This example describes a project to improve upon the quality of interventions for people presenting following an episode of self-harm/distress and reduce the risk of further self-harm across Sussex by:
- Providing a compassionate timely and effective brief follow-up response to adults and older adults who present at A&E where self-harm and suicide attempts are recorded and captured on the A&E dataset
- Supporting connections already made via A&E referrals and signposting according to the support plan agreed following psychosocial assessment.
Evidence from the National Confidential Inquiry into Suicide and Safety in Mental Health (2018) highlights that most post-discharge deaths by suicide occurred in the first week after leaving inpatient care, with the highest frequency on the third day after discharge. Many of these people had died by suicide before their first follow-up appointment.
The NICE quality standard for self-harm in 2013 states:
- People are treated with compassion, respect and dignity
- They receive an initial assessment of physical health, mental state, social circumstances and risk of suicide.
- They receive a comprehensive psychosocial assessment
- They receive the monitoring they need to keep them safe
- They are cared for in a safe physical environment
- Collaborative risk management plan is in place.
- They have access to psychological interventions.
- There is a transition plan when moving between services.
Based on this new standard this A&E Follow-up Service would aim to follow-up with people post self-harm incidents following the principle that they are likely to remain vulnerable during this period of time and to ensure that the agreed plan on leaving A&E has been followed through. For those without a plan, it will provide another opportunity to engage and support them.
We have an ambition for a pan-Sussex service. This pilot phase commenced across three hospitals in Sussex: Eastbourne District General Hospital, the Royal Sussex County Hospital in Brighton and the Western Sussex Hospital in Worthing.
The proposal is based on current demand across the A&E departments. However, with the current COVID-19 situation as of this time in January 2021, demand is likely to increase. The pilot will help us to establish the demand for the service and the capacity needed to provide a flexible and responsive service.
The objective is consistent with the Trust’s view that the suicide of those in our care should be seen as preventable at some point in that person's mental health journey. The project will contribute to the Trust's Towards Zero Suicide Strategy.
The example draws upon recommendations from NICE guidance for self-harm (CG16) and the NICE Quality Standard for self-harm (QS34)
Example
Aims and objectives
This pilot project aims to follow up people post self-harm following the principle that they are likely to remain vulnerable during this period of time and to ensure that the agreed plan on leaving A&E has been followed through.
The proposed service, delivered by Sussex Partnership Foundation Trust, will make contact with those presenting with self-harm at A&E within 3 days of A&E attendance. Before leaving A&E, the person will be offered an appointment slot for follow up with a named person from the team.
The appointment offered is conducted by telephone or using ‘Attend Anywhere’, and will include discussion on the plan made as part of their psychosocial assessment by the psychiatric liaison service. If the person was still suicidal, they would be invited back through the Urgent Care Pathways. It is anticipated that the service would relieve some pressure from the Assessment Treatment Service (ATS) teams by contacting people within the 3-day period.
The service provides an improved level of care, providing individuals with the skills to cope and improve their own safety management with the aim of:
- Reducing A&E re-admissions
- Reducing and preventing further acts of self-harm
- Reducing the risk of completed suicide in patients who self-harm
The ambition was for a pan-Sussex service. Commencing the pilot phase in Eastbourne, Brighton and Worthing with a view to test the approach in the three areas and to roll out further based on evidence. Within a matter of weeks, the service offer was extended to a further four hospital A&E sites. This was largely due to clinical staff seeing the benefits of the timely follow up with patients.
Key data to contribute to measurable quality impact:
- Number of contacts made by service
- Outcome from follow-up contacts
- Number of repeat attenders to A&E
- Qualitative feedback by those experiencing the brief follow-up intervention
Key quality benefits:
- Reduction in re-presentations to A&E
- Longer term reduction in the number of suicides
- Potential relief to existing ATS teams
The service will follow a PDSA (Plan, Do, Study, Act) cycle, setting the aim, selecting the measures, identifying change areas and evaluating the change. An interim evaluation will be completed at six months from commencement which will allow reflection and adaptation of service delivery elements underutilised or that need to be adapted. Further evaluation will allow for sound decision making as to whether the pilot has been successful and warrants extending to other hospital sites across Sussex. Taking this phased approach will ensure that the service offer could be adapted and flexed to fit the existing services and pathways in those areas
Reasons for implementing your project
Approximately 900 adults and older people present to one of the A&E departments across Sussex each month. Of those presentations, a small number will usually be referred to the crisis teams and some signposted to other services, whilst a smaller number will leave without engaging at all.
