Northern Ireland Assembly Flax Flower Logo



Inquiry into the Prevention of Suicide and Self Harm

3 April 2008

Members present for all or part of the proceedings:

Mrs Iris Robinson (Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mrs Carmel Hanna
Mr John McCallister
Ms Carál Ní Chuilín


Mr Martin Bell )
Mr Gerard Collins ) Department of Health, Social Services and Public Safety
Mr Andrew Elliott )
Dr Bernie Stuart )

The next evidence session is with officials from the Department of Health, Social Services and Public Safety. I remind members that this is the final oral evidence session in which to clarify issues with the Department.

Welcome to Andrew Elliott, director of the population health directorate, Dr Bernie Stuart, director of the mental health and disability services directorate, and Gerard Collins and Martin Bell from health improvement policy branch. You are aware of the format of the session; although we will not be watching the clock, you will have approximately 10 minutes to make a presentation, followed by questioning. I look forward to hearing what you have to say.

Mr Andrew Elliott (Department of Health, Social Services and Public Safety):

Thank you. We are most grateful for the opportunity to participate in the inquiry into suicide and self harm. On the two previous occasions that I was in front of the Committee, I was able to begin by saying “This is a highly technical matter”, and then there were no questions, which was wonderful. This occasion is clearly the reverse of that situation.

Suicide and self harm are highly sensitive issues that are most challenging for officials to work on, not only because of the anguish and despair of the affected families, about which the Committee has heard, but because it is difficult to devise interventions that we know will be effective in reducing suicide rates, which are a worldwide problem. Across the globe, people are attempting to find successful means of tackling the problem.

I say that in order to set the context; however, we have developed a strategy. There will always be scope for improvement — for example, we will want to improve the strategy in light of the inquiry’s report — but the strategy provides a good balance of the crucial elements that must be in any strategy if it is to successfully combat suicide. In a nutshell, there are four elements: better joined-up working, particularly in working with communities, which was not always the case in the past; a bigger focus on training and development, which must be implemented across communities, particularly in relation to talking therapies; general improvements in mental-health development; and changes to the way in which services are delivered and resourced.

As I said, there is scope to continue to work on and improve the strategy. Importantly, it was designed to incorporate regular review opportunities. We anticipate that the inquiry will be an important contribution to the next strategy review, providing an opportunity to evaluate and amend it. Therefore, we have followed the inquiry with considerable interest.

Although I do not wish to cover ground that has already been covered, members are aware that the average number of suicides rose from 150 a year between 2000 and 2004 to almost 300 a year by 2006. The 2007 figures indicate a reduction in the suicide rate; however, up to September 2007, 166 suicides were recorded, which means that a great deal of work must still be done to reduce the rate even to 2000 levels. It is well documented that suicide rates tend to fluctuate. Therefore, I am hesitant to claim that the strategy has had any real effect on the figures to date. It is only over the long term that, hopefully, one might begin to detect real changes.

It is also worth reminding ourselves that much of the impetus for the work that we are doing came from families and communities that had been affected by suicide. They had the courage and energy to make the matter a much higher priority than it had been in the past. That has affected the focus of the strategy on issues such as reducing the stigma surrounding mental health in general and suicide in particular.

It is important to say that suicide is often a manifestation of poor mental health and, just as importantly, poor mental well-being. It would be a mistake to try to tackle suicide in isolation from the wider work that is being done in mental health. The Department must always try to keep those two areas of work in tandem.

One in five people here experiences a mental-health problem at some point in their lives. I have read some statistics that suggest that the figure is one in four. There are particular points in people’s lives when they are more vulnerable than at other times, and can be prone to depression, for example. It is important that we be ready and able to help people in those circumstances.

When we assess the various risk factors, we are increasingly seeing the scope for benefits that result from tackling the levels of hopelessness that are to be found in certain parts of society, and in addressing mild depression as well as more severe forms of mental illness. Some pioneering work is going on in Scotland in that regard, particularly in Dumfries and Galloway. We will examine that work closely to determine whether we can use some of the funding that is available as a result of the Bamford Review in that way.

The Department has allocated just over £6 million per annum to suicide-related issues, and some recent developments since the Committee last met have included the establishment of the regional telephone helpline. I am sure that we will talk more about that. Research has begun into the specific effects of the Troubles, how they came to an end and what impact they had on the number of suicides that has occurred.

The new GP depression awareness training programme is also under way. It took a long time to progress, and there is more to do, but a great deal of work has been done in that programme, which is a positive start. We have developed a new North/South public information campaign, which will be beneficial in reaching the wider population. We have also begun to develop a crisis intervention service.

Suicide does not respect boundaries. It is important that we work beyond our borders where necessary, particularly in learning, and we are working with our nearest neighbours in that regard. We must also work more effectively across sectoral boundaries. The various sectors of Government in Northern Ireland can work together more effectively, as indicated in the Investing for Health strategy, in order to achieve better results.

