Written evidence submitted by Mersey Care NHS Foundation Trust (SPR0089)

Zero Suicide Programme

 

Executive Summary

 

  1. Introduction

Mersey Care is a specialist mental health Trust in the North West of England, with over 5000 staff and serving a population of almost 11 million people. We provide specialist inpatient and community mental health, learning disabilities, addiction services and acquired brain injury services for the people of Liverpool, Sefton and Kirkby in Merseyside. We also provide high secure mental health services for the North West of England, the West Midlands and Wales, medium secure services for Cheshire and Merseyside and specialist learning disability services across Lancashire, Greater Manchester, Cheshire and Merseyside. Quality, recovery and wellbeing are at the heart of everything that we do.

 

The National Suicide Prevention Strategy through its confidential inquiry has identified the North West of England as an area of higher than average suicide rates. Suicide is an avoidable death. It is both preventable by wider public health interventions, but also amenable to high quality evidence based care.

 

About 27 per cent of people who die by suicide are under the care of a specialist mental health team. This population carries inherently a higher risk of suicide than the general population, both by virtue of their mental health condition but also by any previous attempts of suicide and self harm and co-morbid factors such as social adversity and a higher incidence of unemployment, social isolation, financial hardship and drug and alcohol use. These people are the primary focus for our Trust as they are the highest risk and amenable to our care.

 

  1. The Zero Suicide programme

Mersey Care agreed an ambitious 'Zero Suicide' Policy in 2015, with the aim to have eliminated suicide for patients within its care over the next five years. The implementation plan includes new training and safety planning, better measurement of self-harm, and creating a supportive culture to maximise learning (MCT Zero Suicide Policy 2015).

 

The Zero Suicide approach aims to improve the care provided and outcomes for people at risk of suicide under the care of Mersey Care NHS Foundation Trust. This approach was adopted by the Trust and was inspired by the pioneering approach of Dr Ed Coffey at the Henry Ford Hospital System, Detroit, Michigan (USA) (Coffey, 2006, 2007).

 

The Henry Ford Hospital System managed to implement a philosophy and practice of ‘perfect depression care,’ which was one of the major factors leading to a 75 per cent drop in suicides within four years, and eventually to years without a single suicide (Hampton, T. (2010)). The Trust hosted a number of workshops led by Dr Coffey and a Trust Board decision was made to adopt the approach in 2014.

 

The MCT approach identified four priority areas with 10 key areas of action described in the figure below (MCT Zero Suicide Policy 2015).

 

 

 

 

 

 

Figure 1 - Zero Suicide strategy

  1. How are we doing this?

The Safe from Suicide team was established with key individuals assigned to the overview and development of the approach. The group has been assigned further goals that are linked to the priority areas as outlined in Figure 1.

 

The priorities for year one of the programme are:

 

3.1 All staff will have undertaken Level 1 Suicide Awareness training by September 2016.

 

3.2 Level 2 Suicide Prevention competency based training for all staff in clinical roles will be developed and delivered by March 2017.

 

3.3 Safety planning intervention to be embedded at the following high risk points in local services by March 2017:

 

 

3.4 Safe from Suicide team to monitor and measure suicide and near-fatal self harm data and respond with enhanced support and interventions, including training, supervision, psychologically informed risk formulations and safety planning by December 2016.

 

3.5 Continued work with Stanford University to develop a ‘zero suicide app’ which aims to improve the detection of suicide risk and prevention. This project is in development, and will undergo a study phase within an ethically approved research framework in late 2016/early 2017.

 

  1. What have we achieved so far?

4.1 Level 1 Suicide Awareness training has been developed and delivered to 55 per cent of Trust staff (2000+), including members of the Trust Board.

 

4.2 The Level 2 training is in development. This is a modular programme and has been developed and co-produced with those who have lived experience. This training will be piloted at two sites in September 2016 and will then be rolled across the Trust from November 2016. A training resource for staff carrying out the Family Liaison Manager role has been developed again incorporating the lived experience of those who have been bereaved by suicide – 28 senior managers have now completed this training.

