Services & Trusts Integrating To improve Care in self-Harm

STITCH Director: Salena Williams

Sal Ball

Robert Carroll

and ‘the HITs’: Health Integrated Teams

Background: Self-harm

• Approximately 200,000 hospital attendances in England annually; 3,000 in Bristol.

• 20-25% repeat self-harm in the next 12 months; 1% die by suicide.

• Past self-harm is the strongest predictor of suicide

• Approx. 1 in 5 Bristol suicides present with self-harm in the year before death

The Self Harm Surveillance Register

•Identify trends in self-harm since Oct 2010

•Identify Repeat attenders

•Methods of self-harm

•Seen for psychiatric review?

•Timely evaluation of new services

•Appropriate targeting of services (timing of attendance)

•Children’s hosptial

•Extended to Southmead in 2013 – contrast services

Self Harm Presentations to Bristol Hospitals

Aims of

Treatment and care is equitable, fully evidence based and non-stigmatising for all people who self harm and to reduce suicides in Bristol

• Improve service user engagement in service planning and delivery throughout the care pathway and with research

• Provide a psychosocial assessment following self harm

• Ensure closer inter-organisational and inter-agency working

• Reduce the ‘the science to service’ gap

• Improve self-harm training

What would you do?

If you lived in a city of 600,000 people and you are considering ending your life by suicide or you used self harm:

what would help you, and what would you change?

We have concentrated on 3 areas. Discuss on your tables

Please take 5 minutes

Emergency Departments (A+E)

Emergency Department (A+E)

Emergency Department (A+E)

Bristol-based peer support group formed in 1998

Currently facilitates weekly support groups, Making Changes groups, Wellbeing workshops

Future Plans: increase number of support groups; talks/training by people with lived experience

Evaluation of A&E by People who Self Injure:

– SISH funded by Bristol public health to gather views

of people who self-injure who use A&E, evaluation of service and recommendations for improvements

– Working closely with the Psychiatric Liaison Team

Self Injury Self Help (SISH):

• Basic Underlying Principle: Experience-led from start to finish

• Used SISH database of contacts and other local and public networks

• Initially sought views on ‘what questions should be asked?’

• Online survey and face-to-face interviews based on these suggestions, questions deliberately left open ended to capture personal perspectives

• Data obtained from: 40 online surveys and 4 face-to- face interviews; time spent in A&E observing

Methodology

Process: Thinking about

Power Imbalance Impact of taking part:

• Need to be anonymous in case it affects treatment

• Impact of discussing very personal experiences for others to analyse

• Meeting staff who may have treated you to discuss improvements

• Meeting in health-related environments

• Being outnumbered by staff • Meeting staff who you know

have different views to you • Having to ask for

expenses/support to take part

Use of A&E Services

In the last 18 Months: • Bristol Royal Infirmary

48%

• Frenchay 30%

• Southmead 3%

• Other/None 13%

Majority - felt that they were given appropriate physical treatment

Majority - felt that the care and support they were given for emotional and psychological needs is not helpful and in some cases puts them off attending.

Overall feeling - inconsistency and not being sure what type of service would be on offer

Summary of Results

• User produced information leaflet

• Body Maps

• ‘It’s ok not to say’ signs

• Training for ED staff

• Better communication with GP/Mental health teams

• Improved access to Psychiatric Liaison Service, when wanted

• REPEAT evaluation survey to monitor effectiveness

Action taken as a result of survey

G.P.

General Practitioner: GP

General Practitioner: GP

• 5% of self-poisoning involve highly lethal tricyclic anti-depressants

• 11% of patients taking these medications in overdose are admitted to ITU.

• STITCH pilot through collaboration with GPs is ongoing looking at dispensing medicines lethal in overdose in small quantities.

GP prescriptions pilot

Stigma

Training/education

Over 150 GPs in Bristol:

- Avon GP Education

- CCG ½ days

- GP forums

South West Ambulance Service

Regular Medical and Nursing staff in both A+E’s

• All with people with lived experience of self harm

• All evaluated: knowledge, confidence, motivation

Psychological support

Psychological support

30%

40%

50%

60%

70%

80%

90%

2013

-Oct

2013

-Oct

2013

-Nov

2013

-Dec

2013

-Dec

2014

-Jan

2014

-Feb

2014

-Mar

2014

-Mar

2014

-Apr

2014

-May

2014

-May

2014

-Jun

2014

-Jul

2014

-Jul

2014

-Aug

2014

-Sep

2014

-Sep

2014

-Oct

2014

-Nov

2014

-Dec

2014

-Dec

2015

-Jan

2015

-Feb

2015

-Feb

2015

-Mar

2015

-Apr

2015

-Apr

2015

-May

2015

-Jun

2015

-Jun

2015

-Jul

2015

-Aug

2015

-Sep

2015

-Sep

% a

sses

sed

Time period

Proportion of self-harm patients receiving a specialist psychosocial assessment (3-week moving average) and pre/post average proportion

assessed (Oct-2013 to Sep-2014 vs. Oct-2014 to Sep-2015)

3-week moving average 12-month average

Psychological support

O’Connor 2013 Annals of Internal Medicine

Psychological support

• Growing body of evidence from trials suggesting cognitive behaviour therapy can reduce risk of repetition.

• STITCH has facilitated the introduction of clinics offering this therapy for SH patients.

• Register will be well placed to evaluate outcomes from this work

Psychological support

• Business case – investment – 7 day service to A+E

• Psychosocial assessments + 60%

• Standardised across Bristol

• Personal support plans

• Self harm clinic

• Self harm enhanced clinic

Other STITCH achievements

• SING: University counsellors, young peoples services, school educators, CAMHS workers

• Carers leaflet

• Research: internet, recession, risk assessment, paracetemol, DV and LGBT

• CLARHC – public and patient participation in research

• Later life equality care