The Department is going through a massive learning process on those issues, and we will know more as a result of this inquiry. We look forward to your questions.

Ms Ní Chuilín:

This has been a very important piece of work for us all. There is a massive amount of interest in the outcome of our inquiry. However, there is even more interest in what the Department is going to deliver.

I want to draw the attention of the policy-makers to the lack of an equality impact assessment of the Protect Life strategy. That is a missed opportunity; there are impacts and variations between rural and urban groups in their experiences of the conflict/Troubles, even in relation to age. Our inquiry is time-bound and age-limited, but the Department must return to those issues.

I also want to highlight the “card before you leave” practice, which has been raised time and time again. It is an important issue on which we have received some correspondence. When someone goes to hospital feeling suicidal, they walk out again with no card, no appointment and no hope. They are put on an endless list. That is a basic measure that could be implemented easily, and would give people something to physically and emotionally hold on to. Families, practitioners, stakeholders in the community and those who have used the accident and emergency departments have suggested such a scheme and, therefore, it cannot be ignored. This is the last opportunity to introduce the measure, which would have a big impact on the ground, unless there are massive financial implications. However, even if that is the case, how can financial implications be compared with potential loss of human life?

Ongoing stakeholder involvement is crucial. I know that Mr Bell has worked with groups such as the Public Initiative for the Prevention of Suicide and Self-Harm (PIPS) and Reaching Across to Reduce your Risk of Suicide and Self-Harm (RAYS) in the Shankill area. Unfortunately, while the number of people taking their own lives fluctuates, there is a massive increase in the number of people who are self-harming. The demands are stringent, the services are scarce, and — as Anne Donaghy said earlier — the bereaved receive little support.

The Protect Life strategy and the budget need to recognise, value and support the contribution of those who deliver that vital service while dealing with their own bereavement and grief; they feel the need to help other people by attracting resources and money.

Finally, I want to discuss the monitoring and evaluation of the helpline. The Committee welcomes the introduction of a 24/7 helpline but, as has been raised previously, few members know the number, and when we spoke to families in the Everton Complex, very few of them knew the number either. Although I do not dispute the number of calls that the helpline may receive, it would receive more if awareness were increased. Equally, the groups who work on the ground with bereaved families were not asked their opinion on the delivery of the helpline, and that is crucial, because its success will be underpinned by awareness and knowledge. We must increase access to information, help and support.

Mr A Elliott:

I am pleased that Bernie Stuart is in attendance; she is the director responsible for mental-health services policy in the Department, and many of the issues before the Committee straddle service provision, mental-health promotion and suicide prevention. Between us, hopefully, we can answer most questions that may arise.

Dr Bernie Stuart (Department of Health, Social Services and Public Safety):

Ms Ní Chuilín talked about the introduction of a card system in hospitals; I am keen to consider that. The Department is aware of major issues concerning the use of hospitals in a crisis situation and has work under way to examine crisis intervention in accident and emergency departments. There are crisis intervention teams in the various board areas, which consider crises from one perspective. The Department is also examining the type of people who attend hospital and are discharged, so we will consider the Committee’s suggestion when developing guidance on those services. We want to develop a protocol that everyone can follow, irrespective of whether the person has, or is on the fringe of, a personality disorder or a mental-health problem.

In our response to the Bamford Review, which is nearing completion, carers’ support is an issue that the Department has raised. The statutory sector must develop its partnership with the voluntary and community sector. That is at the fore of the Department’s strategy, because it is important that the new money gained from the comprehensive spending review is spent not only on the statutory sector but on developing meaningful partnerships with all stakeholders, including the carers’ organisations. The Department has already started to work on that.

Mr A Elliott:

The first issue that Ms Ní Chuilín raised was the lack of an equality impact assessment (EQIA) on the Protect Life strategy, which was slightly before my time. However, the strategy will have been screened and a judgement made that an EQIA was not necessary. Given that the Committee has raised the issue, the Department will reconsider the evaluation of the strategy and examine whether more work needs to be done. As Ms Ní Chuilín rightly pointed out, suicide has a differential impact on various groups.

Ms Ní Chuilín:

I asked the question because suicide has different impacts. Not to consider those differences would create more inequality for those people in the community who are more socially excluded, and that is the last thing that we want to do. I am not asking for an EQIA for the sake of it but to serve a definite purpose.

With respect, it is not enough for a civil servant to screen the strategy and decide that an EQIA is not appropriate. An EQIA is appropriate, because screening it out means that an extremely marginalised group may be excluded. After all the time that Committee members have spent on this subject, we do not want that to happen. My purpose in asking for an EQIA is not to give you more work, or to make you do it because it is politically correct or trendy; it is because of the differentials in the strategy’s impact. I accept, however, that the decision not to carry out such an assessment was made before your time.

