I sometimes wonder about the timing of government reports. I'm sure most of them are pure coincidence. Yet, here we are at Easter (goodness the year is flying by) a time in the Christian calendar to remember the death of Christ and his resurrection. Although this is supposed to be a joyous time, when Christians celebrate Christ's resurrection, Easter has always seemed to me to be about Death. Christmas is about Birth; Easter about Death. I'm not a practicing Christian so I don't really understand it all, but since childhood that's they way it has seemed. Anyway, I was struck by a positive headline on the BBC web site last week. "Suicide rate falls to record low" (full article here). The National Institute for Mental Health in England (NIMHE) have just published their latest progress report on the National Suicide Prevention Strategy for England. So, for me, a report about Death, at Easter, seemed appropriate.
Now I've been called to a number of suicides over the years, most of them were hangings and most, I have to say, were men. All of them, as far as I can recall, have been outside of the government's 'vulnerable' groups – they've mostly been middle aged and middle income. I find these jobs particularly harrowing; not just because of the circumstances but how, in nearly every case, it was so unexpected. Relatives are just left reeling because they never get closure on that crucial question: Why?
I had an in-law who committed suicide. A young man desperately searching for his role in life. He had an elder brother, (now an eminent lawyer) who he had constantly tried to emulate even though his brother's strengths were intellectual and John's (not his really name obviously) were more practical. I'm not a psychiatrist, but I reckon he was probably bi-polar. On a good day he was the funniest, most entertaining person I have ever known. On a bad one he was just an angry young man. I can relate to that. He was the same as me 20 odd years ago. When his marriage fell apart he did his best to put his life back together; moved away, made a new start, went back to university as a mature student and, although we didn't speak that often, he seemed to be far more positive about things than I'd ever known. Then, one beautiful spring morning, he drove up to one of his favourite beauty spots in the Peak District and put a hosepipe to the car exhaust.
I have never come to terms with it. Why? I'll never know. In a search for answers I got hold of James Hillman's seminal work "Suicide and the Soul". With the greatest respect to Dr Hillman, 98% of it was way over my head but I think I did learn one thing. Suicide is not a last cry for help, it's a 'positive' act for someone who desires the ultimate change. With that in mind I was intrigued to know how the Health Service are setting about lowering the suicide rate. People who are feeling low, desperate, in need of help, cry out in various ways; some phone the Samaritans, others attempt para-suicide: drug overdoses, self harm, etc (I know this is a rather simplistic view but then I'm not a mental health specialist). Suicides, as I understand it, are past all that. They know what they want, and it's not help.
Having a day off today, I thought I'd plough through the report and see what positive steps are being taken. How do mental health specialists identify those members of society at risk? especially if those members are not crying out for help – they've already decided what they're going to do.
The report is positive about the success rate of the strategy so far:
Latest available data (for the 3 years 2002/3//4) show a rate of 8.6 deaths per 100,000 population – a reduction of 6.6% from the 1995/6/7 baseline.
The prison population seems to be particularly vulnerable and lots of initiatives are taking place:
Achievements during the past year include an increase in the number and range of prisoner peer support schemes, improvements in reception procedures in some establishments, including the establishment of dedicated ‘First Night Centres’, improved staff skills and knowledge via newly developed training courses; and further expansion in mental health in-reach services into prison.
This is to be welcomed and I'm not going to comment on these initiatives other than to say the prison population is probably the easiest one to influence: their whereabouts are known, their behaviour can be watched and their access to harmful objects/drugs can be controlled. If we can reduce or eliminate suicides here then that's excellent, but my concern in this piece is with the wider community.
In-house mental health patients, and those recently discharged are considered to be at high risk. Consequently the National Patient Safety Agency (NPSA) have been tasked with
"identifying and understanding the complex inter-relation of systems that exist on acute psychiatric wards and how these can be managed to improve safety."
Anyone thought to ask the doctors and nurses who work there?
The Bedfordshire 'Breakout' programme (pp 29) and Southampton's 'No Limits' (pp30) caught my attention. They seemed to be the only ones that are actually about engaging their potential target audience (young men): using role models, training initiatives and interactive projects with those most at risk.
