Services to support people who are vulnerable to suicide
13.Approximately one third of people who end their lives by suicide have not been in contact with health services in the year before their death.21 However, this is not because they are in some way ‘unreachable’—on the contrary, we should regard all suicides as preventable. In Liverpool we met a bereaved mother who said simply “my son wasn’t hard to reach—it was the services that were hard to reach”. If such a high proportion of people in need of help are not accessing current services, then we must adapt the services we offer.
14.We should embrace innovative approaches that reach out to those in distress in order to offer an alternative before an avoidable loss of life to suicide. Supporting this group of people who are vulnerable to suicide involves tackling the stigma that persists—particularly for men—in talking about emotional health, and also in offering non-traditional routes to help for people who are unlikely to approach mainstream services—for example online services, or help in non-clinical settings for young men who seldom contact their GP.22 It is also crucial to enhance practical support to help people deal with the challenges that can push them towards a crisis, including bereavement, relationship breakdown, gambling, poor housing, alcohol and drug use, and financial problems. Unfortunately we have heard that owing to local authority funding reductions, many of these services are being cut.23 The strategy needs to consider how the voluntary sector and commissioned services will be enabled to provide vital support services to those in acute distress and at risk of suicide. We also heard support for the wider use of training in mental health first aid in a number of workplace and public facing roles, including those working in agencies assessing those on benefits, to help identify and provide signposting or support for those in distress.
15.Suicide is complex and rarely if ever attributable to a single cause. Blaming approaches are unhelpful and we should instead focus on all the factors that allow a successful strategy to identify those at risk and intervene early. This should include Government re-examining its own policy in areas such as alcohol, gambling and drugs, where there have been missed opportunities to reduce the risk of suicide.
16.For every life lost to suicide, the estimated total cost to the economy is around £1.67 million.24 The Association of Directors of Public Health told us in written evidence that for every person who ends their life by suicide, a “minimum of six people will suffer a severe impact”.25 Those bereaved by suicide are themselves at greater risk of suicide. During the Committee’s evidence session with bereaved families, we heard how, as well as coping with a devastating loss, they also face onerous practical problems including dealing with coroners’ inquests and incident reviews. They are not entitled to any form of support, nor are they entitled to a family liaison officer which would be standard practice in many other situations. Steve Mallen, a bereaved parent and founder of the MindEd Trust, described being given a leaflet and then left to cope alone: “That is it. That is the sum total of interaction that one gets, and you are facing an abyss that is beyond imagination. That is very difficult”.26 We heard examples of excellent support services for people bereaved by suicide in Liverpool, including SOBS (Survivors of Bereavement by Suicide) and AMPARO, as well as CHUMS in Bedfordshire and If U Care Share in the North East—but these services are few and far between and funding for them is precarious.
17.We need to build greater resilience and wellbeing in young people in order to tackle rising levels of distress and self harm. We also need to take the opportunity to provide support for young people in distress and at times of particular vulnerability, including in higher education settings. We will be looking in further detail at mental health and education in a joint inquiry with the Education Select Committee in 2017.27
18.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.28 Some may have an identified mental health problem, but others may have no obvious mental health difficulties, and identifying these people so they can be supported can be difficult. Tools already exist to support GPs in doing this—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; but without strong, well co-ordinated national leadership to drive forward awareness and implementation, it is too easy for these resources which could save lives to be ignored amidst a huge range of other competing priorities. Whilst we heard concerns in some written submissions about the role of drug treatments and suicide, the evidence we heard from Professor Louis Appleby, Chair of the Government’s suicide prevention advisory group, and Professor Carmine Pariante of the Institute of Psychiatry was that there is greater risk from not using medication where appropriate, provided that this is following evidence-based guidelines.
19.There are serious concerns about the ongoing long waits after referral from primary care to specialist services and we urge the Government to address in its suicide prevention strategy how this situation will be improved.
20.Approximately one third of people who end their lives by suicide are under the care of specialist mental health services.29 Professor Louis Appleby told us that
You have to do crisis teams properly; they have to be 24-hour services; they have to be services that provide the right level of skill in their frontline staff and the right level of contact. They cannot just be an occasional drop-in to check that someone is taking their medication; they have to be a proper substitute, an alternative, as they were originally designed, to in-patient care. What appears to have happened in some parts of the country is that crisis teams are not now providing an adequate alternative to in-patient care: they do not have the seniority of staff; they are taking on a lot of patients who are at a very high degree of risk who probably need something more protective.30
He also told us that the single riskiest time is the three days following discharge from inpatient services.31 We support the calls for all patients discharged from inpatient care to be followed up within three days, rather than the seven days that is the current standard, and recommend that this standard be implemented urgently.32
21.There is a high risk of completed suicide in those who have self harmed. We heard about the importance of liaison psychiatry services in accident and emergency departments as this is the setting in which so many people in acute distress are in contact with services. We welcome the Government’s commitment that every hospital should have this service by 2020, but Professor Appleby told us that there was no reason why this could not be introduced next year, in every part of the country.33 In Liverpool, however, we heard that liaison psychiatry services have just been closed. The suicide prevention strategy should focus on the need for liaison psychiatry to be adequately staffed and resourced. We were also concerned to hear examples of poor and delayed communication between A&E and primary care. Good communication is particularly important when people present with suicidal ideation.
22.Our evidence suggests that there are three distinct groups of people at risk from suicide, and different approaches are needed for each:
- For people not in contact with any service, we support greater emphasis on public mental health and wellbeing as well as ongoing efforts to reduce stigma. We recommend that the suicide prevention strategy should include measures to improve the identification of those at risk of suicide within local communities and the provision of accessible support, including within non-traditional settings and recognising the important role of the voluntary sector. Renewed focus should be given to providing mental health training for staff in public facing roles, especially in higher risk situations, and to providing practical support for those experiencing adversity which may lead to a crisis, including bereavement and financial distress.
- To help people who are in contact with primary care services, GPs need better training in suicide risk. NICE guidelines should be promoted and implemented across primary care.
- We recommend that all patients being discharged from inpatient care should receive follow up support within three days of discharge, rather than the current standard of seven days. The deadline for establishing liaison psychiatry services in every hospital should be brought forward from 2020 to 2017.
23.We recommend that all suicide prevention plans should include mandatory provision of support services for families who have been bereaved by suicide.
21 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH), Suicide in Primary Care in England: 2002–2011, 2014
23 Q91 [Dr Peter Aitken]
26 Q229 [Steve Mallen, MindEd Trust]
27 Children and young people’s mental health—the role of education,
http://www.parliament.uk/business/committees/committees-a-z/commons-select/health-committee/news-parliament-20151/children-young-people-mental-health-education-launch-16-17/
28 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Suicide in Primary Care in England: 2002–2011, 2014
29 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Making Mental Health Care Safer, October 2016
30 Q253 [Professor Louis Appleby]
31 Q255 [Professor Louis Appleby]
32 Q264 [Professor Louis Appleby]
33 Q260 [Professor Louis Appleby]
15 December 2016