Written evidence submitted by Gerry Cadogan, Public Health Principal, Public Health Team, Torbay Council (SPR0017)

Introduction

Written evidence submitted by Gerry Cadogan, Public Health Principal, Public Health Team, Torbay Council. This is a personal submission from a professional perspective.

1        I am the Public Health Mental Health and Suicide Prevention Lead for Torbay Council. Since 2009 I have been undertaking ‘deep dive’ suicide audits for Torbay, and similarly from 2011 for Torbay and South Devon. This reflects the fact that the Local Coroner, Mr Ian Arrow, has been very supportive in the role of preventing avoidable deaths,as I am able to examine employment and relationship status, family issues, contact (or lack of) with the GP and mental health services in addition to the more routine audit requirements of age, gender, method, postcode and so on. The inclusion of South Devon relates to the fact that the South Devon and Torbay Clinical Commissioning Group (CCG)includes the Torbay area.

2        I have been a passionate advocate for suicide prevention for several years. In Torbay we have just won the 2016 Faculty of Public Health Mental Health award as a result of the suicide prevention initiatives that we have been undertaking. But these are unfunded apart from my salary and the finance that I have raised through grant applications, largely in my spare time. Raising awareness is futile if follow-on services are absent.

3        Executive Summary

This evidence relates to:

• The factors influencing the increase in suicide rates, with a focus on particularly at-risk groups
• The social and economic costs of suicide and attempted suicide
• The measures necessary to tackle increasing suicide rates, and the barriers to doing so

4              The factors influencing the increase in suicide rates, with a focus on particularly at-risk groups

4.1              The factors relating to suicide risk are well-known and well-documented by research teams led by Louis Appleby and Keith Hawton. Although the numbers are too small to be statistically significant,the suicide audit undertaken in Torbay and South Devon in 2015/16 reinforces these risk factors in that:

• The greatest numbers of suicides occurred in men aged between 40 to 49 ( 15.4% );
• More suicides occurred by people living in the areas of greatest deprivation (65% ). Compared to England, Torbay is ranked amongst the 20% most deprived district local authorities (46th out of 326 in 2015);
• For men, relationship issues were a major factor in suicides, with recent breakups, divorces, bereavement, or lack of access to children being cited in the majority of these. These may significantly destabilise already vulnerable situations*;
• Hanging and drug overdoses respectively were the most common methods of suicide in both males and females( 77%);
• Where drug overdoses were used, amitriptyline, oxycodone and codeine are the most common drugs of choice, and of note is the fact that if a family member has recently died, their oromorph and painkillers are occasionally removed before the professionals find them, and used in a future suicide by the bereaved;
• Previous suicide attempts and episodes of self-harm are major risk factors ( 40% );
• Alcohol and/or drug abuse, with an increase in New Psychoactive Substances-NPS (21% );
• Where the information had been recorded as depression/suicide ideation or the like, just under fifty per cent had seen their GP within three months of their death;
• Only one-third of suicides were in contact with the mental health services at any time.
• For younger people their emerging sexuality is a factor in self-harm and suicide.

*As a result of this audit, I have decided to focus attention in Torbay on men (of all ages), and people who are in contact with the GP. Plus there is the challenging aspect of attempting to encourage men to talk to somebody if they feel hopeless. There is a lot of UK and international research highlighting the effect of the economic recession on suicide rates. Whilst in Torbay there was an increase at that time, the ‘deep dive’ audit indicated that even if debt and unemployment were involved, the breakdown of a relationship and/or access to children was the factor leading to suicide.

4.2 Although hanging is the most common method of suicide, especially for men, the location has changed. Both myself and the local police have noticed that over the past two to three years most hangings take place in the home and are discovered by friends or family, whereas previously there were a significant number that took place in the woods/open land where they were often discovered by dog walkers.

5              The social and economic costs of suicide and attempted suicide

5.1              Data is useful, but collecting it does not change lives, nor prevent suicide. This is partly because there are so many other NHS and Local Authority priorities that need to be funded so that targets can be met.  There is also a paucity of evidence showing the cost-effectiveness  of preventing suicide, compared to the soaring costs of attending a rescue or retrieving a body. In 2011 Knapp, McDaid et al identified that GPs who go on a suicide prevention training course (ASIST-Applied Suicide Intervention Skills Training) will have a 20% greater chance of identifying those at risk of suicidal behaviour in the year following training. The model indicates that 603, 706 or 669 suicides would be avoided by training over the 1, 5 and 10-year time range, respectively. The Royal College of General Practitioners has a one hour free training programme on suicide awareness on its website, which I am unable to persuade local GPs to undertake, probably because this comes with no credits. Although ASIST Training is now run in Torbay (due to me obtaining a grant from Health Education England), no GPs have applied locally. It would appear that preventing suicide is not a priority for primary care and CCGs.

5.2              Taking into account the direct cost of just one suicide to society-the involvement of the police, ambulance services, the coastguard and helicopter rescue, hospital mortuary services, and the coroner’s inquest as a minimum, why is there no statutory funding available to undertake early intervention and provide low level mental health support for people at risk, which would prevent these costly interventions? Perhaps because there is no joint ownership of the issue, so the incident is not viewed holistically? Despite the myth of joint working, I am told not to worry about any costs other than Local Authority expenditure.

5.3              Platt et al (2006) examined the overall lost lifetime output for men and women in Scotland due to premature death from suicide as £5.66 and £1.44 million respectively (2005 prices). Even using more conservative estimates advocated by Clayton and Barceló (1999 ) these costs would be £1.62 million and £0.41 million respectively. As the majority of suicides occurred in people between the ages of 35 and 44 this age group accounted for 35% of all lost productivity.

5.4              Also important are indirect costs. As a result of premature death, individuals lose the opportunity to contribute productively to the national economy, and have any quality of life.

