Guidance issued by the National Advisory Group to Regional Fora on local suicide and self-harm prevention planning

Transcription

1 Guidance issued by the National Advisory Group to Regional Fora on local suicide and self-harm prevention planning Local suicide prevention planning Ann John, Alex Glendenning, Sian Price Final version 14 th Nov 2017

2 Foreword At the time of writing this, we are seeing a major change in people s attitudes to mental ill health. This has been in part due to a groundswell of people, some in the public spotlight, who have shown willingness to share the personal experiences of their own battles with mental ill health. Consequently, there is a palpable sense that society is becoming more open to discussion about mental health issues; this represents a major step forward in de-stigmatising mental illness. It is now widely accepted that mental health issues, and thoughts of suicide, can affect anyone, irrespective of background or social status. Mental ill health does not discriminate between people, so we should not discriminate against people with mental ill health. We need a collective effort across the whole of society to prevent suicide. It is the responsibility of all of us - as friends, family members, colleagues, or members of our local communities who interact with each other day to day. There is no miracle antidote to relieve feelings of suicide. However, suicide is largely preventable if risk factors are addressed effectively. At a national level, the Welsh Government has laid the groundwork for a concerted approach to suicide prevention. Talk To Me 2, developed by the National Advisory Group on Suicide and Self Harm, sets out our approach to co-ordination and targeting action towards care providers, people and places more likely to be associated with suicide. However, it is the work done at the local level which is vital to the prevention of suicide. People working directly with those who are struggling with dark feelings are often the helping hand which guides them to the light at the end of the tunnel. Working at a local level requires tenacity, empathy, stoicism, foresight and understanding. This guidance brings together the combined strength of different agencies to plan and implement actions to prevent suicide. It will help teams to co-ordinate work locally and to reach out to people in every corner of Wales. We still have a long way to go in fully breaking down the barriers around mental health. Together we can act as agents of change by doing everything we can to prevent suicide. Dr Frank Atherton Prif Swyddog Meddygol Cymru Chief Medical Officer for Wales 1

3 Contents Foreword... 1 Contents Introduction The national context for a focus on suicide prevention Wales National Suicide Prevention Strategy Talk to Me Together for Mental Health Mental Health Crisis Care Concordat Mental Health (Wales) Measure Outcomes Frameworks Public Health Outcomes Framework for Wales NICE guidance Regional Fora cross sectoral, collaborative working Membership Terms of reference Regional Fora Involving health and wellbeing boards Working with Crisis Care Concordat networks Working with primary care Involving people affected by suicide Working with the community and voluntary sector Disseminating Help is at Hand Making sense of national and local data Understanding your local data and introducing real-time suicide surveillance Nationally available data Office for National Statistics Public Health Outcomes Framework data Locally sourced data Local coroner s data Real-time suicide surveillance Building a suicide prevention database Developing a local suicide prevention strategy What to include in a local suicide prevention strategy Building the case for local suicide prevention work Return on investment Mapping the strategy to the wider health and wellbeing agenda Accountability Local approaches to strategy development Priority areas for all local suicide prevention strategies Developing a multi-agency action plan

4 5.9 What to include in an action plan Monitoring and evaluating suicide prevention strategies and action plans Setting outcome measures - building on improving services for self-harm Setting aims and objectives Collecting data Using a theory of change approach Reporting on evaluation Points to remember Ideas for action Reducing the risk of suicide in Priority People and Priority Places Strategic Objective 1 Improving awareness and understanding of suicide and self harm amongst the public and those frequently coming into contact with people at risk - Suicide prevention training Children and young people The Saving and Empowering Young Lives in Europe (SEYLE) project People who are vulnerable due to economic circumstances Strategic Objective 2 Delivering appropriate responses to personal crises, early intervention and management of suicide and self harm Strategic Objective 3 Providing better information and support to those bereaved or affected by suicide Strategic Objective 4 Supporting the media in delivering sensitive approaches to suicide and suicidal behaviour Strategic Objective 5 Reducing access to the means of suicide and self harm Strategic Objective 6 Supporting research, data collection and monitoring Appendix Appendix Acknowledgements

5 1. Introduction This document aims to help all areas in Wales develop their local prevention strategy. Section 5 pages [Developing a local suicide prevention strategy] outlines how to do this and what Welsh Government, Health boards, Local Mental Health Partnership Boards and Regional partnership boards would expect to be contained within the plan. At Section 6 [Ideas for action] there is an ideas for action section to help inform local plans to better meet local needs. There are three main indicators of active local suicide and self-harm prevention activity in Wales: 1. Developing a suicide prevention strategy and/or action plan that is based on the national strategy Talk to Me 2 and local data, which sets out specific actions that will be taken to reduce suicide risk in the local community 2. Participating in Regional Forums (North Wales, NW; South East Wales, SEW; South West Wales, SWW) and involving all key statutory agencies and voluntary organisations whose support is required to effectively implement the plan throughout the local community 3. Completing a suicide audit by collecting data about local suicides from sources such as coroners and health records, to build an understanding of local factors including high-risk demographic groups where resources allow. 4

