Aneurin Bevan University Health Board Response
Health, Social Care and Sport Committee
Consultation on Suicide Prevention
We have provided comments on the consultation topics below, from an Aneurin Bevan University Health Board perspective where there is relevant information, expert opinion or evidence available.
1. The extent of the problem of suicide in Wales and evidence for its causes - including numbers of people dying by suicide, trends and patterns in the incidence of suicide; vulnerability of particular groups; risk factors influencing suicidal behaviour.
2. The social and economic impact of suicide.
3. The effectiveness of the Welsh Government’s approach to suicide prevention - including the suicide prevention strategy Talk to me 2 and its impact at the local, regional and national levels; the effectiveness of multi-agency approaches to suicide prevention; public awareness campaigns; reducing access to the means of suicide.
4. The contribution of the range of public services to suicide prevention, and mental health services in particular.
5. The contribution of local communities and civil society to suicide prevention.
6. Other relevant Welsh Government strategies and initiatives - for example Together for Mental Health, data collection, policies relating to community resilience and safety.
7. Innovative approaches to suicide prevention.
1. The extent of the problem of suicide
The Public Health Wales Observatory provides epidemiological data for suicide for the Aneurin Bevan University Health Board (ABUHB) area. Between 2002 and 2014, the suicide rate in Wales and the ABUHB area overall, has remained fairly stable (see Figure 1). There is more fluctuation in rates at a Local Authority level, due in part to the relatively small numbers involved. There is a need to exercise caution in the interpretation of suicide registration data, particularly on a small area basis and over shorter timeframes, because of the small numbers, delays in registration and recording differences can produce unreliable rates. The limitations of the data presents challenges for planning suicide prevention and responding to community needs.
Figure 1 – Trends in suicide rates in Wales, Aneurin Bevan University Health Board and local authorities, 2002/06 – 2010/14.
Overall in the ABUHB area there were 234 suicides registered in the period 2010-2014. Figure 2 compares the suicide rates for 2010-2014 across Wales, and indicates that none of the Gwent local authorities have significantly higher rates than the Wales average.
Figure 2
– Comparison of suicide rates across Wales,
2010-2014
Figure 3 – Comparison of Suicide Mortality, persons aged 15 to 24, 2002-2011 (Public Health Wales, 2013)
Figure 3 compares the suicide rates of young people aged 15-24 for 2002-2011 across Wales. The average age specific rate for Gwent is 5.7 which is significantly lower than the Wales average of 8.6. None of the Gwent local authorities have significantly higher rates than the Wales average.
Vulnerability of particular groups
There is no local evidence available for the suicide risk in specific groups. ABUHB are focussing on priority groups as outlined in the National guidance (in line with the Talk to Me 2 Strategy). These are:
|
Priority People |
Priority Places |
Priority Care Providers |
|
Men in mid life Older people over 65 with depression and co-morbid physical illness Adult Prisoners Children and young people with a background of vulnerability People in the care of mental health services including inpatients People with a history of self harm |
Hospitals Prisons Police custody suites Workplaces Schools, Further and Higher Education establishments Primary care facilities Emergency departments Rural areas Deprived areas |
People who are first point of contact or first responders, including: Police Fire fighters Welsh Ambulance staff Primary care staff Emergency department staff |
The priority groups, particularly those from the most deprived areas, should be explicitly targeted based on the intelligence we have. However other at-risk groups will also benefit from universal interventions to improve mental health and support protective factors, reduce stigma and increase help seeking behaviour.
Interventions to reduce suicide in children and young people should tackle the specific issues identified in the Child Death Review 2006-12 (Public Health Wales, 2014) including:
· Bullying (mostly school related)
· Misuse of drugs and alcohol
· Physical, emotional and sexual abuse
· Self-harm
· Deprivation
· Social connections
Risk factors
Socio economic influences such as poverty (of opportunity as well as financial) and social cohesion play important roles in mental wellbeing. Addressing these psychosocial risk factors requires a wider approach from across society. Essential to prevention is raising children in a society that promotes and facilitates positive early attachments, and prevents and mitigates the effects of Adverse Childhood Experiences.
