Written Evidence submitted by Samaritans’ (MH0012)

 

Samaritans is the UK’s largest suicide prevention charity. Through nearly 20,000 listening volunteers, we take a call for help every seven seconds. We have 201 branches across the UK and Republic of Ireland, many of them in rural communities.

Suicide is the leading cause of death among young people and among men under 50.[1] We welcome the opportunity to submit evidence to this inquiry about suicide in rural areas, where people often experience multiple disadvantages contributing to their suicide risk alongside difficulties accessing appropriate support. Our submission to this call for evidence focuses on suicide and suicide prevention, rather than mental health more broadly.

We have also encouraged people with relevant lived experience that we are in touch with to submit evidence directly to the Committee rather than through this submission.

 

What specific mental health challenges are faced by those living and working in rural communities?

Suicide is a complex behaviour that rarely has a single cause. It is also a public health issue, associated with a wide range of factors, which impact mental health and wellbeing and go beyond where you live. However, there are many factors that may be exacerbated for some people living and working in rural areas, such as social isolation,[2] poor working conditions, low pay,[3] and limited access to services.[4]

Suicide rates vary between different areas of the country for a variety of reasons, but there is evidence that rurality is a risk factor for suicide.[5] The number of suicides has been rising across the country in recent years, and analysis from the Office for National Statistics (ONS) has found that the number of suicides among men living in rural towns and fringes’ rose by nearly 24% between 2016 and 2018.[6] We have included an analysis of factors impacting suicide among those working in agriculture in response to Question 3.

What is the current state of mental health & suicide prevention service provision for those working in agriculture and those living in rural areas more generally? Do they meet the specific needs of that community?

The COVID-19 pandemic has affected mental health and suicide prevention services in every area of the country. The Samaritans helpline gives us a unique perspective on how these changes have impacted people. Over the year beginning March 2020, we received over one million contacts from people concerned about their mental health. Many of these callers reported being unable to access mental health support and services that they had previously used, due to the pandemic, and expressed confusion or helplessness around new forms of support. Some of our callers said that the mental health support available to them has been inadequate and said they had also lost informal networks of community support.[7]

This evidence suggests that people need to be able to access a variety of support types. However, people living in rural areas are confronted with problems seeking help both on and offline. Difficulties in accessing physical support for people living in rural communities are well-evidenced, related to issues like inflexible hours and poor public transport links, and these issues are particularly prominent in rural areas where fewer people live near a GP or hospital.[8]

For those in rural areas who may have previously experienced these accessibility problems, the move to online support may have brought benefits. However, research shows that the likelihood of an area having no or very poor broadband connectivity increases with the area’s remoteness and population sparsity.[9] Addressing this digital divide has never been more urgent, as many of the changes to the provision of mental health and suicide prevention support remain in place after the pandemic.

Finally, it remains difficult for many people to talk about their mental health or suicide. The most recent survey from The Royal Agricultural Benevolent Institution highlights the ongoing need to tackle stigma and raise awareness particularly for those working in agriculture.[10] In March 2022, Samaritans’ ‘Real People, Real Stories’ campaign will be focusing on reaching men in rural communities, to encourage them to reach out when they are struggling to cope and raise awareness of our helpline, with support from NFU Mutual Trust.[11]

What are the causes of the higher than average rate of suicide amongst those working in agriculture? Are there other linked professions, such as vets, that have similar issues? How effective are suicide prevention services offered to these groups?

Suicide is complex and rarely attributable to a single cause. However, exploring the specific sub-categories of agricultural employment where people are more likely to die by suicide can reveal risk factors that must be addressed to reduce suicide in rural areas.

Data from the ONS show that people working in agriculture are more likely to die by suicide than the general population - 1.7 times more likely if they work in skilled agricultural and related trades, and twice as likely if they work in elementary agricultural occupations’ such as harvesting crops.[12] Overall, 813 people in England and Wales lost their lives to suicide in these two agricultural occupation groups between 2011 and 2019.[13] The higher-than-average rate of suicide amongst agricultural workers is a nuanced issue, with specific occupational subgroups at higher risk. For instance, previous research suggested that farmers may be at increased risk of suicide,[14] although more recent analysis from the ONS in 2017 found that suicide among farmers is not higher than the national average.[15] This analysis found that the rate of suicide remains high among other jobs in the ‘skilled agricultural and related trades’ occupational group, such as gardeners.[16]