 

4.3 The safety planning intervention has been co-produced with service users and is now being piloted in two clinical areas across the Trust. The safety planning training will now be incorporated into the Level 2 training and rolled out across services from November 2016.

 

4.4 All suspected suicides and near fatal self harm incidents are monitored, the clinical teams are supported through the post incident process and the clinical lead supports all investigations, enabling early identification and response to any identified themes. The Risk Authority, Stanford University and Lockton Healthcare are also supporting this process.

 

  1. Safe from Suicide team

To show its commitment to the strategy, the Trust has funded a dedicated team that is based within our Centre for Perfect Care and is a mix of clinicians, quality improvement practitioners and experts by experience.

 

The Safe from Suicide (SfS) team oversees the implementation of the Zero Suicide strategy and policy and provides practical and expert support across the Trust.

 

The Trust has funded a number of posts: 

 

 

MCT feels that the commitment to the strategy is ‘embodied’ by the Safe from Suicide team and they are central to ensuring that the Zero Suicide strategy is delivered and embedded across the Trust. The leadership shown by Joe Rafferty, Chief Executive, and Dr Fearnley, Medical Director, and the Board ensures that the strategy remains at the top of an often busy agenda across all Trust areas and has been helpful in breaking down barriers to implementation.

 

The team meets monthly to monitor progress against the strategic goals and then reports into the Trust’s governance structure. The whole team has had training in Quality Improvement Methodology and have maximised the use of Research and Development and Knowledge services with the goal of developing resources which are evidence-based and innovative. All the strands of the strategy have a robust evaluation framework and the overall strategy evaluation has been commissioned to Manchester University’s Confidential Inquiry Team.

 

The clinical lead role is the only full time role at present, primarily focussing on the learning strategy and learning from incidents. The role has a strong clinical component with the flexibility to support individual clinicians, clinical teams or localities. An example of this is that two Community Mental Health Teams (CMHTs) have been identified as having higher than expected rates of suicide. In both instances the Suicide Prevention clinical lead is providing a range of support to the CMHTs and individual support and reflective practice time for clinicians, prioritising the sites for Level 2 training and providing team reflective practise time.

 

Jane Boland, the Trust’s Clinical Lead, explained: “I’ve been given an incredible opportunity to develop a breadth of knowledge and level of expertise about Suicide Prevention. I’m so excited about the training we are developing. The Level 1 training is all about awareness, but the next level will focus on the clinical skills and knowledge needed to support our very vulnerable service users and will be embedded into practice.”

 

Angela Samata is an expert by experience. She has been incredibly influential within the team, providing insight into the experiences and needs of those affected by suicide. Angela has co-produced the Level 2 training, the Duty of Candour training and will also be supporting the delivery and evaluation of the training.

 

Angela said: “I was delighted to accept the opportunity to work with Mersey Care because it is a Trust which not only values lived experience but uses it to shape and inform their policies and procedures. I have witnessed first hand the power of using lived experience to shape a culture shift and believe that is what Mersey Care is doing by working with people like me with lived experience of bereavement by suicide. I am delighted that the Stage 1 Suicide Prevention training has been made mandatory across the Trust and proud to continue working with Mersey Care in the future”.

 

  1. The importance of the Safety Planning intervention

The Safety Planning Intervention is an additional risk assessment and is based upon a psychologically informed, therapeutic approach to support and intervene when a service user expresses ideas of self harm or suicide. Its purpose is to help identify risk and give control back to service users who are most vulnerable and thinking about self harm or suicide. The safety plan should be used at points of transitions in service and periods of high risk, including as part of safe discharge planning from inpatient services and during episodes of crisis, and when individuals are deemed to be at risk of suicide.

The Safety Planning Intervention builds on and develops the strengths of the service user to understand and manage their own safety. The Safety Plan belongs to the service user and is part of a psychologically informed process of risk assessment, formulation and planning, which will support the service user to develop the skills and social networks needed to stay safe.

