Measures to improve the care for people who self-harm

The number of people who self-harm has risen steadily over the past two decades, meaning the UK now has one of the highest rates in Europe.

The number of people who self-harm has risen steadily over the past two decades, meaning the UK now has one of the highest rates in Europe.

As a result, hospitals are increasingly likely to treat patients who have deliberately injured or poisoned themselves, with around 220,000 people who have self-harmed presenting to A&E wards each year.

The risk of a person who self-harms undergoing a repeat incident is high. People who self-harm are also at greater risk of suicide than those from the rest of the population.

Yet, despite the frequency and seriousness of the condition, the kind of care that a person who self-harms receives varies considerably.

A study from the National Institute for Health Research shows that many who present to emergency services following an incident of self-harm report being treated differently from other A&E patients - a fact they link to the nature of their injury.

The study also found that more than half of people who self-harm feel they have not received enough information about the nature of their injury or condition.

Professor Navneet Kapur, from the University of Manchester, runs the Multicentre Study of Self-harm in England, which has been collecting data on patients who present with self-harm.

"Self-harm is a common problem that is potentially associated with very serious outcomes. Healthcare services need to take this seriously - we need to provide treatment quickly and to intervene," says Professor Kapur.

"We need to make sure we are providing the best quality care we can because there is perhaps a perception that people with self-inflicted problems are less deserving of care.

"It is important that we should drive up standards for people who self-harm across the board."

Treating patients with dignity and respect

To help do this, Professor Kapur worked with NICE to produce a quality standard on self-harm, which aims to drive quality improvements in the treatment that people who self-harm can expect to receive.

The standard consists of eight measurable statements, which if implemented, will help improve the management and longer-term support of people who self-harm.

The first statement says that people who have self-harmed should be cared for with compassion and the same respect and dignity as any service user.

NICE states that everyone who uses healthcare services should be treated with compassion, respect and dignity. However, for people who have self-harmed staff attitudes are often reported as contributing to poor experiences of care

In addition, punitive or judgemental staff attitudes can be distressing for people who have self‑harmed and may lead to further self‑harm or avoidance of medical attention.

Professor Kapur believes that small acts can go far in helping implement this measure.

He says: "We know from the accounts of patients and service users that sometimes people don't quite the get quality of care that they deserve when they come to hospital.

"So the best practical measure for services to take is to ask patients directly - how well were they treated when they presented to a service following self-harm?

"It's a simple measure that can be a very powerful driver of standards."

Initial assessments to prevent repeat episodes

Unless treated quickly, the outcomes for people who self-harm can be poor.

Around 1 in 10 people who self-harm repeat self-harm within 5 days of the first incident. In addition, people who self-harm have a 50 to 100 fold higher likelihood of dying by suicide in the 12-month period after an episode than people who do not self-harm.

To tackle repeat incidents and the risk of suicide, the quality standard includes a statement which says people who have self-harmed should have an initial assessment of physical health, mental state, safeguarding concerns, social circumstances and risks of repetition or suicide.

This initial assessment can identify whether a person who has self-harmed is at immediate physical risk so that steps can be taken to reduce this risk, including referral to more urgent care if indicated.

Professor Kapur says: "We know that repeat incidents of self-harm are common - so, we need to catch this quickly and prevent them from occurring.

"An initial assessment will help healthcare services provide treatment or intervene in a timely manner."

Psychosocial assessments for effective follow-up

The quality standard also includes a statement which measures whether people who have self-harmed receive a comprehensive psychosocial assessment.

Professor Kapur comments: "Psychological assessments are a particular interest of ours at the multicentre. We know that not everyone gets a proper assessment, with our data showing that up to 40 per cent of people miss out on one.

"This is important as a number of our studies consistently show that people who get an assessment are 40 per cent less likely to self-harm than people who don't. That is a really important finding - that just getting an assessment seems to help."

NICE says that carrying out a comprehensive psychosocial assessment can help identify factors that might explain an act of self-harm.

These assessments should be carried out each time a person presents with an episode of self-harm. They can start a therapeutic relationship with the healthcare professional and be used to form an effective management plan.

Professor Kapur believes that providing good staffing levels will help with ensuring that psychosocial assessments are carried out.

"What could services do to implement this measure? It's about providing people on the ground so that they can make those assessments.

"In many places now, people will be seeing members of self-harm teams in emergency departments and in the medical wards. What these teams will be able to do is to increase the proportion of people getting an assessment.

"So, what the quality standard will do is enable wards to say that 'Yes, we have a self-harm team, and we are monitoring the proportion of people that the team sees each year.'"

He adds that implementation of the quality standard could also help save costs through avoiding repeat incidents of self-harm.

"We hope that the quality standard's accompanying commissioning guide will help drive up services as well," he continues.

The NICE pathway on self-harm contains all of NICE's recommendations on the topic and links to the range of tools NICE has produced to help support implementation.

These include a costing report, a costing template, learning resources and resources for service improvement and audit.