6 2. The national context for a focus on suicide prevention Suicide is usually in response to a complex series of factors that are both personal and related to wider social and community influences. There is therefore no single reason why someone may try to take their own life. Suicide is best understood by looking at each individual s life and circumstances. It is however important to remember suicide and self-harm are largely preventable, if risk factors at the individual, group or population level are effectively addressed. This requires a public health approach, broader than focusing on services for mental health service delivery, which demands collective action by individuals, communities, services, organisations, government and society. This means no single organisation or government department can take sole responsibility: suicide and self-harm reduction must be cross-governmental, cross-sectoral and collaborative, with shared responsibility at all levels of the community, if it is to have a chance of success. The agenda therefore requires joint working across and between government at all levels, involving health boards, the third sector, and service users and professionals drawn from multiple settings. Real partnership achieves more than individual action and the development of this strategy and action plan reflects that. People who self-harm or people in distress and at risk of suicide may come into contact with statutory or third sector services, in response to their actions or because they are actively asking for help. Wales s suicide and self-harm prevention strategy Talk to Me 2 promotes the importance of a compassionate response to these individuals, encouraging future help seeking behaviour. Those engaging in suicidal behaviours should be encouraged to be active partners in planning and managing their own care. National policy provides the framework for local suicide prevention strategies and action plans. It is important to also consider wider public mental health and wellbeing programmes targeting adults and children: 2.1 Wales National Suicide Prevention Strategy Talk to Me 2 Talk to Me 2 sets out the strategic aims and objectives to prevent and reduce suicide and self-harm in Wales over the period It identifies priority care providers to deliver action in certain priority places to the benefit of key priority people, and confirms the national and local action required. The six key objectives identified by the strategy are: Objective 1: Further improve awareness, knowledge and understanding of suicide and self-harm amongst the public, individuals who frequently come in to contact with people at risk of suicide and self-harm and professionals in Wales Objective 2: To deliver appropriate responses to personal crises, early intervention and management of suicide and self-harm Objective 3: Information and support for those bereaved or affected by suicide and self-harm Objective 4: Support the media in responsible reporting and portrayal of suicide and suicidal behavior Objective 5: Reduce access to the means of suicide 5

7 Objective 6: Continue to promote and support learning, information and monitoring systems and research to improve our understanding of suicide and self-harm in Wales and guide action Some of the priority people that the strategy targets include: Men in mid life Older people over 75 with depression and co-morbid physical illness Children and Young People with a background of vulnerability People in mental health services People with a history of self-harm Priority care providers Police Welsh Ambulance Primary Care workers Emergency department staff Fire fighters Some of the priority places and settings that the strategy targets include: hospitals; prisons; police custody suites; workplaces; schools; further and higher education establishments; primary care facilities; emergency departments; rural areas; and deprived areas. 2.2 Together for Mental Health Implemented in 2012, this is a 10-year Welsh Government strategy whose purpose is to improve the mental health and wellbeing of all people in Wales using mental health services as well as their families. It is based on the principle of co-production, which is the belief that people who use services are experts in their own lives. More information on the strategy can be found here. 2.3 Mental Health Crisis Care Concordat The concordat sets out how those involved in responding to people experiencing a mental health crisis can improve the quality of care and support that is given. These include various partners spanning health boards, police constabularies, third sector organisations and governmental organisations. More information on the concordat can be found here. 2.4 Mental Health (Wales) Measure 2010 This measure passed in the Welsh Assembly is concerned with making provisions for primary and secondary mental health services; assessments for former users of mental health services; and providing independent advocacy of those detained under the Mental Health Act 1983 as well as other people receiving in-patient hospital treatment for mental health. More information on the measure can be found here. 2.5 Outcomes Frameworks The Public Health Outcomes Framework and NHS Outcomes Frameworks include specific indicators for suicide as well as a range of other indicators that are likely to have an impact on suicide. These may be used to influence action to be taken by key stakeholders who have a mandatory duty to report against these indicators. 6

8 2.5.1 Public Health Outcomes Framework for Wales 1 Indicator specific to suicide prevention: 2.6 NICE guidance It is recommended that NICE published guidance is reviewed during the production of a suicide prevention strategy. This practice resource does not reproduce this information. See Appendix 1 for a list of relevant guidance

