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Suicide prevention

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What is covered

This interactive flowchart covers setting up suicide prevention partnerships in community and residential custodial and detention settings. It explains how the partnerships should develop a strategy and plan to:
  • raise awareness
  • reduce access to methods of suicide
  • support people bereaved or affected by suicide
  • prevent suicide clusters
  • reduce the potential harmful effect of media reporting.
It also covers training for gatekeepers.
This interactive flowchart should be read in conjunction with Public Health England's Local suicide prevention planning: a practice resource.

Updates

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Short Text

Everything NICE has said on preventing suicide in community and residential custodial and detention settings in an interactive flowchart

What is covered

This interactive flowchart covers setting up suicide prevention partnerships in community and residential custodial and detention settings. It explains how the partnerships should develop a strategy and plan to:
  • raise awareness
  • reduce access to methods of suicide
  • support people bereaved or affected by suicide
  • prevent suicide clusters
  • reduce the potential harmful effect of media reporting.
It also covers training for gatekeepers.
This interactive flowchart should be read in conjunction with Public Health England's Local suicide prevention planning: a practice resource.

Sources

NICE guidance and other sources used to create this interactive flowchart.

Quality standards

Quality statements

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

NICE has produced resources to help implement its guidance on:

Information for the public

NICE has written information for the public on each of the following topics.

Pathway information

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Supporting information

Gather and analyse information

Rationale

Good information is essential for planning, monitoring success and improving the strategy and plan for all settings. The committee agreed that the information should come from different sources to get a clear picture of what is happening. But they also agreed that it is important to make sure the local data collected is as reliable as possible, so that the strategy and plan is as effective as possible.
Although the evidence was limited, the committee agreed with an expert that more rapid and frequent information gathering (rapid intelligence gathering) is important, for example for early detection of suicide clusters.
The committee also agreed that because analysing information on suicides may expose staff to some distressing material, training and support is essential to help them cope.

Impact

Gathering and analysing data may involve some additional resources. But most multi-agency suicide prevention partnerships have some work already in place. So we do not expect this will have a significant resource impact.

Gatekeepers

People in groups that have contact, because of their paid or voluntary work, with people at risk of suicide. People in these groups may be trained to identify people at risk of suicide and refer them to treatment or supporting services as appropriate.
They may include: health and social care practitioners, criminal justice and detention settings staff, police and emergency services, people who provide a paid or voluntary service for the public, faith leaders, railway and underground station staff, and staff in educational institutions.

High suicide risk

High suicide risk means that the rate of suicide in a group or setting is higher than the expected rate based on the general population in England. Groups at high risk can include: young and middle-aged men, people who self-harm, people in care of mental health services, family and friends of those who have died by suicide, people who misuse drugs or alcohol, people with a physical illness, particularly older adults, people in the LGBT community, people with autism, people in contact with the criminal justice system, particularly those in prisons, people in detention settings, including immigration detention settings, and specific occupation groups (see Suicide by occupation, England: 2011 to 2015 Office for National Statistics).
These include high buildings such as multi-storey car parks, railways and bridges and places where other means of suicide are accessible, such as medical, veterinary or agricultural settings where human or animal drugs may be readily available (see Public Health England's Preventing suicides in public places: a practice resource).

Set up partnerships

Rationale

Approximately 6,000 people take their own life each year in the UK. The risk of suicide in the UK prison population is considerably higher than among the general population. The number of people dying by suicide in custodial or other detention settings such as prisons, immigration detention centres, young offender institutions and police custody has increased over the past decade.
Many local agencies can be involved in preventing suicide in the community. Although the evidence was limited, the committee felt strongly that these agencies need to work together to focus on the most effective and cost-effective interventions. By combining expertise and resources, partnerships can cover a much wider area more effectively and implement a range of activities.
Likewise, different services within residential custodial and detention settings can be more effective if they work together in a local multi-agency partnership and with similar partnerships in the community.