5.5              The emotional costs of suicide on family and friends are known as the intangible costs, as they are impossible to assess. Some areas commission services for those bereaved by suicide, but this is inconsistent. Research indicates that losing a family member to suicide is a risk factor for suicide in itself.

6              Measures necessary to tackle increasing suicide rates, and the barriers to do so.

6.1              Madeleine Moon MP has done some wonderful work by initiating the debate on suicide. Yet despite the myriad of publications that are produced (a new guide for Local Authorities is soon to be published by Public Health England) there is no statutory requirement to undertake suicide-related work. The lack of interest in commissioning services for suicide prevention is not helped by the split between the Clinical Commissioning Groups (NHS) and the Public Health team (Local Authority). Certainly in many areas this is seen by the CCG as the responsibility of Public Health to fund suicide prevention, leaving the CCG to commission mental health secondary and crisis services. The implementation plan of the Mental Health Taskforce Five Year Forward View (2016) reinforces the role of the CCG in prevention. But will this be primary prevention of tertiary, targeted prevention? Suicide prevention targets, in the Public Health Outcomes Framework only relate to the suicide rate for Persons, Male and Female for each Local Authority. This is an outcome impossible to influence currently, so surely it is the outputs that should be the targets? Although I collect detailed information annually in my suicide audit, as many of my public health colleagues do-there is no requirement for me to report this anywhere, and it does not even go to the Health and Wellbeing Board. This indicates the relative unimportance of suicide prevention.

6.2              Because of the close link between self-harm and suicide, there is merit in studying the two together. But this detracts from suicide. Prevention may involve responding to self-harm alerts, as these may be averting suicide, but suicide ideation is often not followed up. In the 2015/16 audit there were individuals who attended A and E, were discharged, and took their life within days. Yet self-harm is often referred to as ‘attention-seeking’. Consequently the costs of suicide are under-reported. Additionally, the health and social care of self- harm can be costly as it may be repeated over a period of years.

6.3              Is the reason why people, especially men, do not ask for help, a result of the myriad of myths and stigma around the subject of suicide? This hides the prejudice and misunderstanding there is around suicide and those who take their life. Even the common term ‘commit’ relates to the fact that suicide was a crime until 1961 in England (1993 in Eire)-the stigma still abounds for the survivors and families. In a mini-survey of male attenders at a Torquay barbershop, 50% said that they would not talk to anyone if they were feeling hopeless.

6.4              The Kings Fund (2012) identified that as result of the changes contained in the Health and Social Care Act 2012, the NHS is implementing one of the most radical reorganisations in its history and more than four-fifths (85 per cent) of local authorities restrict publicly funded care to those with substantial and/or critical needs (Association of Directors of Adult Social Services 2012). “Much greater priority needs to be given to public health and prevention in health and social care………... Services are still too heavily focused on treating ill health and dealing with acute need and those in crisis”. Increasing suicide rates are apparently not considered a crisis.

6.5              Leading on from the above, despite the transition to community-based care, inpatient services remain a core component of mental health care, and account for a significant proportion of overall mental health spending. Of the £6.5 billion spent on specialist mental health services for adults of working age, 40 per cent is accounted for by inpatient care in acute, secure or rehabilitation units (Mental Health Strategies 2011). Conversely, relatively little is spent on care for the very large numbers of people with less severe mental health problems who are supported in the community. These are the people who are at a greater risk of suicide because they are unsupported, and for whom there is inadequate service provision.

7              The Challenge

Perhaps it would be helpful to describe the stories behind some of the statistics in order to illustrate the extremes, from where  it would be nigh impossible to identify a potential suicide, to what could only be called ‘the bleedin’ obvious’ - where any person in several settings could have predicted the outcome. Humanising the situation often challenges indifference.

These have been included in Annex 1 which should not be published as it may be possible to identify the individuals on a local basis. However it can be summarised as:

- Difficult but with retrospective clues from which lessons can be learnt (Long term condition diagnosis, pain, relationship breakdown)

- ‘Bleedin’ obvious’  People of all ages repeatedly stating that they want to die/take their lives

8              Recommendations for consideration

As a result of the information above, I have summarised key issues that could be considered by the Select Committee

1                     That a decision is made as to the relative responsibilities for Suicide Prevention of the Local Authority and the NHS. Every health and social care organisation should be given a role.

2                     Suicide Audits and Prevention Strategies should be made a requirement rather than a recommendation for each local authority area.

3                     Currently there are four different Suicide Prevention Strategies for each country of the UK. Suicide prevention would be more influential if there was one, with a common framework and opportunities for local requirements based on the suicide audits. This would also be an opportunity for sharing good practice.

4                     As a minimum, specific targeted requirements and initiatives should be commissioned for male suicide prevention.

5                     There should be more scrutiny over the authorisation and collection of painkilling drugs such as Oromorph.

6                     Whilst there are links between suicides and self-harm, suicide prevention must be given equal priority to the more crisis-inducing self-harm.

7                     CCGs should ensure that GPs and primary health care teams receive awareness raising and suicide prevention training

8                     Research should be commissioned to look at the direct, indirect and intangible costs of suicide which will aid commissioning decisions

9                     Local Authority and CCGs should be given pragmatic targets rather than outcomes too difficult to influence

10                Greater emphasis should be given to the information communicated when anti-depressants are prescribed, both at the surgery and when dispensed at the pharmacy. For example: ‘These medications are dangerous if stopped without medical advice’ .

11                Commissioning services for suicide prevention should include

• community wellbeing centres which focus on early intervention for mental health issues;
• Bereavement services for those who have lost people to suicide;
• Peer support groups and 24/7 helplines should be facilitated by experienced practitioners who are aware of the services available.

6 October 2016