9 3. Regional Fora cross sectoral, collaborative working There are three Regional Fora in Wales to support the local implementation of the National Suicide and Self-harm Action Plan: North Wales South East Wales South West Wales Regional Fora report to and share minutes with the National Advisory Group to Welsh Government and chairs of the Regional Fora attend NAG quarterly meetings. 3.1 Membership Strong leadership from public health, primary care and mental health services within Health Boards is required to bring together and maintain a multi-agency partnership (Regional Fora) on suicide prevention. The support of elected members is also essential. Membership of a multi-agency suicide prevention group will depend on local context in order to reflect a community wide approach. The group commonly comprises a small number of core members who are formally accountable to their organisations for this role and have terms of reference that may include representatives from: Public health Local Health Boards Primary care providers and Primary Care Clusters Voluntary sector organisations Secondary mental health care providers Emergency services Criminal justice services Local Authority This is not a prescriptive list; the membership of multi-agency suicide prevention groups varies, reflecting the local context: Armed forces British Transport Police Carers organisations Clinical commissioning group Coroner s office Crisis Care Concordat networks Drug and alcohol services Education Emergency services Employers Faith leaders Housing associations Jobcentre Plus and/or benefits advisers Network Rail NHS provider organisations People affected by suicide Police Primary care including GPs Prisons and probation Public health Social services adult and child safeguarding Universities Voluntary sector 8

10 3.2 Terms of reference Regional Fora There is a template to use as a basis for Terms of Reference for Regional Fora (Appendix 1). 3.3 Involving Public Service Boards or Regional Partnership Boards Public Service Boards (PSB), Regional Partnership Boards (RPB) or similar structures bring together key representatives from across health and local authorities in order to establish greater integration between health and social care services and establish joint health and wellbeing related strategies within local areas. As with elected members, it is important to gain the support of one or both of these board as they can help build collaborative working across the local system with joint commissioning and pooled budgets. Enabling the close involvement of primary care and mental health services with public health, alongside areas of public services such as housing and education is vitally important given the wide determinants of suicidal risk. 3.4 Working with Crisis Care Concordat networks There is a network of local crisis care concordat groups across Wales to ensure 24/7 access and care for anyone experiencing a mental health crisis. These groups typically involve close working between health services, ambulance, police, local authority and other local organisations. Given that every area now has a mental health crisis action plan in place it is likely that many individuals and organisations that are also key to suicide prevention will already have been identified and have established means of partnership working. Establishing effective methods of data gathering and intelligence sharing is recommended. It is likely that there will be some overlap in the targeting of particular at risk groups, including those who may be in the care of mental health services. Examples of how suicide prevention work is embedded in Crisis Care Concordat action plans are available at Working with primary care GPs, Primary Care Clusters and other primary care representatives such as pharmacists are key partners in effective suicide prevention, contributing intelligence and leading on targeted interventions. This role is acknowledged in Talk to Me Involving people affected by suicide Suicide prevention work can be greatly enhanced by engaging people who have personal experience of suicide those who have experienced suicide ideation or have been bereaved by suicide. The involvement of service users is an established part of national and local government policy and practice. More recently, an approach based on co-production has become more common in developing policy and services. 3.7 Working with the community and voluntary sector There is a long history of public health and the NHS in Wales working jointly with community and voluntary sector organisations to promote health and wellbeing. 9

11 3.8 Disseminating Help is at Hand Help is at Hand is a self-help booklet developed by Professor Keith Hawton and revised to reflect the Welsh context (Welsh language version also available) by the National Advisory Group. It is aimed at supporting those who experience bereavement by suicide or sudden unexplained death. It contains advice and signposts resources for parents, partners, children and friends, as well as offering advice to those who may come into contact with bereaved people (such as health care professionals, teachers and the police) to assist them in providing help. More information can be found here. 10

12 4. Making sense of national and local data 4.1 Understanding your local data and introducing real-time suicide surveillance Collecting and analysing local data on the number of suicides, the context in which they occur, the groups most at risk and how the picture is changing over time is critical for effective suicide prevention work. Local intelligence informs the development of the suicide prevention strategy, provides an evidence base for action and the means to monitor and review progress. However numbers of suicides in Wales regionally are small and it is always worth discussing data with the Public Health Wales Observatory and the Chair of the National Advisory Group to Welsh Government on Suicide and selfharm prevention 4.2 Nationally available data Office for National Statistics The Office for National Statistics (ONS) provides figures on deaths from suicide in the UK. Data is available to download from 1981 up to 2015 and includes suicide rates by gender, age and by country region of the UK. There is also information about method. It is updated yearly. It is important to note that ONS will not record a suicide until an inquest has taken place and a coroner has reached a suicide conclusion. Due to the length of time it takes a coroner to complete an inquest, half of the total number of suicides registered in the UK in 2014 will have actually occurred prior to It can also be difficult to be sure whether a person intended to take their own life, so if intent is unclear, an open or accidental death conclusion is likely and there may also be a narrative conclusion with a written chronicle of the circumstances of the death without suicide being officially determined. There are some variations in coroner s practice regarding the recording of suicide conclusions. This data is available at Public Health Outcomes Framework data This data provides information around each of the Public Health Outcomes Framework indicators. The data are updated yearly. A number of the indicators are relevant for suicide prevention 2 It is important to note the following about suicide data: the suicide rates use ONS data with its associated limitations regarding timing and inquest conclusions it is crucial that the results are interpreted alongside local intelligence about the demography, diversity and geography of each area It is vital to recognise and be motivated by the fact that suicide is not inevitable and that suicides are preventable. Concerted action is therefore required across all areas. Low comparative rates of suicide as compared to other areas cannot be used as a justification for not taking preventative action