An education system that builds skills, confidence and resilience is key. Bullying, particularly cyber bullying and the access to web sites that support and promotes suicidal behaviour, also needs to be addressed.
Anecdotal evidence from GPs, as expressed by the Primary Care Cluster Lead for Mental Health, suggest an increase children expressing suicidal thoughts and ideation and rising rates of self-harm as a way of managing distress, particularly in young adults. In children’s services some practitioners feel unskilled and unsupported to deal with mental health issues leading to an over-reliance on mental health services. Improved undergraduate and postgraduate training for children services on mental health and wider wellbeing issues are therefore essential.
A society wide understanding of resilience would be beneficial. A life free of adversity is not possible, however, understanding that resilience is often developed by being supported to successfully overcome small adversities, is key. Early year’s attachment and exploration of risk through play are the important building blocks of resilience.
2. The social and economic impact of suicide
While there is no hard, local evidence on the social and economic impact of suicide to report, the ripple effect that suicide has on a community is recognised and cannot be underestimated. There are specific financial costs to public services arising from the acute response, legal process and support services for families, colleagues and schools. There are other economic impacts to businesses, for example, when major transport routes are closed.
3. The effectiveness of the Welsh Government’s approach
The Government’s approach has been welcomed, in particular the supporting evidence base and work on bridge design and media reporting. It’s unclear from a Health Board perspective whether there will be additional resources at national level, or whether this will be reliant on the enthusiasm and expertise that can be drawn from local areas.
4. The contribution of the range of public services
The Local Public Health Team are members of the South East Wales Regional Suicide Prevention Forum with representatives from Cardiff and Vale and Cwm Taf University Health Boards who are leading suicide prevention work in these areas. The group are able to share information and engage national and regional-level agencies such as Network Rail and South Wales Fire & Rescue Service.
Representatives of the Regional Suicide Prevention Forum attend the National Advisory Group on Suicide and Self-harm (NAG), in order to inform national action and policy. Locally, we see the NAG as playing an important role in providing specialist advice, guidance and ‘once for Wales’ resources to support local action. For example, it has been successful in training and lobbying Welsh media outlets to improve reporting of suicide, and has co-ordinated production of ‘Help is at Hand’. Both these interventions would have been difficult to do effectively at a local level.
However, we recognise that a lack of resources to complete work centrally sometimes limits the capacity of the NAG to progress planned pieces of work, and this has hindered the progress of the local action plan. For example, there was a delay in the production of local planning guidance as well as a national dedicated website which would allow timely access to information and resources (e.g. an up-to-date list of quality assured training courses to support the national training framework). We note that in other nations these pieces of work are either commisioned separately or a funded post supports work undertaken nationally.
The recently issued local suicide prevention planning guidance advocates for more detailed analysis of suicide data to build a picture of groups most at risk and enable effective local suicide prevention work. Due to issues associated with access to data and interpretation of small numbers locally, we consider that real-time suicide surveillance and building of a suicide prevention database is best co-ordinated at a national level. Co-ordination of data collection nationally will improve the quality of the evidence and ensure most efficient use of resources as the numerous organisations could potentially be involved in collating and providing data.
At local level effective implementation of Talk to Me 2 is dependent on a multi-agency partnership. Aneurin Bevan Gwent Public Health Team have been leading on the implementation of a local response to Talk to Me 2, alongside partners. The Gwent action plan is implemented by a multi-agency Suicide and Self-Harm prevention Group, accountable to the Gwent Mental Health & Learning Disabilities Partnership Board. Progress is reported as part of monitoring against the national strategy, Together for Mental Health in Wales.
The Gwent Suicide and Self-harm Prevention group includes representation from ABUHB (Mental Health & Learning Disabilities Division, Unscheduled Care Division, Primary Care and Community Division), Gwent Police, South Wales Fire & Rescue Service, Welsh Ambulance Service, Communities First, Samaritans, Mind, Social Services, National Offender Management Service, Prison Healthcare Team and Community Health Council.