Given the current COVID-19 situation as of January 2021, it is anticipated that this number will increase with more people vulnerable to mental health problems and potentially suicidal ideation and this proposal will help to meet the anticipated increased need.
Detailed A&E outcome data indicates that between 7-10 people per day would likely benefit from the proposed service.
As standard practice the A&E Liaison teams would conduct mental health assessments, risk assessments and offer one-off follow-up appointments to patients. Referrals would be made by the team for example to the Urgent Care Lounges, referred to Crisis Resolution and Home Treatment Team, Assessment and Treatment Service or a Mental Health Act assessment.
How did you implement the project
A project group was convened to include representatives from each of the A&E sites. Weekly meetings were set up with the suicide prevention leads within the trust, operational leads, deputy directors from each Care Delivery Service (CDS), the Quality Improvement (QI) lead and Experts By Experience (EBE). The project management office set out the requirements regarding contracts, workforce and governance and the performance team were involved in setting up some of the data collection.
At the beginning of the project, team capacity and how the project would fit in the current team structures were considered, along with the number of people that would need the service.
Pathways into the new service were mapped across each area and a standardised referral pathway and process developed by the group and through wider consultation.
The Standard Operating Procedure was drafted by the project lead, which along with the referral criteria and leaflets were taken to the working groups by the project EBE.
An external evaluator (Professor Stephen Briggs, FAcSS Centre for Social Work Research, University of East London) in consultation with the QI lead will conduct the process evaluation interviews, collect and analyse data, and lead on integrating analysis of data from all sources, review and report writing.
Following the appointment and induction of the Mental Health Support Workers, meetings with the A&E liaison teams took place and the referral process refined. Data collection tools were created and agreed. The mental health workers contacted local service providers for signposting. Regular catch up meetings with the liaison teams and the project team are in place.
The biggest challenge for the project was getting engagement from all three liaison teams in the hospitals. This was overcome by regular meetings with the liaison leads, visits to the teams by the Mental Health Support Workers and clear communication.
This project included ‘Expert by Experience’ input throughout and appropriate documentation went through Expert by Experience working groups. Follow-up call appointment leaflets and self-harm leaflets (including support with safety planning) were created and shared as part of the project.
Key findings
So far the calls have been well received by service users and there have been clear benefits to individuals from these calls. The project made 53 calls in its first month, which has risen to 135 seven months in. There has been a total of 596 calls made in the 7 months the project has been live.
For those who have not yet followed their safety plan (e.g. self-referring to IAPT), it is a helpful opportunity outside of a busy hospital environment, to encourage people to follow this. Some people have also asked to be reminded of what their safety plan is or asked for clarification on how they can access services.
Many of the people have not had prior contact with mental health services, so the call has been a perfect opportunity to ensure the individual knows how they access support. This service is helping people to follow their safety plan and have a compassionate conversation after a traumatic period of crisis.
It is important to offer individuals time to reflect on what has happened and plan how to care for themselves in the future and the follow up call allows for this.
Whilst the ambition is for the service is to be offered Sussex-wide, having commenced with only three A&Es, the appetite to extend that is evident with a further 4 hospital sites going live in the early months of the service. Following consultation with Mental Health Liaison teams, the criteria for referral was also expanded to include those presenting at A&E with anxiety and low mood.
Interim external evaluation highlighted that the number of referrals and calls have been increasing monthly, and that the Mental Health Support Workers have provided a skilled and sensitive service that appears to be appreciated by clinical staff and service users. This feedback has been gained through data collection, interviews and feedback on calls. The report suggests that further work on exploring if care plans are followed through (although this is a significant challenge), obtaining a wider view of experiences of clinical staff and increasing the depth of service user feedback, along with further analysis of referral rates will provide further evidence of the impact of this pilot.
A final external evaluaion report (November 2021) is now attached as a supporting document.
Key learning points
With any new service, it takes time for this to become established and for clinicians to routinely make referrals. It is too early in the project to see if the aims to reduce A&E admissions, self-harm and reduce suicide risk are being achieved, but early feedback from the mental health support workers suggest a positive response from the people they have contacted.
The service has been requested by other hospitals in the area so is being expanded from three hospitals to seven. The decision to extend the service not just in terms of location, but in terms of the criteria for suitability for a call was made following discussion with the Mental Health Liaison Teams who felt that those presenting with anxiety and low mood would benefit from the service.
A big part of setting up the new service has been establishing good working relationships with the referring teams and standardising referring procedures from different services and locations.
Other localities are asking for information to share and learn from the practice of this project which we are happy to provide.