13 Other sources of national data include: Compendium of Health Indicators Hospital Episode Statistics National Confidential Inquiry into Suicide and Homicide by People with Mental Illness National Drug Treatment Monitoring System Primary Care Mortality Database Safety in Custody Statistics Secondary Use Services data The Segment Tool 3 Suicide Information Database Cymru 4.3 Locally sourced data Local coroner s data By reviewing coroners records it is possible to gain a detailed retrospective insight into the circumstances of individual suicides. Coroners investigate all deaths that are considered to have been sudden, violent or not due to natural causes. Deaths that may have been self-inflicted can be given one of three conclusions: suicide: where it can be established beyond reasonable doubt that the person took their own life open: if there is insufficient evidence to establish the mode of death narrative: in which the coroner simply sets out relevant facts Suicide audits usually examine open and narrative conclusions as well as conclusions of suicide, to make sure they take into account all deaths that are thought likely to have been self-inflicted. The individual records provide information on the demographic characteristics of the deceased, the place of death, method of suicide, contact with secondary and primary care services and other details specific to the individual case. Research suggests that there is a danger some public health teams can become too engaged in local data collection without a clear purpose and no demonstrable link between suicide audit activity and suicide action plans 3. It is worth being mindful of this and demonstrating clear aims and objectives when and if this work is undertaken. There can be concerns about the strength of local data given that the numbers of suicides in a local authority area tend to be small and the changes detected through monitoring over time even smaller. Sharing the work of data collection across a wider area (i.e. regionally) might help to mitigate this risk and wider discussion and advice from Public Health Wales Observatory and the Chair of the National Advisory Group may help. 3 Owens C, Roberts S, Taylor J. Utility of local suicide data for informing local and national suicide prevention strategies. Public Health 2014; 128(5):

14 4.4 Real-time suicide surveillance There are two potential models, one that is led by coroners, and one that is led by the police who are often the first responders at the scene of a death. Some local areas have been exploring the benefits of these different models in order to gather earlier intelligence on suspected suicides that have taken place locally. 4.5 Building a suicide prevention database Given the wide range of sources of relevant data it may be useful to establish a database into which all information can be collected and analysed. This will help to support a continuous process of building up data from national and local sources and coroner s records in order to create a long-term view of patterns in your area, rather than seeing data collection as a one-off activity. Ongoing information is vital to ensure that the local suicide prevention strategy and action plan can be monitored and regularly reviewed. The resources required to maintain this and its utility should be discussed. It is worth noting that on a national level the SID-Cymru study exists at Swansea University. 13

15 5. Developing a local suicide prevention strategy A local suicide prevention strategy sets out the case for suicide prevention work, where to target that work and the approach through which partners agree to work. It is the why of suicide prevention rather than the how. Developing the strategy is a public health responsibility, in collaboration with the multi-agency suicide prevention Fora and with input from the wider suicide prevention network. Public Health should take a lead role in ensuring a local strategy is developed. The process of developing a suicide prevention strategy is important. It provides an opportunity to engage key stakeholders and create a vision for suicide prevention that is locally owned by those working in statutory agencies, the voluntary sector, people affected by suicide and communities at large. The strategy requires the approval of elected members in order to ensure that it is resourced effectively and embedded across all relevant local authority programmes that can have an impact, such as housing and employment. Demonstrating the involvement of a wide group of stakeholders, setting out a case, and working with champions and people with lived experience are all important for securing councillor support. 5.1 What to include in a local suicide prevention strategy A local suicide prevention strategy usually covers at least a three-year period. It needs to set out clear objectives and provide a framework for the action plan based on relevant elements of the Talk to Me 2 action plan it typically includes: a foreword from a stakeholder in a senior role, for example from the director of public health, an elected member or the chair of the health and wellbeing board the case for suicide prevention locally, including data and intelligence on high risk groups and/or risk factors a clearly stated ambition and objectives for what wants to be achieved the approach to monitoring and evaluating outcomes in order to determine progress priority areas for action based on the national strategy priority areas for action based on local data and needs, Talk to Me 2 priority people and providers, interventions focused on particular public areas links with other strategies, such as mental health and well-being The action plan, detailing the specific activity that is going to be delivered, is often presented together with the strategy as one document, with the action plan updated annually. 5.2 Building the case for local suicide prevention work It is recommended that the strategy includes a case for action setting out the rationale for why suicide prevention is required in the local area. Locally available data and intelligence can be presented alongside nationally available data, and insights from the existing evidence and policy base can be highlighted. There is a range of information that could include: the reasons people take their own lives, including intelligence and data about local factors the public health profile, including any particular populations at risk of suicide 14

