Written evidence submitted by the Samaritans' (CYP0060)
Introduction
i.1 Samaritans is the UK and Ireland’s largest suicide prevention charity. Through nearly 20,000 listening volunteers, we take a call for help every seven seconds. We believe in the power of compassionate and non-judgemental listening to give people a safe place to work through their problems.
i.2 Suicide was the leading cause of death among young people in England and Wales in 2019, with rates increasing in recent years[1].
i.3 There are a variety of risk factors for suicide among young people. These include adverse childhood experiences such as abuse, bullying, mental illness, substance misuse and self-harm. Each of these can contribute to a person’s risk and can be combined with “last straw stressors” such as academic pressures[2].
i.4 We have chosen to focus this submission on self-harm as while most people who self-harm will not go on to take their own life, it is a particularly strong risk factor for future suicide[3]. We would be happy to discuss with the Committee the wider antecedents of suicide among young people in more detail.
i.5 Concerningly, there has been a steady increase in rates of self-harm in the last twenty years. Rates have increased for both men and women and among every age group. This increase is particularly pronounced among young people and particularly young women – from 7% to 20% between 2000 and 2014[4].
i.6 There has also been an increase in suicide rate among young people. In 2018, following a period of relative stability, the rate of suicide among young men increased significantly in 2018 and remained the same in 2019 (8.2 deaths per 100,000). There was also a stark rise in the rate among young women, which rose significantly from 2012 to its highest level on record in 2019 (3.1 deaths per 100,000)[5],[6] .
i.7 The reasons that people take their own lives are complex. It would be overly simplistic to draw a direct causal link between the rise in self-harm and the rise in suicide among young people. However we are very concerned that young people are increasingly using self-harm as a way of coping with emotional distress, presenting long term concerns around future suicide risk.
i.8 Self-harm was discussed in over 272,000 calls received by Samaritans in 2019. This equates to a call every two minutes and almost ten per cent of calls for emotional support responded to in that year.
i.9 During the Coronavirus pandemic, our volunteers have told us that young people have been struggling more than usual to maintain their wellbeing as they struggle to access the things which keep them well normally. Some of our volunteers have reported an increase in calls from young people using self-harm as a coping mechanism during this time.
i.10 Large-scale studies show stable overall levels of self-harm among young people before and after the onset of the Coronavirus pandemic, but we must guard against complacency[7]. We know that the full mental health impact of the pandemic on children and young people is still to be felt and that for many it has already been severe[8].
i.11 Samaritans welcomes the chance to respond to this inquiry and would be happy to follow up with oral evidence at an appropriate time. We also offer our support to the Committee on the safest way to discuss self-harm and suicide in relation to this inquiry and beyond.
Samaritans’ key calls
i.12 The Government should implement a new system of early intervention to support young people who self-harm. This could be based on a network of open-access mental health services based in local communities, which provide immediate support in a non-clinical setting. Pause in Birmingham is an example of one such model.
i.13 Planned investment in mental health services through the NHS Long Term Plan should ensure that many more children and young people who self-harm are given timely access to primary mental health services such as Children and Adolescent Mental Health Services (CAMHS) and Improving Access to Psychological Therapies (IAPT). Expertise and capacity of these services must be expanded to ensure that services lower thresholds and waiting lists, remove exclusion criteria and provide targeted support for the behaviour.
i.14 DHSC, the NHS, and Local Government Association should work together to support both Integrated Care Systems and local authorities to improve access to, and the design of, support services for young people who self-harm. This work should particularly focus on at-risk groups and those who currently particularly struggle to access support, to ensure that they can access help within their own communities.
i.15 There needs to be a cross-Government approach to suicide prevention for young people, working in collaboration with the third sector and other stakeholders. It must address risk factors for suicide among this group, including self-harm, and tackle wider determinants including reducing adverse childhood experiences.
System changes needed to tackle increasing rates of self-harm and suicide among children and young people.
1.1 Young people who have self-harmed have told Samaritans that mental health support is arriving too late and not until they have reached a crisis, if at all. By the time help arrives from specialist mental health services, their mental health needs are often much more acute than when they first sought support. The Government must prioritise a system shift away from crisis interventions towards a preventative model of support, based on early intervention. This shift must ensure that young people are helped long before ever reaching crisis.
1.2 The financial, not to mention human, motivation to move from crisis intervention to prevention is clear. Research has shown that the overall mean hospital cost per episode of self-harm is £809, equating to around £162m per year spent on hospital management of self-harm[9].
1.3 Specialist mental health support through CAMHS or IAPT will be the best option from the outset for some children and young people who self-harm. But for many, earlier community based support dealing with the wider social or emotional drivers of self-harm would lead to better outcomes.
