Strengthening Responses in Tayside to People who Present Following an Incident of Self
Harm – Further Briefing For Stakeholders on an Improvement Programme
Background: The Mental Health Strategy for Scotland 2012 – 2015 includes four “Key change
areas” the second of these “rethinking how we respond to common mental health problems”
discusses among other things people who experience distress and how this is responded to. In
recognition of the challenge this presents and the need to explore and develop improved ways of
responding commitment 19 of the strategy is as follows.
“We will take forward work, initially in NHS Tayside, but involving the Royal College of General
Practitioners as well as social work, the police and others, to develop an approach to test in
practice which focuses on improving the response to distress. This will include developing a
shared understanding of the challenge and appropriate local responses that engage and support
those experiencing distress, as well as support for practitioners. We will develop a methodology
for assessing the benefits of such an approach and for improving it.”
A previous briefing was circulated to stakeholders in September 2012 outlining the
background to the improvement project being developed in response to commitment 19 of
the mental health strategy for Scotland. Set out below is a summary of the subsequent
progress with the project and an outline of the future work.
1. Partnership working and project management.
A small project group has been established with membership drawn from Tayside Police,
Dundee City Council Social Work, Dundee voluntary Action, and NHS Tayside
A reference group of stakeholders with a wide membership representing a range of
statutory and voluntary organisations has been consulted with and received a presentation
on initial progress with the project. A further discussion with this group is scheduled for
27th February 2013
An improvement panel comprising senior staff from Scottish Government, NHS Tayside,
Dundee City Council, Tayside Police and Dundee Samaritans has been convened twice.
The purpose of the panel is to monitor progress; review proposals challenge assumptions,
and confirm that the project is able to continue to the next stage.
2. Understanding the current state.
An early challenge to resolve was to have a common understanding of the relationship
between, distress /self harm and suicide. In the absence of data on distress the proxy of
self harm was adopted. It is our proposal that distress as a broader concept of poor mental
health/ wellbeing sits below this model and includes an even larger proportion of people
in need of support.
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Work was undertaken to review the literature relating to distress and self harm. This
preliminary review of the literature revealed minimal yield on distress specifically.
However it is reasonable to adduce from the literature that
- Distress is known to sit on a continuum of mental wellbeing and mental illness
- Self- harm is commonly understood as a behavioural response to, or reflection of
emotional or psychological need
- It is people’s best efforts in alleviating emotional pain/ distress
To develop a good understanding of where people present to services following an
incident* of self harm and what happens to them thereafter data from NHS Tayside,
Tayside Police and Dundee City Council has been collated and analysed; detailed process
mapping has been undertaken to help understand what happens after people come into
contact with a service and people have been asked about their experiences.
(* An incident of self harm included people expressing an intent to self harm, attempts at
self harm and actual harm to self of varying severity)
Some of this extensive work is summarised below.
Data collected over a three month period relating to people whose contact or presentation
had been coded or described as relating to an incident of self harm by Tayside Police,
NHS Tayside Accident and Emergency, Liaison Psychiatry service, the mental health
acute response service was examined and analysed.
This demonstrated that a large number came into contact with one of those services during
the three month period. (See Figure 1 below) Most (702 people) only presented once but
some people presented four or more times in that period.
Figure 1. No of people and frequency of contact.
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Number of new presentations per person
: Jan – Mar 12
Total: 1005 people
5 presentations or
more, maximum 20
1 presentation
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We also looked at how many agencies each person came into contact with and this is set
out in figure 2 below.
Figure 2 No. of services attended per person
Services attended per person Jan – Mar 12
5 agencies
Range, per person:
1 – 20 presentations.
1 – 4 services.
1 – 20 presentations per
service per person.
Total: 1002 people
1 agency
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Examining what happened to people following a presentation at any of the services
revealed that there was a wide range of responses ranging from urgent admission to
hospital, referral on to a specialist service to no further intervention. This varied pathway
was mapped and the “journeys” of a number of people were examined to check whether
what happened with people was what the data was telling us. This complex picture is
represented in figure 3 below.
