4Self-harm
84.Self-harm is the single biggest indicator of suicide risk. Approximately 50% of people who have died by suicide have a history of self-harm.70 We agree with the Government therefore that “it is timely that we increase our efforts to address this issue”. We are pleased that the third progress report expands the 2012 strategy to include self-harm prevention in its own right.
85.As the Government sets out in its report, the NICE guidelines for the treatment of self-harm “set out effective pathways for self-harm and in particular highlighted the importance of undertaking psychosocial assessments for people who have presented at emergency departments for self-harm”.71 The report continues
The evidence suggests this can be effective in achieving better outcomes for people who self-harm as well as being a low cost intervention that all hospitals could implement. Yet, only around 60 per cent of people receive such an assessment. This is unacceptable: it is essential that everyone who attends A&E for self-harm receives and assessment that meets NICE guidelines.72
86.We agree that it is unacceptable that only 60% of people who present at emergency departments for self-harm receive a psychosocial assessment. It is promising that the Government is working with a variety of partners to “explore how to improve the measurement of self-harm in emergency departments and incorporate measurements of whether those presenting receive a psychosocial assessment into the new Emergency Care Data Set, which is in development”.73
87.We note the variation in secondary care services: in some hospitals, as few as 1 in 5 people receive the appropriate assessment.74 Professor Nav Kapur, Head of Research at the Centre for Suicide Prevention in the University of Manchester, told us in written evidence that
This is not simply a resource issue but a consequence of how services are organized and prioritized. It also perhaps an indication of how people who harm themselves are sometimes viewed within health services. 75
88.We heard that from the point of view of one of the witnesses to our inquiry:
I know from my personal experience of going through A&E, having either selfharmed or attempted suicide, of one occasion being left in the corridor and hearing, “Oh, we all know Mrs Ash; she is always in here.” You feel you are worthless anyway; you do not need somebody you have come to ask for help to make you feel even more worthless.76
This perception by health professionals of individuals who present at emergency departments after self-harm or attempted suicide is extremely concerning, and cannot be resolved without culture change within secondary care services.
89.Professor Keith Hawton, Director of the Centre for Suicide Research at the University of Oxford, outlined the importance of psychosocial assessments being of an appropriate quality:
It is also important that the quality of psychosocial assessment is ensured. This should not just be an assessment of possible presence of mental illness and risk, but a much fuller assessment, including of the individual’s problems and needs. Establishing a quality criterion for such assessment could be useful.77
90.The Royal College of Psychiatrists told us that after receiving a psychosocial assessment, every patient should have a ‘safety plan’:
This plan should be co-produced with the patient, who will identify most of the elements; if the patient is unable to articulate their wishes or when the risk is high, however, the clinician may have to take a more directive role. Rather than targeting only ‘high’ risk patients (a subjective and hence meaningless phrase) a more universal low level approach may be more effective - ie ensuring all patients have a safety plan.78
91.Dr Aitken told us that “the rate limiter in delivering those services is simply workforce”.79 We state again our concerns that the workforce is not sufficient to provide an effective mental health service which takes opportunities to detect suicide risk and ensure appropriate support to reduce that risk.
92.All patients who present with self-harm must receive a psychosocial assessment in accordance with NICE guidelines. Patients who present at A&E with self-harm should have a safety plan, co-produced by the patient and clinician, and properly communicated and followed up. We urge the Government to set out its plans for ensuring that the workforce is sufficient to meet these objectives.
70 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, paragraph 56
71 Ibid, paragraph 58
72 Ibid
73 Ibid, paragraph 61
74 Professor Nav Kapur (SPR0178)
75 Professor Nav Kapur (SPR0178)
76 Q184 [Marie Ash]
77 Professor Keith Hawton (SPR0030), paragraph 5
78 Royal College of Psychiatrists (SPR0174)
79 Q421 [Dr Peter Aitken]
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