Impact

Improved communication and information sharing between statutory agencies and community organisations may have resource implications. For example, the costs of staff time, communication, interventions and the meetings associated with multi-agency teams.
But multi-agency partnership working is already enshrined in the Department of Health and Social Care's suicide prevention strategy for England, updated in the Suicide prevention: third annual report. As a result, multi-agency suicide prevention partnerships have been set up in most community and residential custodial and detention settings, so no additional costs are expected.
These include high buildings such as multi-storey car parks, railways and bridges and places where other means of suicide are accessible, such as medical, veterinary or agricultural settings where human or animal drugs may be readily available (see Public Health England's Preventing suicides in public places: a practice resource).

Suicide clusters

A series of 3 or more closely grouped deaths linked by space or social relationships. In the absence of transparent social connectedness, evidence of space and time linkages are needed to define a cluster. In the presence of a strong demonstrated social connection, only temporal significance is needed. (Adapted from Public Health England's Identifying and responding to suicide clusters and contagion: a practice resource).

Develop a strategy

Rationale

Some evidence and expert opinion showed that having a strategy for how to connect local organisations can help prevent suicide in community and residential custodial and detention settings. (For general reasons why we have made the recommendations see set up partnerships: rationale and impact.)
If the strategy has clear leadership and is based on what is currently happening in the area or setting, it is likely to be effective. This involves gathering data on suicide rates and sharing best practice. A strategy may also help to ensure organisations are prepared to respond to a suicide.
Expert opinion showed that when partnerships share knowledge and experience, this is of greater benefit than working individually. It may include collaborating with neighbouring organisations in the same setting to develop a shared strategy.

Impact

Improved communication and information sharing between statutory agencies and community organisations may have resource implications. For example, the costs of staff time, communication, interventions and the meetings associated with multi-agency teams.
But the Department of Health and Social Care's suicide prevention strategy for England advocates multi-agency partnerships, and suicide prevention strategies have been set up in most community and residential custodial and detention settings. So no additional costs are expected.

Develop and implement an action plan

Rationale

Having a detailed action plan based on local knowledge and clear leadership can help prevent suicide in the community and in residential custodial or detention settings. The plan will be effective if it is based on knowledge of what is happening in the area or setting, involves stakeholders and is adaptable. (For general reasons why we have made the recommendations see set up partnerships: rationale and impact.)

Impact

Multi-agency suicide prevention action plans have been set up in most community and residential custodial and detention settings, so no additional costs are expected. For example, Public Health England's Suicide Prevention Atlas shows which local authorities have suicide prevention plans.

Raise awareness

Rationale

Many people who take their own lives are not in contact with mental health services and may not necessarily be in contact with a GP, so opportunities for clinical interventions can be limited. Non-clinical interventions, such as telephone or text helplines or volunteer-run face-to-face talking are important to support people with suicidal thoughts and keep them safe.
There is increasing demand for non-clinical interventions but little evidence on the benefits. Research is needed to evaluate how effective they are. (The committee made the following research recommendation: 'How effective and cost effective are non-clinical interventions to reduce suicidal behaviours?')
The committee agreed that awareness-raising activities and messages, tailored to people's needs and circumstances, can help get rid of common misconceptions about suicide and self-harm and let people know where they can go for help. They also agreed that increasing local awareness of suicide and the support available is likely to encourage people to seek help. But there can be a fine line between helpful and potentially harmful messages. (The committee made the following research recommendation: 'How effective and cost effective are interventions to support people in the community who are bereaved or affected by a suicide?' )
In residential custodial and detention settings, they agreed that extra support during particularly vulnerable times, such as 'early days', might reduce the risk of suicide. Peer support, along with measures such as the provision of 'safer cells', might also help to act as deterrents. But there is a lack of evidence and more research is needed to evaluate the effectiveness of different interventions in a range of custodial settings. (The committee made the following research recommendation: 'What interventions are effective and cost effective in reducing suicide rates in custodial and residential settings?' )

Impact

Increasing local awareness of suicide and the support available could encourage more people to seek help and so increase health and social care costs.

Reduce access to methods of suicide

Rationale

The committee agreed that it is important to identify local suicide trends, including common methods and places where suicide is more likely, such as bridges and railway stations. That way action can be taken to reduce people's access to both the methods and places.
Physical barriers like fences and netting could reduce the number of suicide deaths in places where suicide is more likely because it makes it more difficult for people to put themselves in danger. Evidence showed that if a barrier stops a person from taking their life in one place they will not automatically go somewhere else and try again.
Similarly, compliance with national guidance, for example on safer cells in custodial settings (see the Ministry of Justice's Quick-time learning bulletin: safer cells) and restrictions on painkiller sales in the community can act as an effective deterrent.
The committee agreed that, despite the lack of evidence, it may be worth thinking about implementing these measures because they can sometimes give people time to stop and think – and so may prevent deaths. The presence of staff at high risk locations may also give people a chance to reconsider, as well as being a source of timely support.