 

This intervention has been co-produced with service users and carers and has gone through an iterative quality improvement ‘Plan Do Study Act’ (PDSA) process.

 

The Safety Planning Intervention has evolved from a research evidence base (Stanley 2008) and is being robustly evaluated locally.

 

  1. The importance of the Training Strategy

The core of the Suicide Prevention policy learning strategy is the development and implementation of competency based training for staff, with a clear understanding of performance criteria, knowledge and skills that are required to undertake their role in regards to suicide prevention.

 

The development of the core competencies learning model has been adapted from existing evidence based models originating from the US. No competency based frameworks were found for suicide prevention training in the UK following a literature search.

 

The training is delivered at different levels, and is accessible to all staff (clinical and non-clinical).

 

Level 1

Level 1 Suicide Prevention training is mandatory for all staff at Mersey Care irrespective of their roles. All staff must have a basic awareness of suicide and what to do if asked to help someone in distress. As staff members for a mental health trust, being able to talk to someone in distress should be part of all of our core skills and is a key part of our values-based approach. All staff in MCT are required to know how to recognise someone in distress, to know how to help, who that help can come from and will commit to ensuring that the person gets the help they need - this is the outcome from our training.

 

Each area of the Trust develops its own “Locality Safety Plan” to ensure there is a specified pathway in that area of the service if someone is thought to be in distress and at increased risk of suicide.

 

MCT has developed a learning resource which is accessible and effective with over 2,000 of our staff having accessed training.

 

Level 2

Level 2 Suicide Prevention training is for clinical staff, it is delivered within teams and follows a modular approach. The outcomes for the learning are an improved knowledge and skills and a clear evidence of practice change evidence through reflective practice and linked to supervision by senior clinicians. It is offered as a flexible modular approach with learner and supervisor resources. Each module is delivered in a 45 minute session.

 

The modules and resources have been co-produced by staff, service users and experts by experience. The six core modules are:

 

  1. Understanding Suicide
  2. Person Centred Care
  3. Risk Assessment
  4. Risk Management
  5. Safety Planning
  6. Lived Experience.

 

  1. The post incident review process

Post incident suicide reviews are an important part of learning from past events and ensuring that any preventable risks are addressed to prevent future deaths in similar circumstances.

 

Mersey Care has engaged in new approaches to reviewing suicide and engaging with the bereaved in the process. The model follows a process of communication and resolution following a serious incident, with transparency, candour, apology and commitment to learning.

 

All deaths by suicide are reviewed by the clinical divisions and include staff independent of the service involved in the persons care. The suicide clinical lead is available to support the investigation, including support for the clinicians involved in the incident.

 

Post incident reviews are standardised to favour learning and collection of relevant data. Data are collected, analysed and disseminated on suicides and serious suicide attempts to enhance opportunities for learning across the organisation.

 

  1. Outcome measures

The zero suicide approach adopted by Mersey Care can be described as a complex multi-modal intervention and there are a number of strands to the project.

 

The Trust has undertaken extensive data collection audit work on suicide to review and highlight historical areas of risk - to allow us to target interventions to areas of highest risk. We are also working with the National Confidential Inquiry to ensure that we are utilising a standardised criteria for inclusion, which aligns itself to the national data collection.

 

This quality improvement approach utilises measures of progress based on two categories ’leading’ measures which determine progress in terms of process such as number of people trained in suicide prevention, number of teams trained to deliver safety planning interventions, and staffing levels.

 

Additionally we are monitoring ’lagging’ measures or outcomes, and events. The focus lagging measures identified by our programme are:

 

  1. Number of people who complete suicide whilst an inpatient and three-day post-discharge (target = 0 from 2016/17).
  2. Number of people who complete suicide within seven days of discharge from inpatient services (target = 0 from 2016/17).
  3. 20 per cent year on year reduction in the number of people on a community team’s caseload that completed suicide from the baseline period of 1 April 2015 to 31 March 2016.
  4. 20 per cent year on year reduction in the number of people who complete suicide within three months of discharge from the Trust’s inpatient services from the baseline period of 1 April 2015 to 31 March 2016.

