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Suicide Reduction Plan? Oh really?

January 29, 2015

By Basket Press

Another week, another set of politicians making health pronouncements and, oh look, it’s an area I know something about!

Before I go into that, can I just make it clear that I have no more against Nick Clegg than I have against any other senior politician who has overseen cuts to services then tries to claim that they are “campaigning” in support of those services. If he shut up I wouldn’t need to criticise quite so much.

On the surface this looks unarguable: no-one in Mental Health (MH) services wants to see suicides. However, once we scratch below the surface it all becomes more complicated.

Back in the latter days of the last century Louis Appleby produced the National Confidential Inquiry Into Suicide and Homicide (see here for the latest reports following on from that) which was an excellent piece of work and laid out a framework for reducing deaths by suicide in patients of MH services. Admittedly some of this was the bleedin’ obvious which should have been done years before, such as removing ligature points on wards. The Office for National Statistics figures on suicide rates can be found here, showing a broad downward trend since 1981 to a low point in 2007 before rising slightly since.

The risk factors for suicide are well known and researched in the extensive UK suicidology literature (there are too many references for me to link to so I will stick with this one ) and MH trusts train their staff in risk assessment for suicide and self harm. They also provide training to other health care staff, children’s services, education and the like (reference: me, as I used to do this and helped write training packages).

So what is being proposed that is any different to what MH services were already trying to do or wanted to do before they were cut over the last 5 years?

Why yes, let’s import an “idea” from America! Details are in short supply on the Henry Ford website, presumably for reasons of “commercial confidentiality”, but what we seem to be looking at is a streamlined care pathway dealing mostly with depression. This again is pretty unarguable and the numbers they quote look good. But again is it that simple?

No, it is not at all that simple! This is an American system, so it is not available to the entire population only to those who have the means to pay (check the section on “Billing” in the link I gave)…This automatically excludes some of those at highest risk of suicide and depression and other chronic MH conditions. This is not comparable to what the NHS has to do: we cannot exclude any potential patients on the grounds that they cannot pay. Now, if I was able to exclude many of the highest risk groups from my service I could rapidly bring suicide rates in my patient population down to zero as well! Although it makes the task far easier, it’s clearly not an option available to NHS services!

This is such an obvious confounding factor that I cannot believe it’s being taken seriously and suggested as an exemplar of what we should do in the UK. I would give this more credence if Henry Ford could show the same apparent success rate while providing a service to the entire population of their region. But they don’t, so I can’t. And it took me no more than a couple of minutes going over Henry Ford’s website to realise that…

Which makes me wonder why certain politicians are so convinced.

Let me repeat, because it bears repetition: the numbers they quote for reduced suicide rates are from within their patient population, i.e. known to the service and actively seeking treatment; not the wider population of Michigan nor even Detroit. This is NOT a general figure but one from within a specific and selected group which already excludes many of those at highest risk of suicide.

To try to restore a sense of perspective here I shall quote some figures gathered by a former colleague in adult liaison psychiatry in a trust I worked in (these are in keeping with national figures): over half of those who killed themselves in the two year study period had not even seen a GP in the four weeks prior to their death; only a quarter were in current contact with MH services and nearly half had never had any contact with MH services; around 40% were unemployed, compared with a regional unemployment rate of 8%; suicide rates were three times higher in those living in the most deprived areas than even in areas of intermediate deprivation. Those last two figures surely point to a significant, and very high risk, group that would be without health insurance in the US. In what way is this comparable to the Henry Ford figures being trumpeted? The short answer is – it isn’t.

And in the UK, as I have pointed out in previous posts, MH services, both community and in-patient, have been cut in the last five years. Teams set up to work specifically with populations at high risk of suicide have been disbanded or cut…And that is before we throw in socio-economic factors over which MH services can exert no control.

And yet this is being reported completely uncritically: there was a representative of Henry Ford interviewed on Radio 4 and no hard questions, like those points above, were asked; The Guardian article I link to at the top avoids any questions and doesn’t have comments enabled; and the politicians get a free ride yet again and their responsibilities for much of the current situation are avoided as usual.

I don’t know which is worse, opportunistic politicians or craven journalists. Either way, neither are helpful and serve to obfuscate what is really happening and what might be done.

  1. Basket Press permalink

    Addendum: While this piece was awaiting publication, if you will, a piece appeared in The Guardian – – which further highlights the lack of joined up policy making and commissioning.

    It seems to me highly likely that the current commissioning regimes will worsen problems as strategic oversight disappears, threatening national or regional specialist services.

  2. lesley58 permalink

    This is worrying. Often those making the decisions have no idea of what it is like to suffer mental health issues or have a family member who suffers.

    We have found in trying to ensure our family member has decent treatment it is an easy option for a Trust to cite confidentiality issues and even worse cause relationship problems within the family.

    A sufferer at their most vulnerable will have no inclination to fight for treatment, if that opportunity is taken from the family too it is all too easy to see how Trusts get away with providing sub standard care.

  3. Basket Press permalink

    Thanks for commenting, Lesley.

    You raise some interesting points: it is more complicated than trusts hiding behind confidentiality, as the way our consent laws “work” is a mess and does not always make it easy to share information about treatment with family members, the upshot being what you say. That said, I am not convinced that standards of training around consent are very high, which is the responsibility of trusts (it isn’t part of the “ticky box” list required for foundation trusts, for example, so it isn’t accorded a high priority compared to those areas which ARE).

    To change this would require some political will and action but I am not holding my breath (you might have gathered that my opinion of how politicians treat mental health issues is not great and that my opinion of much NHS management isn’t much better).

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