Local progress since 2015 includes:
Promoting Mental Well-being and Resilience
There are a range of universal actions being developed to improve mental well-being in the ABUHB area, which are an essential foundation for preventing suicide and self-harm, including:
· Integrated well-being networks developing on an NCN footprint. Work is on-going to strengthen the network that exists to ensure Foundation tier services form an integral part of a holistic approach to community well-being, reducing silo working.
· Mental well-being ‘Foundation Tier’ provision has been developed by the Primary Care Mental Health Support Service (PCMHSS) through the Road to Well-being programme www.wales.nhs.uk/roadtowellbeing
· A new multi-agency model for Children and Families PCMHSS is being piloted in Newport with plans to roll out across Gwent
· Four of the 12 NCNs have prioritised the National Clinical Priority - Early Intervention CAMHS (Newport North, Newport East, Caerphilly South and Blaenau Gwent West)
Interim Gwent Suicide Prevention Action Plan
Specific suicide prevention actions undertaken 2015-2017 include:
· A Gwent Mental Health Crisis Care Concordat Delivery Plan is in place, and a programme has been initiated to develop a ‘Whole Person, Whole System Mental Health Crisis Support Model’ to provide a timely, person-centred, effective and efficient 24/7 response for those in crisis and their carers across the whole care system in Gwent. Elements already in place include Approved Mental Health Professionals in the Police Control Room and a protocol for appropriate conveyance of people in mental health crisis.
· Mental Health & Learning Disabilities Divisional Plan includes action on suicide prevention among mental health service users including anti-ligature measures
· Suicide prevention training (ASIST and Safetalk) provided for South Wales Fire & Rescue Service personnel who respond frequently to suicide-related incidents. Training delivered to 120 staff across Gwent, to ensure at least one person on each shift is trained. Adapted training has been delivered to Gwent Police personnel.
· When the national training framework is published, there are plans to identify organisational leads to ensure relevant suicide training is provided to front line professionals and review through an annual audit.
· ‘Help is at Hand’ guide for people bereaved by suicide promoted locally
· South Wales Fire and Rescue Service have identified places where they are frequently called to suicide-related incidents across the region, including several bridges in the Newport area. They are working with the Samaritans and Newport Local Authority to affix signage to bridges in Newport, and will continue to work with partners to make identified sites and new structural developments safer.
5. The contribution of local communities and civil society
The Health Board organised a two day workshop on assets based community development lead by Cormac Russell, Managing Director of Nurture, who is an internationally renowned expert on Asset Based Community Development.
6. Other relevant Welsh Government strategies and initiatives
ABHUB consider that other Welsh Government strategies and initiatives such as the Well-being of Future Generations (WBFG) Act, Prosperity for All, Social Services and Well-being (Wales) Act, Together for Mental Health, Together for Children and Young People, Adverse Childhood Experiences should impact on suicide and self-harm prevention. The contribution that each programme of work makes to the suicide and self-harm prevention needs to be acknowledged and linked together.
The proposed education reforms and promotion of community prosperity across age ranges supported by the WBFG Act and Social Care and Well-being Act have the potential to make a positive impact on mental well-being. However, changes to social benefits (universal credit and changing to PIP) may had a negative impact on mental health and wellbeing and personal resilience causing pressures in primary care as a result.
7. Innovative approaches to suicide prevention.
A research project led Swansea University is being conducted into reduction of suicide in the general population via the use of Structured Professional Judgement in Accident and Emergency Departments.
There are innovative approaches to suicide prevention in Torfaen and Newport high schools around the early identification of psychosis and on-line school counselling.
Summary
The strategy Talk to Me 2 and national guidance has been welcomed and supported locally. Despite a lack of local surveillance data and lack of dedicated resources to support the actions, a local interim action plan was produced, following publication of Talk to Me 2. Progress of the interim plan has been reviewed with partners, against the recent Welsh Government guidance, and actions agreed for the coming years. This plan will be presented to the Mental Health and Learning Disabilities Partnership in January 2018 and submitted to Welsh Government in February 2018.
References
Public Health Wales, 2013. Health of Children and Young People in Wales report; Deaths in Children and Young people
Public Health Wales, 2014. Thematic Review of Deaths of Children and
Young People Through Probable Suicide, 2006-2012