1.4 Instead of a system reliant on crisis interventions for supporting children and young people who self-harm, the Government should undertake long-term investment in early intervention provided by wider community based services and alternative support provided by the third sector specifically for self-harm.
1.5 Government investment must mitigate the impact of years of underfunding in wider community-based services. Between 2010/11- 2017/18, against the backdrop of shrinking budgets from national government, local authority spending on early intervention services for children and young people decreased by 49% (£3.7 billion to £1.9 billion), five times faster in the most deprived areas than the least[10]. This squeeze has necessitated local areas pushing remaining funds into crisis services, further exacerbating issues of late interventions, increased waiting times and higher thresholds before young people can access support.
1.6 Recommendation: The Government should implement a new system of early intervention to support young people who self-harm. This could be based on a network of open-access mental health services based in local communities, which provide immediate support in a non-clinical setting. Pause in Birmingham is an example of one such model.
1.7 Recommendation: Central government should empower local authorities to invest in a broad range of community-based services well placed to reach and support young people much earlier, before problems become entrenched. As such, investment in community youth facilities, based on a wider understanding of the social and emotional drivers for self-harm, should be prioritised.
1.8 Recommendation: In addition, Samaritans is calling for Government funding for third sector services specifically designed to support young people who self-harm in the communities that they live. There is much innovative work going on within communities offering an alternative to, or collaboration with, statutory services. There needs to be more integrated pathways and collaboration between NHS and voluntary and community services to provide a more responsive offer where help arrives sooner. These organisations range from less intensive group and peer support models to psychosocial support for people who have struggled to access NHS help for a number of reasons.
1.9 Recommendation: A shift towards a preventative system will take some time to achieve. There must also be simultaneous and immediate investment in existing specialist mental health services for children and young people, to reduce waiting times, lower thresholds, remove exclusion criteria and improve capacity and expertise to support people who self-harm effectively.
The ambitions laid out in the 2017 Green Paper and provision of mental health support in schools.
- The 2017 Green Paper, Transforming Children and Young People’s Mental Health Provision set out important commitments relevant to self-harm, with a welcome commitment to ‘earlier intervention and prevention’. Three years later there remains some way to realise this vision.
2.1 Schools are likely to be the first place for many where mental health or self-harming support needs are flagged. Facilitating effective interventions in these settings, before mental health needs become more acute, will be crucial in realising a model of early intervention.
2.2 Current available mental health support in schools is inconsistent, with a third of schools offering no on-site mental health support in 2019[11]. Teachers often lack the training, confidence and capacity to support a young person with mental health issues, leading to increased referrals CAMHS[12] and subsequent rejections.
2.3 The Green Paper also committed to 70,000 more children and young people per year receiving support by mental health services by 2020/21 (equivalent to 35%), which Samaritans understands has been met. This still leaves over two thirds of children and young people not receiving crucial support.
2.4 Recommendation: Mental Health Support Teams (MHSTs), introduced as part of the Green Paper’s plans, are well placed to provide early interventions and to greatly increase the capacity of educational settings to support young people who are struggling. These Teams need to be rolled out much quicker and more comprehensively than the current plan of between a one fifth and a quarter of the country being covered by the end of 2023. They must be trained in self-harm and suicide prevention specifically.
Addressing capacity and training issues in the mental health workforce
2.5 Capacity and training in the mental health workforce remains a serious issue which prevents young people who self-harm from getting the support they need.
2.6 The Department of Health and Social Care (DHSC), in its submission to a 2020 inquiry by the APPG on Suicide and Self-Harm Prevention, noted that a lack of CAMHS capacity represents ‘a significant barrier for many young people receiving support’, including for self-harm[13].
2.7 While there have been cuts to budgets for preventative interventions through wider community-based youth services, demand for specialist NHS mental health services such as CAMHS and IAPT has increased exponentially, outstripping investment and exacerbating workforce issues. Third sector and community-based organisations, operating on limited budgets, struggle to plug the gaps provision, leaving many young people who self-harm with no formal support at all.
2.8 The aforementioned Green Paper’s commitment of a four-week waiting time for access to CAMHS is yet to be realised. Last year only 1 in 5 children referred to mental health services started treatment within four weeks[14]. It should be noted that the impact of the £500m allocated to tackling mental health waiting times through the Spending Review is still to be seen[15].
2.9 These delays have real life impacts for young people who self-harm. There is an ever-present risk that long waits to receive support will lead to deterioration in mental health, increasing severity of the behaviour and worsening outcomes in the long term[16].
2.10 Capacity issues within mental health services also result in increasing thresholds and greater likelihood of rejected referrals from those deemed not to warrant immediate care. Young people who self-harm but are not actively or imminently suicidal are often placed on waiting lists for CAMHS[17].
Improving access to mental health services
- Samaritans has heard the testimony of a number of young people who self-harm who have fallen between the gaps in available support and struggle to get the help they need.
