Take action to improve outcomes for people who are emergency admissions for intentional self-harm
UK specific research has shown that hospital admissions for self-harm behaviours can be a significant risk factor for future suicide attempts[i]. Studies report that the risk of suicide in the first year after a hospital admission for self-harm is 66 times greater than the annual risk of suicide in the general population with a greater risk among women and those aged over 55[ii].
There is a huge variation in how hospitals manage self-harm behaviours and onwards referrals. Across 32 hospitals in England the amount of essential, evidence-based psychosocial assessments offered following an admission for self-harm ranged from 24% to 88% and the frequency of onward referrals made to specialist mental health services ranged from 11% to 64%[iii]. It has also been found that follow up care following a self-harm admission is less likely to be offered to those from more deprived communities[iv] [v]. Recent research suggests that psychosocial assessments can be associated with a 40% reduction in repeated suicide attempts, particularly with those from more deprived areas[vi].
Action for NHS bodies
1. Ensure availability of excellent mental health liaison services in acute hospitals and community setting with training of all acute staff in mental health awareness and brief interventions.
The Five Year Forward View for Mental Health recommended that by this year (2020/21) NHS England investment should have ensured that every acute hospital has all-age mental health liaison services in emergency departments and inpatient wards, and that at least 50 per cent of acute hospitals are meeting the ‘core 24’hour service’[vii].
Liaison psychiatry services address the mental needs of people who are being treated primarily for physical health problems or symptoms. NHS England and NICE have produced guidance for providing this effectively.
A Centre for Mental Health study[viii] suggests that every liaison psychiatry service should be established on a sustainable basis with:
- secure funding
- a critical minimum size of the service and
- a critical minimum level of expertise, particularly in terms of the input of consultant psychiatrists.
The research suggests incorporating related services such as clinical psychology and substance misuse services within a hospital-based liaison psychiatry service.
Liaison psychiatry services should seek to integrate psychiatry and psychology fully into medical care. This requires close day-to-day working with medical teams, a strong focus on the education, training and supervision of acute hospital staff and a leadership role in changing the culture of the hospital so that the central importance of psychological factors is much more widely recognised and embedded in the routine care of patients.
In hospitals where liaison psychiatry support is currently limited or non-existent, the initial priority should be to set up a rapid-response generic service, focusing on assessment, the day-to-day management of patients during their time in hospital and onward referral to community services. The core work of such a service is likely to be in medical inpatient wards and emergency departments.
Established in 2013 using the Core 24 model based on the Rapid Assessment Interface and Discharge (RAID) model of liaison psychiatry the liaison psychiatry service works with patients in the Royal Derby Hospital who are admitted with self-harm injuries as well as those with other mental ill health or substance misuse related admissions.
This service was set up after an economic evaluation of a similar model in a Birmingham hospital showed reduced hospital stays and a cost to benefit ratio of more than 4 to 1.
The service involves:
- 24/7 rapid response to requests for help
- quick response targets - one hour for the emergency department, 24 hours for hospital wards
- having a comprehensive range of specialist knowledge including mental health, substance misuse, self-harm, suicidal thoughts, dementia and delirium
- working with around 600 adult patients a month