As for the rest of the report, from what I can gather, there seems to be an excessive amount of 'talking shop'
- Lots of 'strategies ' going on. Sunderland, Doncaster, the North East, Hull, Humber are all mentioned. Plenty of 'informed' people sitting around in committees discussing proposals over tea and a plate of bourbons then.
- There'll also be "workshops and public health events beginning with suicide prevention and rural settings early in 2006." Excellent. More tea and coffee and perhaps a few custard creams this time.
- and "Mental health awareness sessions have been carried out at 8 London underground stations". For staff I assume or are these new 'venues'?
- A series of Master Class Forums have been delivered.[Eastern region]
- An Exhibition Fayre was held in Bedford to showcase the 21 mental health promotion projects that had been developed for young men.
- Keynote presentations at stakeholder events.[South West]
- …and two residential events have been developed and run jointly with the regional CAMHS support service.
- …[and] a working group has been established within the development centre.
- The Development Centre has worked proactively to deliver bespoke workshops.[North West]
- …[and] The quarterly suicide prevention practitioner’s network has continued to meet over the year. More tea and biscuits then.
- ..[they've also] established partnerships … through the development of a strategic collaborative. Excellent. Networking. Makes the NHS go round.
- Tees and North East Yorkshire NHS Trust has launched a Suicide Prevention Charter – that'll help then!
Now if you're going to set up lots of collaboratives, strategic partnerships, working groups, forums, master classes or whatever, it's going to create more 'jobs for the boys'.
- A new post around Suicide Prevention in acute service areas across the West Midlands Health Authority.
- A new full-time programme lead post has been created for the North East of the region.
- A Fellow for Prison Mental Health Awareness Training has been appointed.
There are some positive steps which center around know suicide hotspots, for example:
Potential measures include the use of CCTV at train stations, provision of signs & posters with helpline numbers on road bridges and at rail stations and consideration of the use of safety barriers at key access points;
Is there any evidence to support these initiatives? Where there's a will there's a way. I would have thought people intent on suicide are not going to be in the right 'frame of mind' to read notices and will find a way to satisfy their desire for 'change' regardless of restrictions.
Some initiatives just seem a bit 'oddball' to me.
Newcastle, North Tyneside & Northumberland NHS Trust is leading on a regional campaign to help local media focus on responsible reporting of mental health problems and the incidence of suicide.
Where's the evidence that people commit suicide as a result of 'poor' media reporting?
And, of course, no strategy in the health service would be complete without an I.T. component.
- The electronic audit tool for environmental, policy and practice risks has been updated as edition 1.5 and has been piloted in two NHS trusts.- Goodness me. Is this an NHS computer system that actually works? What does it do? How much did this one cost?
- Development of the PCT-based suicide audit toolkit and database.[East Midlands]
Plus some good old gobbledygook:
"A literature review has also begun which will produce auditable standards for both environment and practice that will be referenced to inquiry reports and guidance documents."
Help! What does that mean in plain English please?
In the end I was struck by this overall assessment:
Extra investment in mental health services in the NHS Plan has led to significantly improved community mental health services. In particular, investment in three priority areas has almost trebled since 2001/02 from £78 million to almost £229 million. This means that there are now;
• 343 crisis resolution teams providing intensive support for those in mental health crisis;
• 262 assertive outreach teams providing intensive support for people who are difficult to engage with;
• 109 early intervention teams providing assessment and care for individuals experiencing the first onset of psychosis.
Excellent, but where in all of this do John and my middle aged, middle income suicides fall? They don't count as vulnerable. They're not difficult to engage with. And, from what I can tell, they weren't psychotic. But they were in crisis and didn't know where to turn. They just reached a point in their life where (to them) there was no other option. What are we doing to help them before they get to this state? Nothing, as far as I can tell – and that makes me really despondent.
One last thought. This is the National Health Service we're talking about. To my mind if you're in need of, or using, health services then you're a patient – surely? But no, silly me, they're all 'service users' now. Is this the latest euphemism? And how does it help, not calling them patients?
Once again Magwitch is left scratching his head and wondering what on earth is going on.