chair of the Health Committee, 19 January 2017, Table 1, 2016 Specialty fill rates
61 Q421 [Dr Peter Aitken]
62 Q422 [Dr Peter Aitken]
63 Q422 [Dr Peter Aitken]
64 Q422 [Dr Peter Aitken]
65 Maternal, Newborn and Infant Clinical Outcome Review Programme, Saving Lives, Improving Mothers’ Care: surveillance of maternal deaths in the UK 2012–14 and lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2009–14
66 Ministry of Justice, Safety in Custody Statistics Bulletin, England and Wales, Deaths in prison custody to December 2016, Assaults and Self-Harm to September 2016
67 Royal College of Psychiatrists (SPR0174)
68 Sixth Report of the Justice Committee, Session 2015–16, Prison safety, HC 625, paragraph 35
69 Sixth Report of the Justice Committee, Session 2015–16, Prison safety, HC 625; Joint Committee on Human Rights, Mental health and deaths in prisons
1087