Written evidence from the Department of Health (SPR0110)

 

Introduction

 

This evidence has been prepared for the Health Select Committee (HSC) by the Department of Health in response to the Committee's invitation to provide written evidence to assist in its inquiry into the action which is necessary to improve suicide prevention in England.  The Department is grateful for the opportunity to contribute to this process.

 

Background

 

The suicide rate (deaths per 100,000 of population) in England has increased steadily since a record low in 2007; but remains low compared to other UK countries and Europe. The latest official statistics1 for 2015 show that there were 4,820 suicides in England, decreasing from 4,882 in 2014This is the first time the number of suicides and the suicide rate has decreased since 2012.  The suicide rate in England was 10.1 in 2015, decreasing from 10.3 in 2014 (UK suicide rate was 10.8 in 2014) – the suicide rate in 2007 was 8.9. See figures 1 & 2. 

 

Men are three times more likely to die by suicide than women and suicide is the leading cause of death in men under 50, as well as the second leading cause of maternal death.  However, the most recent data shows that the suicide rate in men decreased slightly in 2015, yet increased slightly in women. 

 

The cross-Government Suicide Prevention Strategy, Preventing Suicide in England: A cross-Government outcomes strategy to save lives2 was published in 2012 and supported by investment of £1.5m into new research.  Two annual reports have been published showing progress against the National Strategy and the third annual report will be published soon.  This annual report will set out ways in which we are increasing our efforts in key areas to progress the aims of the Strategy.

 

The National Strategy has two aims; to reduce suicide and support people bereaved by suicide.  It identifies six key areas for action:

  1. Reduce the risk of suicide in key high-risk groups;
  2. Tailor approaches to improve mental health in specific groups;
  3. Reduce access to the means of suicide;
  4. Provide better information and support to those bereaved or affected by suicide;
  5. Support the media in delivering sensitive approaches to suicide and suicidal behaviour; and
  6. Support research, data collection and monitoring.

 

The independent Mental Health Taskforce Forward View for Mental Health3 made recommendations for reducing suicides which include reducing the national suicide rate by 10 percent by 2020/21, ensuring all local areas have multi-agency suicide prevention plans in place by 2017 and learning lessons from all deaths in NHS settings, including suicides.  Implementation of the recommendations has been supported by an additional investment to the NHS of £25 million by 2020 (£10m in 2018/19, £10m in 2019/20 and £5m in 2020/21).  NHS England will work with partners before setting out the funding priorities for this additional investment.

 

At a national level, the Department of Health leads work across Government, with Arm's Length Bodies (ALBs) and across statutory organisations and voluntary and charitable organisations.  This work includes:

 

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

 

There are a wide range of social and environmental factors which may increase the risk of suicide as well as mental illness or poor mental health and wellbeing which may also increase suicide risk.

 

We know that suicides are more likely to occur in people living in areas experiencing social and economic challenges.  People from lower social-economic backgrounds and those who experience unemployment and financial hardship are at higher risk of suicide.  Also, people who experience poor physical health, especially serious and long-term conditions, and people with poor mental health are at higher risk of suicide.  Other people at greater risk of suicide are those in contact with mental health services and criminal justice services. People who have been subject to abuse and who have been bereaved by suicide are also at higher risk.  

 

Risk factors can vary according to age, gender, sexual orientation and occupation.  In England, suicide rates are highest in men and women aged 45-59 (in 2014 the rate for men was 23.9 and 7.3 in women).  Evidence shows that people from lesbian, gay, bisexual and transgender (LGBT) groups also experience more factors for suicide risk, with stigma and discrimination from society being the main reasons for this.  A recent study by the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH)7 in 2016 examined the factors relating to risk of suicide in young people, which highlighted ten themes including family adversity, academic pressures and bullying.  These differ from the factors in older people such as financial pressures, relationship break-down, occupation and health issues.

 

The National Strategy identified the following high risk groups where suicide prevention should be focussed:

 

It also identified the following groups that require tailored interventions to meet their specific mental health needs:

 

The social and economic costs of suicide and attempted suicide

 

Analysis estimates that each suicide costs the economy around £1.67 million (based on 2009 prices)8, although the full costs may be difficult to quantify.  Around 60–70 percent of the cost of each suicide is attributed to the impact on the quality of life of those bereaved by suicide.   

 

The costs to the public purse of repeated non-fatal suicide events are difficult to estimate and will vary by means of suicide attempt.  A study indicated that around 14 percent of costs are associated with emergency department attendance and medical and surgical intervention and more than 70 percent of the costs are associated with follow-up psychiatric inpatient and outpatient care.  This is because people who survive suicide attempts are likely to make further attempts, which in some cases are fatal.   