Impact

Where physical barriers or other measures are needed this may have a resource impact in terms of staff time and construction and maintenance costs. NICE has an implementation tool to help determine the cost effectiveness of different interventions.

Support people bereaved or affected by suicide

Rationale

The committee agreed that people affected by a suspected suicide may, as a result, be at risk of harming themselves. This includes family members and friends of people who have died, as well as first responders.
The committee heard that bereavement support can reduce this risk, especially when tailored to the person's needs. People who had bereavement support were also likely to experience lower levels of depression and anxiety. Some of these benefits were based on personal accounts because the evidence was limited.
Some services have been developed locally to provide this type of support. But because there is very little evidence on the benefits, local authorities are reluctant to commission such services. Research is needed to build an evidence base on these interventions for people in the community so that effective and cost-effective statutory and voluntary services can be developed. (The committee made the following research recommendation: 'How effective and cost effective are interventions to support people in the community who are bereaved or affected by a suicide?')

Impact

The committee recognised that providing support for people affected by suicide may be cost effective from a societal perspective, when the costs of productivity losses are taken into account. However, because of the lack of evidence this supposition needs to be treated with caution.

Prevent suicide clusters

Rationale

Suicide clusters can emerge quickly and unexpectedly. But an expert told the committee that if the right systems are in place then it is possible to reduce the likelihood of further deaths.
This was supported by the committee's own experience. An expert also explained to the committee that the police and the coroner's office need to notify agencies as soon as possible when a suspected suicide is being investigated. That is because an inquest to confirm cause of death is usually only held 6 to 12 months after the event. This is too late to prevent new suicide deaths if a cluster is developing.
Residential custodial and detention settings have a duty to undertake and learn from reviews of incidents of self-harm to prevent future occurrences and make custody safer.
Based on this information and their own experience, the committee agreed that rapid intelligence sharing is important.

Impact

Improved communication and information sharing between statutory agencies and community organisations may have resource implications. For example, the costs of staff time, communication, interventions and the meetings associated with multi-agency teams.

Reducing the potential harmful effects of media reporting

Rationale

Irresponsible reporting of suicide may have harmful effects, including potentially increasing the risk of suicide.
Reports of the method used in a suspected suicide seems to increase the risk of other people copying the suicide – so-called copycat suicides. And inaccurate media reporting upsets people bereaved by suicide. So steps to encourage responsible reporting could prevent further suicide deaths.
Although there was little evidence on personal experiences of suicide or suicidal behaviour shared through social media, the committee agreed that the guidance given to the media should also apply to social media.
To combat the harmful effects of irresponsible reporting, the committee agreed that it is important to promote best practice and also monitor media coverage.

Impact

Providing training for journalists may have cost implications. But better reporting generally has beneficial outcomes.

Training

Rationale

Some evidence showed that training improves people's knowledge about suicide, the risks and how to prevent it. The committee agreed that it may be effective to train a range of people involved with both the public and with occupational groups known to be at high risk of suicide. That way they can help spread general prevention messages and encourage people at risk to talk and seek help.
But UK evidence on the effectiveness of gatekeeper training is limited and there are only a few specific training programmes available. Training for all gatekeepers is important because it may help to identify more people at risk of suicide. But research is needed to evaluate how effective it is. (The committee made the following research recommendation: 'How effective and cost effective is gatekeeper training in preventing suicides?')

Impact

Training can be costly. But it is expected to be made available through existing continuous professional development programmes, so the costs for professionals and organisations could be minimised. For example, Health Education England has developed generic and specialist competencies for people working with adults and children with suicidal behaviour or ideas and for non-specialists working in community settings.

Glossary

(reduced access to time out of cell and purposeful activity, usually as a result of short staffing or serious incidents)

Paths in this pathway

Pathway created: September 2018 Last updated: September 2018

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