Figure 3 pathways map.
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High Level Process Map for Person in Distress
In Hours Referral
Triage
Assessment
Police
Decline
support
Treatment
Outcome
CAMHS
CAMHS
AMHRT Support
AMHRT (ESD)
Public
Friends
Ambulance
Informal care
support
CMHT
Individual
CMHT
NHS 24
GP
A&E
A&E
Psychiatric
Admission
Family
Social Work
GP
Vol. Agencies
Carers
Hot Chocolate
Xplore
Corner
Primary Care
Nurses (open
case)
Social work (Open
Case)
Liaison Psychiatry
GP
Informal Care
General
Admission
Signposting
AMHRT
Voluntary
Agencies
Decline
support
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Most importantly we sought the views and experiences of people who described
themselves as having previously experienced distress that led them to contemplate or
cause an act of self harm. This information was gained from people attending “choose
Life” information stands and through targeted questionnaires and focus groups.
The main themes of what people told us were that:- People go to a variety of places when they are in distress.
- They are frequently looking for a safe, confidential, compassionate and
understanding response.
- They want to be taken seriously, listened to and not dismissed but this was often
not what they experienced
3. Tests of change
Having gained a clearer understanding of our “current state” a number of small tests
of change were initiated to help identify improvements. These can be described briefly
as follows:i) Is providing opportunistic advice & support taken up by people. If so do the
location/ time matter?
This followed on a pre-planned information stall set up under the aegis of Choose Life
in the concourse of Ninewells Hospital. Further information stalls have been run or are
scheduled in a variety of locations including shopping centres, libraries, community
centres and a supermarket. To date the results have been inconclusive.
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ii) Does the process map accurate reflect people’s journey through services?
The high level map was devised using an amalgamation of cases and the various
scenarios that may have happen to people dependant on where they seek help and
what the particular issue is. This test of change was devised to ensure the map
accurately reflects people’s journeys. Case studies were randomly selected from the
police and the Social Work department to test their journey through the process. This
work indicated that there was often poor communication between crises services and
mainstream services.
iii) Identify & measure the content of current training for its compassionate/
understanding response.
Over the past four years there has been significant investment in training for staff in
the identification of and response to people who are at risk of suicide and self harm.
However, people told us that they did not feel that staff responded to them in a caring
and helpful manner. Strengths and weaknesses were identified in each of the training.
The outcome of this needs to be considered by the local choose life groups and NHS
Tayside who currently commission or deliver the training.
iv) Is it possible to establish a minimum data set to understand people’s journeys
throughout various services?
The project quickly discovered that although we were able to access anonymised data
from a number of agencies datasets were difficult to compare directly as indicators
were too diverse. Information was categorised in different ways by different agencies.
A minimum dataset was established and from this a clearer understanding of our
current state and the capability to measure change over time has been established.
Some of the outcome of this is shown in the earlier tables.
4. Next steps
At the end of January 2013, following endorsement by the improvement panel, the
project team are exploring and establishing further “test of change”
We have therefore proposed that there are three improvements that need to be made to
improve services response for people in distress.
1) Arrangement in place that bring the “at risk” in to structured care & treatment to
meet their needs
2) Those who don’t meet this criterion are given the offer & support to access a
listening & emotionally supportive approach and may include practical support to
access existing supports and services.
3) A qualitative approach aimed at improving the nature of the response individuals
receive when in distress from services who are often feel ill-equipped, not the
appropriate place to help people in distress.- A caring, compassionate,
understanding & informing response through the services
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There is much other work, locally and nationally that will also provide learning or the
project and the outcomes and learning from of these will be used to inform the work.
These test of changes have been developed and are in progress and will be reported to
an improvement panel at the end of April 2013, following this a further briefing note
will be prepared & distributed.
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