 

However, given that people with mental health problems are at higher risk of suicide, we should also take into account that mental ill health costs the economy around £105 billion each year.  Tackling the determinants of mental ill health is also imperative to reducing suicide risk in the population.

 

Annual spending on mental health has increased to around £11.7bn and clinical commissioning groups are committed to increasing spending each year up to 2020 at least in line with the growth of their overall funding allocation.

 

The Government is also increasing investment in mental health services.  This includes an additional £1.4bn for children and young people’s mental health up to 2020, including eating disorders. There will be a further additional £1bn for mental health services by 2020 including £400m to deliver 24/7 community based services as a safe alternative to hospital, £250m to ensure all hospitals have liaison psychiatry services in emergency departments and £290m to improve perinatal mental health services.

 

The Government is also introducing the first waiting time standards for mental health, starting with access to psychological therapies and early intervention in psychosis.  The aim is to implement a comprehensive set of community-based mental health pathways and standards of care by 2020/21, which together with additional investment will provide access to services for a further 1m people.  In addition, the Government is committed to expanding access to psychological therapies to to around 600,000 more people a year by 2020/21.

 

The measures necessary to tackle increasing suicide rates, and the barriers to doing so

 

One of the most significant barriers to people seeking help is the stigma which surrounds suicide and talking about mental health issues generally.  The Department of Health has provided financial support, along with Comic Relief and the Big Lottery Fund, to the Time to Change programme9 since 2012, which works to tackle the stigma associated with mental health.  Led by Mind and Rethink Mental Illness, Time to Change gathers data on social attitudes to mental health and delivers a series of social marketing campaigns to influence change.  To date the programme has helped improve the attitudes towards mental health of 3.4 million people.  The Department of Health is working with Time to Change on the next phase of the programme up to 2020 which will place more focus on addressing stigma within local communities and empowering them to develop their own local responses.

 

Achieving a sustainable reduction in suicide rates will require concerted efforts by a range of organisations across sectors to match the national policy with local delivery.  Since 2013, local authorities have had responsibility for local suicide prevention.  This will be best achieved by local areas implementing multi-agency suicide prevention plans that are informed by local data and tailored to address the challenges in each area.

 

Local suicide prevention plans should clearly set the case for suicide prevention and agree indicative targets and trajectories for the reduction in suicides, to support transparency and monitoring locally over the period.  Multi-agency groups should be established to support delivery of the plan with clear objectives for delivery.  As well as engaging Health and Wellbeing Boards, multi-agency groups should include a wide range of local organisations covering public health, NHS (including primary and secondary care), voluntary sector, emergency services and criminal justice services.

 

Public Health England has refreshed the practice guide10 to support local areas in developing these plans, which it expects to publish in September.  This will be followed by a series of masterclasses held across the country.

 

The National Institute for Health and Care Excellence (NICE) is also developing a guideline on suicide prevention11 expected in 2018 which will provide further evidence and advice of what works well to support local areas to implement effective local suicide prevention interventions.  The scope of the guidance includes public health interventions as well as guidance for the NHS and custodial settings.

 

In 2015, the Government announced a number of ‘Zero Suicide’ pilots12, based on a model of suicide prevention from Detroit, USA.  We are analysing the early outcomes of those pilots.

 

Prevention

 

Effective suicide prevention is key to supporting people before they reach the point of suicide.  Public Health England is developing a Mental Health Prevention Concordat14 to be published next year which will include a focus on suicide prevention.   Public Health England provides a wide range of guidance to local authorities to support them in developing local plans, identifying high risk groups and high risk suicide locations, and working with specific groups such as the LGBT community.

 

Self-harm, included attempted suicide, is the single biggest indicator of suicide risk and should be addressed as an issue in its own right.  The Department of Health continues to fund data collection to identify and monitor trends13. NHS England will plans to lead development of an evidence-based treatment pathway for self-harm during 2017/18 and 2018/19.

 

The number of suicides by children has remained low but there is a growing body of evidence that shows early intervention in mental health should start with children and young people, including mental health awareness, promoting mental health and wellbeing and encouraging open discussions about mental health and supporting children and young people to seek help when needed. 

 

Schools and colleges have a key role to play in promoting good mental health. The Department for Education is supporting schools through a number of activities, including funding the development of Personal, Health, Social and Economic (PSHE)14 guidance and age-appropriate lesson plans on mental health, publishing guidance on the provision of high-quality school-based counselling and on mental health and behaviour, and funding a joint pilot (with NHS England) to test how having single points of contact in schools and mental health services can improve initial support and quick referrals to specialist services. 