16 the financial and human cost of suicide and the cost effectiveness of suicide prevention the national policy drivers for local action the potential return on investment It can be helpful to consider how to make the case for action in an impactful and engaging manner. 5.3 Return on investment The economic cost of each death by suicide for those of working age is estimated to be 1.67 million (2009 prices). 4 This covers the direct costs of care, indirect costs relating to loss of productivity and earnings, and the intangible costs associated with pain, grief and suffering. It is estimated at least six people are intimately affected by every suicide. 5 A business case for suicide prevention can be made by multiplying the cost per suicide by the number of suicides in a particular area. If an area-wide suicide prevention intervention were to achieve only a modest 1% reduction rate in the number of suicides, in most scenarios this remains highly cost-effective. 6 The King s Fund demonstrates how key facts around return on investment in public health can be set out. 5.4 Mapping the strategy to the wider health and wellbeing agenda Suicide is a complex issue and prevention strategies need to recognise the importance of tackling factors that can lead to suicide in order to be most effective. It is therefore important that suicide prevention activity is aligned with and/or incorporated into other strategies and programmes including: needs assessment mental health and wellbeing strategies within local partnership structures for the Together for Mental Health Delivery Plan crisis care concordats sustainability and transformation plans Public Service Boards (Well-being Assessments and Well-being Plans are currently being developed under the Well-being of Future Generations Act) will be part of the wider response to suicide and self-harm commissioning of substance misuse services See Section 2 for further information about the wider policy context and Section 3.4 for Crisis Care Concordat. It is recommended that local authorities map suicide prevention to the wider health and wellbeing agenda and any joint strategies and needs assessments. 4 McDaid D, Kennelly B. An economic perspective on suicide across five continents. In D Wasserman, C Wasserman. Eds. Oxford textbook of suicidology and suicide prevention: A global perspective. Oxford: Oxford University Press; p Dosomething.org. 11 facts about suicide. [Online]. Available at: [Accessed 13th Jan 2017]. 6 McDaid D. et al. Making the case for investing in suicide prevention interventions: estimating the economic impact of suicide and non-fatal self harm events. Injury Prevention 2010; 16:A257-A

17 5.5 Accountability Accountability for the suicide prevention strategy and its associated action plan lies locally with the Health Board, PSB or RPB, as the bodies with responsibility for overseeing the planning of health and other services in the area. Key decision makers are members of the board, and often include senior councillors and directors of key departments in the local authority. Police and voluntary representation may also be included in the membership. These boards can provide crucial influence and impetus to support the design and delivery of a suicide prevention strategy and enable it to be adopted under the wider health and wellbeing strategy. In addition to the health and wellbeing board, there may be lines of accountability to the safeguarding adults board and the children and families partnership board. Regional Fora need accountability mechanisms for the regional element of any strategy. This could be through related HBs, PSB or RPB. One mechanism for this wider accountability could be to create a strategic partnership board, with local groups feeding into this central board but it seems sensible to use existing arrangements. 5.6 Local approaches to strategy development There will be different approaches to developing and implementing local suicide prevention strategies reflecting local structures 5.7 Priority areas for all local suicide prevention strategies The national suicide prevention strategy provides a ready-made framework for local strategy development. 1. Improving awareness of suicide and self-harm amongst the public and professionals 2. Delivering appropriate responses to crises and managing suicide and selfharm 3. Provide better information and support to those bereaved or affected by suicide 4. Support the media in delivering sensitive approaches to suicide and suicidal behaviour 5. Reduce access to the means of suicide 6. Support research, data collection and monitoring 16