Attempting to explain suicide among different occupational groups is complex because numerous factors act together to increase risk. One factor which may play a role in explaining higher rates of suicide among some agricultural occupations is gender - around three-quarters of registered suicides occur among men,[17] and men are heavily overrepresented in agricultural work.[18]

There is also a strong socioeconomic gradient to suicide risk – the less well-off you are financially, the more likely you are to die by suicide. Samaritans’ research has found that men from the most disadvantaged backgrounds are up to ten times more likely to die by suicide than those in more affluent areas.[19] Evidence also shows that the highest rates of suicide tend to be among workers who are worse-paid and have less control over their work, while the lowest rates of suicide are generally seen amongst those working in highly-paid occupations.[20] This research is evinced in the data cited above, which show those in elementary agricultural roles at higher risk of suicide. The ONS conclude: …it may not be the actual occupation that puts individuals at risk, but features of the job such as low pay, job security and the wider socio-economic characteristics of individuals employed in a particular sector.[21]

At the sharpest end of many of these features of low-paid agricultural work are those experiencing, or at risk of, labour exploitation. Research highlights some agricultural work, especially that involving seasonal work or where numbers of temporary migrant workers are higher, as particularly susceptible to exploitative practices including modern slavery.[22] This is concerning because evidence suggests there are higher rates of depression, anxiety, PTSD, and suicidal ideation among people who have experienced these practices.[23]

Historically, suicide rates have risen following periods of economic crisis, due to factors like rises in unemployment.[24] Samaritans has recently undertaken research examining the experiences of young adults, who have borne the brunt of the COVID-19 pandemic both in terms of its economic impact and their mental health. Our research has found that young adults who experienced economic disruption – like job loss or reduced hours – during the pandemic were more likely to report suicidal thoughts.[25] This is especially troubling in the context of research that shows young people living in rural areas have been disproportionately affected by economic crises in the past.[26]

Suicide risk factors may be compounded in rural areas due to some people’s greater access to means with which to take their own lives.[27] For example, there are differences between agricultural and related trades and other occupation groups in terms of methods used which may be explained by accessibility.[28] Access to – and knowledge of – methods may also contribute to the higher rates of suicide among other occupations, such as veterinarians, alongside other features of these professions like social isolation.[29]

In the context of these broad and multifaceted risk factors, ‘suicide prevention services’ is itself an extremely broad term. Issues around the provision and accessibility of mental health services in rural areas have been addressed in Question 2 above. However, approximately two thirds of people who take their own lives are not in touch with mental health services in the year before they die.[30] A public health approach to suicide therefore requires a more joined-up response, with every element of local and national government adopting policies to prevent people from ever reaching the point of wanting to take their own life and needing crisis intervention. This approach must include robust financial and employment support, restriction of access to means, and localised interventions which target the most at risk occupation and demographic groups in rural areas.

Does the Government’s recent investment in mental health services adequately provide for agricultural mental health?

We are deeply concerned that the most recent Spending Review did not include renewed funding to support suicide prevention initiatives at the local level, acknowledging the stark regional inequalities in suicide. £25 million of the £57 million for suicide prevention and bereavement services that was allocated to local areas through the NHS Long Term Plan ran out in 2020/21. This money was not specifically for agricultural mental health but is meant to be used in areas with the highest suicide rates overall and among at-risk groups.9 Samaritans is calling for ringfenced funding across three years to support local areas to develop and deliver targeted non-clinical support services to prevent suicide. Remaining funding for local areas’ core suicide prevention plans ceases in 2023/24. Government must urgently commit to ongoing funding supporting these plans, in line with commitments in the NHS Long Term Plan. This is not a policy area where resourcing can be left to local discretion.

Previous funding models allocated money to local areas at roughly 63p per capita, while research using data from 2009 approximates the financial cost of each suicide of someone at working age to be £1.67million (over £2.2 million today when adjusted for inflation).[31] Though suicide prevention in rural areas is likely to incur additional delivery costs and organisational challenges,[32] the economic impact of suicide in rural areas drastically outweighs investment in suicide prevention.   

How joined up are key actors, such as Defra, DHSC, NHS England, Public Health England and Local Government in their approach to improving quality of, and access to, mental health service in rural and agricultural communities?

Defra should be an active stakeholder in the government’s national suicide prevention strategy. In the most recent progress report on the strategy, the only mention of the department is related to nature social prescribing.[33] This is a welcome policy, but it is only a fraction of the wide-ranging public health approach needed to address the specific factors associated with suicide among people living and working in rural areas.