 

High Risk Groups

 

At a national level action is focused on targeting high risks groups and especially male groups.  This will require innovative ways of targeting men, especially middle-aged men, and undertaking further research to understand the barriers that prevent them from seeking help and which interventions and services would be most effective to meet their needs.  This may include promoting help-seeking through online services, through sport and other common interests. Local suicide prevention plans should be focused on reducing suicides in high risk groups such as men

 

Alcohol and/or drug use is a major risk factor for both suicide and self-harm.  Public Health England and NHS England are collaborating on how to improve services providing care for people with co-morbid mental health and substance misuse problems, such as closer working between alcohol care teams and liaison mental health teams in acute general hospital settings.

 

Action will be required across other sectors where people are at higher risk, including people in contact with health services and criminal justice services.

 

NHS

 

NHS England strongly supports the goal of suicide prevention as a priority for the health and care system which requires the full range of NHS services to play their part and work together to tackle this complex public health challenge.

 

Between 2003-2013 patient suicides, defined as people who have been in contact with mental health services in the 12 months prior to their death, accounted for 28 percent of suicides in England.  Although inpatient suicides have continued to fall – more than halving between 2003 and 2012 – the number of suicides of patients in the community have steadily increased over the same period.  This reflects both improvements in patient safety in hospitals and the changing model of care to more provision of mental health care in the community. 

 

Crisis Care

 

The Five Year Forward View for Mental Health recommended new investment to improve 24/7 mental health crisis response services across the NHS. The Mental Health Crisis Care Concordat15 published in 2014 sets out how national partners will work together to improve crisis care for people of all ages and it articulates the standards of response that people should expect from local public services working together.  Every area in the country now has a multi-agency local action plan in place.  New local suicide prevention plans should dovetail with these Concordat action plans and other relevant initiatives such as Local Transformation Plans for Children & Young People’s Mental Health & Wellbeing.

 

Primary Care

 

Nine out of ten adults with mental health problems are supported in primary care and it is well-known that people who show depressive symptoms are more likely to attempt suicide. NHS England is developing its overall primary mental health care offer including exploring new models of enhanced primary care and training for staff.

 

Perinatal Care

 

Suicide is now one of the leading causes of death in pregnant women and new mothers.  Almost a quarter of women (23%) who die between six weeks and one year after pregnancy die from mental-health related causes, and one in seven women die by suicide. The Government has invested an additional £290 million to provide specialist mental health support to pregnant women and new mothers.

 

Workforce

 

The Five Year Forward View recommended that Health Education England develops a workforce strategy to support the implementation of recommendations to transform mental health.  This will include ensuring staff are sufficiently trained to provide high quality services.

 

As also recommended by the Five Year Forward View for Mental Health, the Department of Health and NHS England will be working with the Royal College of GPs and Health Education England to ensure that by 2020 all GPs receive core mental health training.

 

NHS England and Health Education are also looking at suicide awareness and prevention training for GPs and GP practice staff.

 

Criminal Justice

 

People in contact with criminal justice services often present with complex mental health, substance misuse and physical health problems.  There was a sharp increase in suicide following release from police custody from 36 in 2011/12 to 60 in 2012/13 and rising to 62 in 2013/14.  HM Chief Inspector of Constabulary published recommendations in 2015 for protecting the Welfare of Vulnerable People in Police Custody (reference) which included a range of improvements including more robust suicide risk assessment. 

 

There were 105 apparent self-inflicted deaths in prison in England and Wales in the 12 months up to June 2016, rising from 82 in the previous 12 monthsThis is a rate of 1.2 self-inflicted deaths per 1,000 prisoners, compared to 1.0 per 1,000 in the previous 12 months. 

 

In 2016 the National Offender Management Service (NOMS) established a Suicide and Self-Harm Project, in conjunction with NHS England and Public Health England, to reduce self-inflicted deaths and self-harm.  This includes improved delivery of the Assessment, Care in Custody and Teamwork (ACCT) care planning process, updating training for staff with prisoner contact, holding regular learning days open to staff from all prisons, reviewing the approach to the use of safer cells, working with the Samaritans to further strengthen the long-established Listener scheme, and improving the support provided in the early days and weeks of custody.

 

Further prison reforms and Government investment to build new modern prisons will help to provide better and safer environments for prisoners.