18 Local strategies should aim to tackle all areas in the long term, but in the short term may need to identify priorities. Local data and intelligence (see Section 4.3) together with consultation with key stakeholders is essential to identifying the local priorities. Some strategies and supporting action plans have chosen to concentrate on three or four areas for action where local partners believe they can make the most difference in their area. Where local prevention strategies span across all six of the areas this is often as a result of work that has developed over a long period of time. 5.8 Developing a multi-agency action plan The local suicide prevention strategy provides the framework and sets out the overall aims and objectives and the rationale for the approach being taken. Once this is in place, the next step is to develop a multi-agency action plan to detail how the strategy is going to be achieved. 5.9 What to include in an action plan The action plan sets out what will be done, by whom and by when. It usually focuses on planning activities over a one to two year period, and is monitored quarterly. It typically includes: What is going to be done under each objective set out in the local strategy The target audience for the intervention Delivery lead Implementation partners Resource Timing, including key milestones Monitoring Many local areas use a table format to record their action plans as seen in the national Talk to Me 2 Action Plan. More information on this can be found here. It may be helpful to review a selection of action plans from different areas to gain useful pointers and determine the approach that best suits local need. Appendix 2 contains a rapid review mapping guidance and evidence of interventions to prevent and manage suicide and self-harm up to Monitoring and evaluating suicide prevention strategies and action plans As part of the establishing a local suicide prevention strategy it is important to be clear from the outset how effectiveness and impact is going to be determined. It is too late to plan evaluation once a strategy and action plan has already started to be delivered. It is helpful to clearly determine the aims, objectives, outputs and outcomes that are being sought. Each action or intervention should aim to be SMART (specific, measureable, achievable, realistic, time bound), with responsibility and accountability clearly identified from the outset. An appropriate monitoring process is required that produces data and insights to enable the tracking of progress. It is advisable to allocate of proportion of resources, including time and budget for evaluation. 7, 8, 9 7 Centers for Disease Control and Prevention. Programs for the Prevention of Suicide Among Adolescents and Young Adults; and Suicide Contagion and the Reporting of Suicide: Recommendations from a National Workshop. Morbidity & Mortality Weekly Report 1994; 43(RR6): SPAN USA. Suicide Prevention: Prevention Effectiveness and Evaluation. SPAN USA, Washington, DC: SPAN USA;

19 5.11 Setting outcome measures - building on improving services for self-harm The ultimate aspiration is to see a reduction in the number of suicides, and this is the fundamental outcome desired for all areas, regardless of whether the local rate is currently comparatively high or low. However, suicide is a rare enough occurrence to make it difficult to measure a change in rates, particularly at a local area level. As a result, in addition to the local suicide rate, other proxy indicators can be considered, including self-harm and stigma. Both are amenable to measurement. There is growing evidence to support using self-harm as an outcome measure for suicide prevention work. Evidence shows that hospital presentation following self-harm is a clear risk factor for suicide and for alcohol-related death. 10, 11 Other measures include the extent to which patients presenting at hospital receive assessment following self-harm in line with NICE guidelines, to enable early identification and treatment of alcohol problems, and the number of people presenting with self-harm who go on to receive cognitive behavioural therapy. Another suggested measure for the effectiveness of suicide prevention is evaluating the extent to which the stigma against talking about suicide is changing. This can be done through opinion surveys, by monitoring the number of people receiving accredited training, or by measuring the number of people reached by a media or social marketing campaign. The WHO has said that outcome measures based on reductions in mortality are only suitable for the largest scale interventions, for example reducing paracetamol pack sizes to reduce the incidence of self-poisoning. 12 It suggests that the success of suicide prevention strategies can be measured through indicators such as the number of suicide prevention interventions successfully implemented and a decrease in the number of people hospitalised after suicide attempts Setting aims and objectives These describe the specific aims and objectives for action plans. So while the strategy and action plan s overall objective may be to reduce the number of suicides over a given time frame, specific aims and objectives may be linked to tactical interventions. In a somewhat simplistic but important example, aims for Action 5: Supporting the media in delivering sensitive approaches to suicide and suicidal behaviour might be: To enable editors of local media to become familiar with national guidelines for reporting suicide and suicidal behaviour To enable partners to work with the media in such a way that they support reporting according to the national guidelines 9 Hergel U et al. Optimizing Suicide Prevention Programs and Their Implementation in Europe (OSPI Europe): an evidence-based multi-level approach. BMC Public Health 2009; 9: Bergen H et al. Alcohol-related mortality following self-harm: a multicentre cohort study. JRSM Open 2014; 5(8): Hawton K et al. Suicide following self-harm: Findings from the Multicentre Study of self- harm in England: Journal of Affective Disorders 2015; 175: World Health Organization. Towards evidence-based suicide prevention programmes. Geneva: WHO; Available at: [Accessed 13th Jan 2017]. 13 World Health Organization. Preventing Suicide: a global imperative. Geneva: WHO; Available at: [Accessed 13 th Jan 2017]. 18