Suicide prevention in rural communities is everyone’s responsibility – efforts to address the wider determinants of health go far beyond closer cooperation between local government, Defra, and health authorities, and must encompass action at the national and local level on transport, digital inclusion, economic regeneration, unemployment support, and accessible health services amongst many other factors.

 

January 2022


[1] Office for National Statistics. (2020). Leading causes of death, UK.

[2] Stickley, A. & Koyanagi, A. (2016). ‘Loneliness, common mental disorders and suicidal behavior: Findings from a general population survey’, Journal of Affective Disorders, 197, 81-87.

[3] Samaritans. (2017). Dying from inequality: socioeconomic disadvantage and suicidal behaviour.

[4] Congdon, P. (2012). Assessing the impact of socioeconomic variables on small area variations in suicide outcomes in England’, International journal of environmental research and public health, 10(1), 158–177.

[5] Ibid.

[6] Office for National Statistics. (2020). Recent trends in suicide: death occurrences in England and Wales between 2001 and 2018.

[7] Samaritans. (2021). One year on: how the coronavirus pandemic has affected wellbeing and suicidality.

[8] Local Government Association. (2017). Health and wellbeing in rural areas.

[9] Philip, L. et al. (2017). The digital divide: Patterns, policy and scenarios for connecting the ‘final few’ in rural communities across Great Britain, Journal of Rural Studies, 54, 386-398.

[10] The Royal Agricultural Benevolent Institution. (2021). The Big Farming Survey: The health and wellbeing of the farming community in England and Wales in the 2020s.

[11] Read more about Samaritans’ Real People, Real Stories campaign on our website: https://www.samaritans.org/support-us/campaign/real-people-real-stories/

[12] Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015.

[13] See Minor Group 511: Agricultural and Related Trades and Minor Group 911: Elementary Agricultural Occupations in Table 3, Office for National Statistics. (2019). Suicide by occupation, England and Wales, 2011 to 2019 registrations.

[14] Hirsch, J.K. (2006). A review of the literature on rural suicide: risk and protective factors, incidence, and prevention’, Crisis, 27(4), 189-99.

[15] Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015.

[16] Ibid.

[17] Office for National Statistics. (2021). Suicides in England and Wales: 2020 registrations.

[18] Department for Environment, Food and Rural Affairs. (2019). Agricultural labour in England and the UK: Farm Structure Survey 2016.

[19] Samaritans. (2017). Dying from inequality: socioeconomic disadvantage and suicidal behaviour.

[20] Milner, A. et al. (2013). Suicide by occupation: systematic review and meta-analysis’, British Journal of Psychiatry, 203(6), 409-16.

[21] Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015.

[22] Focus on Labour Exploitation. (2019). The Risks of Exploitation in Temporary Migration Programmes: A FLEX Response to the 2018 Immigration White Paper.

[23] Wright, N. et al. (2020). Mental health recovery for survivors of modern slavery: grounded theory study protocol’, BMJ Open, 10:e038583.

[24] Oyesanya, M. et al.Systematic Review of Suicide in Economic Recession, World Journal of Psychiatry, 5(2), 243–54.

[25] 

Samaritans. (2021). The Impact of Economic Disruption on Young Adults.

[26] Commission for Rural Communities. (2012). Barriers to education, employment and training for young people in rural areas: executive summary.

[27] Congdon, P. (2012). Assessing the impact of socioeconomic variables on small area variations in suicide outcomes in England’, International journal of environmental research and public health, 10(1), 158–177.

[28] Office for National Statistics. (2017). Suicide by occupation, England: 2011 to 2015.

[29] Ibid; Bartram, D.J. & Baldwin, D.S. (2010). Veterinary surgeons and suicide: a structured

review of possible influences on increased risk’, Veterinary Record, 166, 388-397.

[30] John, A. et al. (2020). Contacts with primary and secondary healthcare prior to suicide: Case–control whole-population-based study using person-level linked routine data in Wales, UK, 2000–2017’, The British Journal of Psychiatry, 217(6), 717-724.

[31] McDaid, D. (2016). ‘Making an economic case for investing in suicide prevention: quo vadis?’ in O'Connor, R. & Pirkis, J. (eds.) International Handbook of Suicide Prevention: Research, Policy and Practice. 2nd ed. Chichester: Wiley Blackwell.

[32] Local Government Association. (2017). Health and wellbeing in rural areas.

[33] HM Government. (2021). Preventing suicide in England: Fifth progress report of the cross-government outcomes strategy to save lives.