 

Transport

There has been a long relationship between suicide and the transport framework, specifically the railway network.  The Department for Transport fully supports the British Transport Police’s Suicide Prevention Strategy and will seek to ensure that its aims are fully enshrined in train operating franchise agreements.  The Department for Transport is in the process of considering the specification in the rail franchise agreements of compliance with the strategy, and with the Samaritans’ 12-point plan for suicide prevention. In addition the Policing and Crime Bill currently before the House of Lords includes amendments to the Mental Health Act 1983 which will enable police to intervene more readily when someone appears to be considering suicide on railway property.

 

Media reporting of suicide, the effectiveness of guidelines for the reporting of suicide, and the role of social media and suicidal content online

 

The Department of Health works closely with the Samaritans which leads on providing advice and guidelines16 to the media on the responsible reporting of suicide, which is effective in reducing the likelihood of publicising methods of suicide, especially new methods.

 

Studies into the influence of the internet and social media have made mixed conclusions, recognising both the negative impact of promoting suicide methods but also through the support and advice that is available online for people seeking help.  The Samaritans works with a range of stakeholders to explore ways of making online content safer from a suicide prevention perspective.  It recently worked with Facebook to update its online suicide prevention toolkit.

 

The value of data collection for suicide prevention, and the action necessary to improve the collection of data on suicide

 

Good quality data on suicide is key in monitoring trends and identifying any new trends in key groups and new methods of suicide.  As well as the Department of Health supporting national data collection and analysis, Public Health England provides guidance and tools to local authorities to encourage the use of better local data to inform suicide prevention plans, including conducting suicide audits.

 

The Department of Health supports the following national data collections:

 

Conclusion

 

The Department of Health continues to lead the cross-Government response to suicide prevention, as well as supporting the valuable role that local organisations and the voluntary and charitable sectors play.  The Department of Health expects to publish the next annual progress report of the cross-Government strategy ahead of the Committee’s inquiry in October.  The report will set out how we are increasing our efforts in a number of areas to drive the implementation of the National Strategy. 

 

September 2016

 

 

Figures

 

Figure 1 – Suicide rates England

 

 

 

Figure 2 – Suicide rates UK

 

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Source: Office for National Statistics, 2016

 

References

 

  1. Suicide in the England and Wales: 2015 registration, ONS (2016): https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/causesofdeath/adhocs/006086suicideinenglandandwales2015registrations
  2. Preventing Suicides in England: A cross-Government outcomes strategy to save lives (2012): https://www.gov.uk/government/publications/suicide-prevention-strategy-for-england

https://www.gov.uk/government/publications/suicide-prevention-report

https://www.gov.uk/government/publications/suicide-prevention-second-annual-report

  1. Five Year Forward View for Mental Health, NHS England (2016): https://www.england.nhs.uk/mentalhealth/taskforce/
  2. National Suicide Prevention Alliance: http://www.nspa.org.uk/
  3. Suicide Bereavement Support Partnership/Support After Suicide: http://supportaftersuicide.org.uk/
  4. National Confidential Inquiry into Suicide and Homicide: http://www.bbmh.manchester.ac.uk/cmhs_ARCHIVED_20160801/research/centreforsuicideprevention/nci/
  5. Mental Health Promotion and Prevention: The economic case, London School of Economics, Centre for Mental Health (2011): http://www.lse.ac.uk/businessAndConsultancy/LSEEnterprise/pdf/PSSRUfeb2011.pdf
  6. Time to Change programme: http://www.time-to-change.org.uk/
  7. Guidance for developing a local suicide prevention action plan, Public Health England (2014): https://www.gov.uk/government/publications/suicide-prevention-developing-a-local-action-plan
  8. Preventing Suicide in Community and Custodial Settings, NICE (2016): https://www.nice.org.uk/guidance/indevelopment/gid-phg95
  9. Zero Suicide pilots launched, Department of Health (2015): https://www.gov.uk/government/news/nick-clegg-calls-for-zero-suicides-across-the-nhs
  10. Multi-Centre Study of Self-Harm: http://cebmh.warne.ox.ac.uk/csr/mcm/
  11. Personal, Social, Health and Economic Education, Department for Education (2013): https://www.gov.uk/government/publications/personal-social-health-and-economic-education-pshe
  12. Mental Health Crisis Care Concordat, Department of Health (2015): https://www.gov.uk/government/publications/mental-health-crisis-care-agreement
  13. Media guidelines on reporting suicide, Samaritans: http://www.samaritans.org/media-centre/media-guidelines-reporting-suicide
  14. Ministerial Council on Deaths in Custody: http://iapdeathsincustody.independent.gov.uk/about/ministerial-council-on-deaths-in-custody/