3.1 While waiting lists and increasingly high thresholds do not only impact young people who self-harm, there are barriers to support which are unique for this group. Samaritans has found that NHS mental health services are not commissioned or designed with self-harm in mind. Instead, self-harm is often ignored or even banned by mental health services, an approach that fails to support people to stop self-harming[18].
3.2 Young adults who self-harm have told us they are ping-ponged between services [see appendix (i) for an illustrative example of these problems] excluded from primary mental health support such as IAPT on the basis of being deemed “too high risk”, while not ill enough for secondary mental health services such as Community Mental Health Teams[19]. National guidance for IAPT does not exclude people who self-harm [20], however we found evidence that in practice local trusts delivering the service often do, based on a perception of suicide risk and their capacity to manage it[21].
3.3 The high threshold for secondary care, in the form of Community Mental Health Teams, means that many people who self-harm are excluded on the basis of not suffering a ‘severe, complex or enduring mental health disorder’[22]. This is particularly concerning considering that nearly half (48%) of people who self-harmed in the past year did not have severe levels of depression or anxiety at the time of interview, making it unlikely that they meet the threshold for secondary mental health care[23].
3.4 Last year’s report from the Children’s Commissioner, assessing the state of children's mental health services, spoke of ‘a chasm between what children need and what is being provided.’[24] Unfortunately, at present, NHS specialist mental health services for children and young people are not set up to support people with self-harm consistently enough.
3.5 Children under 18 have a similar experience of being bounced between support. For instance, when schools, who feel unable to bear the perceived risk presented by self-harm, refer children to CAMHS. Young people often fail to access CAMHS support, on the basis that their mental health needs are deemed to be insufficiently acute, so their referral is bounced back to the school.
3.6 Self-harm is one of the key reasons that a quarter of CAMHS referrals are rejected. As noted by the Education Policy Institute, alternative mental health support services for those excluded from CAMHS have been decommissioned in recent years [25].
3.7 Young people also face serious hurdles in transitioning between children and adult mental health services. They are stuck in limbo, falling outside CAMHS eligibility for being too old, while being too young to start treatment with IAPT. Valuable relationships with clinicians are often lost in the move to adult services. Samaritans welcomes DHSC plans to extend mental health models ‘to create a comprehensive offer for 0-25 year olds’ by 2028 in order to ensure that there is no ‘cliff edge’ for support[26]. However this is little comfort for the many young people who will struggle with this transition in the intervening seven years.
3.8 DHSC is increasing investment in CAMHS capacity in an attempt to ensure young people get the mental health support they need[27]. However, the extent to which this will lead to better support for people who self-harm specifically is unclear. At present, in many cases, presentation of self-harming behaviour does not act as a trigger for NHS support and often is a basis for denial of care.
3.9 The problems accessing services are not experienced equally by all young people. An understandable focus on supporting young women impacts how self-harm is understood and defined. In turn this affects how services are designed and marketed, impacting the likelihood that young men will access them[28]. The barriers faced by LGBT young people in accessing services due to discrimination and lack of understanding on the part of health professionals are well documented[29]. A lack of cultural sensitivity and understanding also presents barriers to young people from ethnic minorities, especially young men, in how mental health services are designed and accessed. The stats bear this out, as White people are more likely to access support compared to other ethnicities[30],[31].
3.10 Improving access to services is a crucial part of the puzzle for ensuring that young people who self-harm get better, timely, support. But the suitability of those available services is no less important. The Government’s 2017 progress report of the National Suicide Prevention Strategy asserted that there was ‘a lack of high-quality self-harm services across the country’[32]. Four years on, young people who self-harm are still struggling to get help which is right for their needs.
3.11 Research published last year by Samaritans, which included young adults, found that NHS mental health services are rarely commissioned to deal with self-harm directly. Participants who overcome waiting times and thresholds were given support on the basis that they did not mention self-harm during group therapy sessions or use the behaviour as a coping mechanism while accessing support. This led to some of those we spoke to dropping out and limiting the utility of support for others[33].
3.12 Recommendation: Samaritans welcomes the increased funding for CAMHS services announced through the NHS Long Term Plan, the impact of which is still to be fully realised[34]. However we want to see this funding brought forward to ensure that young people who self-harm receive better care immediately. Funding should prioritise recruiting more frontline staff to increase capacity and expertise to support young people who self-harm, ensure that thresholds are lowered, and waiting times shortened.
3.13 Recommendation: DHSC, the NHS, and Local Government Association should work together to support both Integrated Care Systems and local authorities to improve access to, and the design of, support services for young people who self-harm. This work should particularly focus on those from at-risk groups and those who currently particularly struggle to access support, to ensure that they can access support within their own communities.
Appendix (i)