 

The Zero Suicide programme was launched in September 2015, during the first year of implementation there has been significant progress in key areas of the policy.

 

There have equally been challenges within the organisation, and managing the change process, and therefore some delay within some of the expected targets, however the Trust remains confident that these targets will be achieved.

 

Significant progress has been made in regards to implementation of the suicide training intervention, the initial implementation and evaluation of the safety planning interventions and our post incident review process.

 

The Trust is engaged in the development of new technologies to aid further with both risk detection and management.

 

In terms of our lagging measures, it is still very early days with regards to an accurate evaluation of suicides for the first year of implementation. Coroner’s verdicts typically take longer than six months to be completed, therefore we do not have outcomes for all of the measures. At present we have six confirmed Coroner’s verdicts for this time period where the outcome is “Death by own Hand”.

 

  1. Conclusions

Suicide rates in the UK hit an all time low in 2007, but have since been increasing. Many approaches have been tried including a National Suicide Prevention Strategy.

 

Mental health trusts are in a good position to identify people at highest risk of suicide, and indeed 27 per cent of all suicides occur in people in contact with mental health care services. Improved referral pathways from primary care, AED and liaison services will ensure that the people at highest risk of suicide are accessing appropriate care.

 

The social and economic costs of a death by suicide are enormous and the impact on those left behind, difficult to describe. Each suicide death has been estimated to have an economic cost of £1.7 million, mainly due to years of life lost, and does not include many of the indirect and hidden costs, emotional and financial of such a loss.

 

Systematic health care improvement approaches can go some way to reduce risk. Suicide deaths for people in services are avoidable and preventable.

 

Mersey Care NHS Foundation Trust has adopted a Zero Suicide approach, which is a complex multi-modal intervention. There have been significant organisational challenges in embedding and implementing some of these principles in some areas, and as such initial estimates on compliance rates have seen to be overly optimistic. However, the programme has adapted and we’ve discussed with clinical teams ways of overcoming these obstacles for the benefit of patient care. During the first year of implementation there have been significant and tangible achievements.

 

The Trust and its leadership have taken a paradigm shift in the way suicides are viewed within the organisation, and remain committed to a relentless approach to reduce the number of suicides for people in our care year on year.

 

The Zero Suicide initiative is an ambitious five-year improvement programme that uses systematic quality improvement methods, co-production, measurement and culture change to attempt an unprecedented reduction in suicide within the Mersey Care patient population. During the programme, learning cycles enable improvements across a range of activities, drawing upon best practice and feedback. The ambition is matched by support for people after self-harm or suicide so that all opportunities to learn are harnessed and shared quickly.

 

Mental health care trusts are in a good position to adopt programmes aimed at suicide risk reduction.

 

September 2016

 

References

1 While, D., Bickley, H., Roscoe, A., Windfuhr, K., Rahman, S., Shaw, J., Appleby, L. & Kapur, N (2012). Implementation of mental health service recommendations in England and Wales and suicide rates, 1997-2006: a cross-sectional and before-and-after observational study. Lancet, 379(9820), 1005-1012

 

2 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Avoidable Deaths: five year report Dec 2006. University of Manchester

 

3 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Healthy services and safer patients: links between patient suicide and features of mental health care providers. Manchester: University of Manchester, 2015

4 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Annual Report 2015: England, Northern Ireland, Scotland and Wales July 2015. University of Manchester

5 Hunter, C., Chantler, K., Kapur, N. & Cooper, J (2013). Service user perspectives on psychosocial assessment following self-harm and its impact on further help-seeking: A qualitative study. J Affect Disord, 145(3), 315-32

 

6 The National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. Safety First: five year report 2001. University of Manchester

 

7 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Patient suicide: the impact of service changes. A UK wide study. Manchester: University of Manchester 2013