20 Specific objectives associated with this might be: To deliver training to editors of local media To deliver training to local partners The specific outcome might be: To see a measurable reduction in the number of articles that breach national guidelines over a 12 month period It should be noted here that if local reporting breaches Samaritans guidelines for appropriate reporting of suicide the Samaritans will contact editors, if reporting does not breach these guidelines yet is still considered inappropriate, local Fora should contact the National Advisory Group who will contact the Editors through the Chair Collecting data Evaluating aims and objectives requires data. At a minimum, both at the outset of any intervention to provide the baseline against which to measure change and then post intervention. In the media example outlined above this might include: Baseline data, such as the number of local media reports that breached national guidelines in the previous year Post intervention data, the number of local media reports that breached national guidelines after training was delivered The number of people trained Qualitative data about the perceived value of the training Data collected during delivery can also allow the timely monitoring of progress and enable modifications to be made if necessary Using a theory of change approach A theory of change approach helps to map out who a service works with and why (the aims), what resources and skills are needed to provide the service (inputs) what a services will provide (outputs), what the service wants to achieve (outcomes divided into intermediate and longer term). It is gaining increased recognition as an approach for evaluation across the health and social care sector. It can be co-produced with staff, clients and funders and it can help to: Build and maintain a staff and volunteer team who have clarity over the aims of a service, and how outcomes can be achieved Provide a clear way to communicate with funders and donors why selected activities are important (and need resource) and how they achieve stated outcomes Help to engage with potential clients so they can see what the service might be able to help them with Support service reviews and innovation plans to develop the service 19

21 5.15 Reporting on evaluation The format for presenting evaluation findings will vary depending on the audience or project. In addition to formal reports detailing the background, aims, objectives, results of analysis and conclusions for improvement and development, evaluation can feed into less formal formats such as blogs, videos, presentations for conferences or reports for funders Points to remember Don t reinvent the wheel. Be consistent and use established approaches where they exist. For example, use standard questionnaires to measure depression and anxiety in interventions focusing on people with depression. Don t be afraid of showing that an intervention has had no or low impact, as lessons can still be learned, especially if the study is high quality. Don t feel you need to work alone. Ask academics for help. Approach your local university to explore an evaluation partnership. Universities may be able to provide guidance on developing high quality research and evaluation studies. Psychology and psychiatric departments usually employ clinical academics that bridge practice and research. 20

22 6. Ideas for action The most effective action plans reflect the evidence of local need (see Section 4.3), the best available research evidence/guidance (see Appendix 2) and the priorities agreed in the local suicide prevention strategy (see Section 5) by the multi-agency suicide prevention group. This means each area s plan will differ. In suicide prevention, as noted by WHO, one size does not fit all. To support the design and delivery of local intervention this section provides an overview of the latest evidence for targeting particular audiences and some ideas for action; this is not intended to be exhaustive. Some actions require the leadership and involvement of clinical services rather than local authorities, which demonstrates the importance of a multi-agency partnership to enable an integrated and collaborative approach to achieving a reduction in suicides. The section considers the six priorities set out in the national strategy and the priority areas for action Strategic Objectives Further improve awareness, knowledge and understanding of suicide and self-harm amongst the public, individuals who frequently come in to contact with people at risk of suicide and selfharm and professionals in Wales To deliver appropriate responses to personal crises, early intervention and management of suicide and self-harm Information and support for those bereaved or affected by suicide and self-harm Support the media in responsible reporting and portrayal of suicide and suicidal behaviour Reduce access to the means of suicide Continue to promote and support learning, information and monitoring systems and research to improve our understanding of suicide and self-harm in Wales and guide action 6.1 Reducing the risk of suicide in Priority People and Priority Places The first priority area in the national strategy is for all local strategies to deliver work to reduce the risk of suicide among the following high-risk groups: Men in mid life Older people over 75 with depression and co-morbid physical illness Children and Young People with a background of vulnerability People in mental health services People with a history of self-harm First responders - Police - Welsh Ambulance - Primary Care workers - Emergency department staff - Fire fighters These groups are identified as those where the number of suicides is high, there is a known statistically increased risk and there is evidence that preventative measures can be effective. 21

23 Priority places are: Schools Psychiatric hospitals Prisons Police custody suites Work places Further education establishments Primary care facilities Emergency departments Rural areas Deprived areas The Workplace Wellbeing Charter enables employers of all sizes and sectors to achieve nationally recognised accreditation against an evidence-based set of standards on promoting health and wellbeing in their workplace. It provides a way to drive improvements in workplace health, including enabling implementation of NICE guidance and the HSE Management Standards for Stress. Health boards, ocal authorities and professional associations should be aware of their high risk groups and take steps to reduce stressors to improve the safety, and reduce the suicide-risk to their workforce. This may also involve work on access to means. See Section Strategic Objective 1 Improving awareness and understanding of suicide and self harm amongst the public and those frequently coming into contact with people at risk - Suicide prevention training Training programmes for suicide prevention seek to improve the knowledge, skills and attitudes of professionals, community members and friends who may have proximity to those with suicidal ideation to improve their ability to intervene and offer support. Or alternatively, they aim to reduce suicidal thoughts and death by suicide in a target population. Broadly, there are three key approaches to training programmes: Gatekeeper training General awareness and educational curricula Skills based training. There are few evidence-based suicide prevention training programmes. A limited number of studies have been undertaken, but they have been limited in their approaches. The Liverpool Health Observatory has undertaken a rapid review of the existing evidence, and a summary is outlined in this section. The report includes further evidence and details of a wider range of available training programmes and is available here. The Wales Training Framework gives some guidance for localities to make decisions regarding gatekeeper and general awareness training that is suitable to their needs. Skills based training involves building positive mental health and well-being by developing skills such as those required to build strong personal relationships, a personal belief system and effective coping strategies that will reduce the risk factors associated with suicide, amongst other things. It is an 'upstream approach to prevention. Information about training to prevent suicide in public places is included in the PHE practice resource: Preventing suicide in public places 22

24 6.3 Children and young people Improving the mental health of children and young people, including looked after children, care leavers and children and young people in the youth justice system is crucial to reducing deaths by suicide. Evidence shows suicide is one of the main causes of mortality in young people 14 and for families its impact is particularly traumatic. The Child Death Review into Probable Suicide identified a number of key recommendations for Wales. It is likely that actions to support children and young people will be part of wider strategies around mental health and well-being: Improving young people s health and wellbeing: a framework for public health Promoting children and young people s emotional health and wellbeing: a whole school and college approach A public health approach to promoting young people s resilience Together for Children and Young People Further sources of information relating to children and young people s mental health and wellbeing are provided in Appendix The Saving and Empowering Young Lives in Europe (SEYLE) project The SEYLE research project investigated the effectiveness of school-based interventions aimed at reducing suicidal ideation. 15 It involved 11,110 students, with a median age of 15 years, from 168 schools in 10 EU countries. It tested three interventions: Gatekeeper training for teachers and other school staff A youth mental health awareness programme targeting school pupils Professional screening of students considered to be at risk of suicide The youth mental health awareness programme was found to be effective in reducing the number of suicide attempts and severe suicidal ideation. 6.4 People who are vulnerable due to economic circumstances Suicide is a significant inequality issue as there are marked differences in the suicide rates according to people s social and economic backgrounds. This was highlighted in Talk to Me 2. Improving the mental health of people who are vulnerable due to these circumstances supports suicide prevention. 14 Public Health Wales. Thematic Review of deaths of children and young people through probable suicide, Cardiff: Public Health Wales NHS Trust. Available at: 03c3fa1/$FILE/PHW%20probable%20suicide%20web.pdf [Accessed 13 th Jan 2017]. 15 Wasserman D et al. Schools-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. The Lancet 2015; 385(9977):

25 Evidence shows: People in the lowest socio economic group and living in the most deprived areas are ten times more at risk of suicide than those in the most affluent group living in the most affluent areas 16 Men of lower socio-economic position in their mid-years are excessively vulnerable to death by suicide compared to males in other age groups and compared to females of all ages 16 46% of patients with mental illness who died by suicide between were unemployed at the time of death 17 18% of patients with mental illness who died by suicide between 2012 and 2013 had experienced serious financial difficulties in the three months before death 17 In % of patients with mental illness who died by suicide were in unstable housing, i.e. homeless or living in bed and breakfast or a hostel. 17 Given that reducing health inequalities and addressing the social determinants of health are a central concern for local authorities it is recommended that action to address these are explicitly linked to suicide prevention strategies. Ideas for action include: Collaborating with voluntary sector and community groups, such as Citizens Advice Bureau, housing associations and homelessness services to provide and promote financial and debt counselling support to vulnerable individuals Providing suicide awareness training to frontline service providers across education, housing, employment and others Increasing information and support services available in response to significant economic changes in any community, for instance the closure of a major employer Providing supportive parenting training and advice to vulnerable families The UCL Institute of Health Equity has produced four papers that include evidence and examples of practical action that can be taken at a local level to reduce health inequalities. They are designed to support directors of public health and public health teams as well as people working in local authorities services that may influence health and wellbeing. The papers are available here. 6.5 Strategic Objective 2 Delivering appropriate responses to personal crises, early intervention and management of suicide and self harm Local plans should ensure services for self-harm are in keeping with NICE Guidance and that locally the % of people who have self- harmed who have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition or suicide. the % of people who have self- harmed who receive a comprehensive psychosocial assessment. Presenting at least to hospital services is known. 16 Platt S. Inequalities and suicidal behaviour. In O'Connor R, Gordon J, editors. International handbook of suicide prevention: research, policy and practice. Chichester: John Wiley & Sons Ltd; Chapter National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH). Annual Report 2015: England, Northern Ireland, Scotland and Wales. Manchester: University of Manchester;