Mr A Elliott:

I do not for a moment mean to suggest that EQIAs are done purely for the sake of it.

Ms Ní Chuilín:

There has been a culture of that kind of thinking, although I accept that it is not of your making. However, it is important, particularly for people who are extremely vulnerable, that an EQIA be carried out.

Mr A Elliott:

The strategy details some stark figures on the differential impacts on, for example, deprived and non-deprived communities.

The question of stakeholder involvement was also raised. The Department considers that the establishment of the implementation body and the opportunity that that provides for a wide range of stakeholders to become involved in influencing and affecting the direction of the strategy will have the greatest impact. We want that to be an effective mechanism and, if there is anything that we can do to strengthen or improve the body, we will consider it.

The Chairperson:

I want to flag up a topical and sad issue. The basic finding of the report of the independent inquiry into the case of Madeleine and Lauren O’Neill was that there was poor communication between the professionals involved in Madeline’s care. Reading the report, I was appalled to discover that two thirds of counselling work takes place outside the National Health Service. There is little recognition of professional counsellors who work outside the Health Service and the communication between the private and statutory services is poor — and not just in Madeleine’s case.

What is being done in light of the report’s recommendation that feedback should be available on communication between the private and statutory sectors? In Madeleine’s case, for example, her counsellor had no input into the involvement of the statutory sector in her case. The report suggests that her counsellor was, at best, treated with indifference. Can I be given an assurance that there will be a learning curve from that case, and that we can ensure that the public know and are given some cause to believe that a working engagement exists?

Mr A Elliott:

I will speak about the issue in general; not specifically about the O’Neill case. I will then ask Bernie to make a few comments.

The Chairperson:

I am referring to the wider issue. Two thirds of counselling work is conducted outside the remit of the NHS. Why is there that lack of communication, which seems to be one of the pitfalls that led to that untimely incident?

Mr A Elliott:

An ongoing area of work for the Health Service generally — not simply in Northern Ireland — is to ensure that the statutory services appreciate and value work that is often conducted effectively in the community and voluntary sectors. Such work is not always valued. It is an ongoing cultural issue that we must address.

Dr Stuart:

The O’Neill case raised many terrible issues. All the recommendations that have been mentioned are being progressed.

The issue of poor communication has been raised in many independent inquiries. We are considering the issue in a more general way. Apart from reinforcing the existing guidance, we are considering how to train people to communicate better.

Communication between the counselling services of the different sectors was mentioned. In response to the recommendations of the Bamford Review, and as a result of the money that we received from the comprehensive spending review, we have a significant amount to invest in the development of psychotherapies. The process of developing a psychotherapy strategy is ongoing, and we hope to have it ready later this year. In advance of that, targets have been set — by March 2009, no patients within a certain range should have to wait for more than 13 weeks from when they are referred to when they get access to psychotherapy treatment.

The relationship between the private sector and the statutory sector will have to be developed further as part of the wider work on that issue. Workforce issues are part of the response to the recommendations of the Bamford Review. We have realised that it will be a major shift to move towards more delivery of health services in the community, and less in the hospitals, which will require a different workforce. Therefore, a project to consider that issue is under way.

Committee members will be aware that last autumn, the Minister announced a campaign to try to recruit extra mental-health nurses and learning-disability nurses. However, those are not the only areas in which there is a shortfall. We are considering new ways of training more counsellors in order to be able to meet the increasing demand. That will mean that people with mild or moderate depression will have access to that type of service.

We are also considering other innovative ways of addressing that kind of need so that people who do not need access to the most highly qualified psychiatric nurses, can get access to those with lower-level qualifications.

There are probably issues about the standard training of counsellors in general. Some work is under way in England to consider the level of NVQ that should be required in order to allow people to practice. We are awaiting the outcome of that.

In certain cases, people will need to be highly qualified in order to deliver certain services. However, other services — for example, those that require early intervention — may be able to be delivered by someone with a relatively low qualification.

I do recognise the point that much better co-operation is required between both sectors. We do not want all the psychotherapy services to be delivered by the statutory sector, and that will never be the case.

Mr Easton:

The document focuses on the statutory medical bodies, as opposed to those based in the community, although you did touch on those, which I was glad to hear.

As regards the community approach, it is important that community groups, the Churches, councils and the various bodies are taken extremely seriously and that they are involved fully in partnership with Department. Without that, the strategy will not work or, at least, its impact will be lessened. I urge the Department to put that approach at the forefront of its thinking. That is vital.

As Carál said, when patients are discharged from hospital, they should be given an appointment card to give them hope. She said also that discharged patients should not merely be given a card and the number of a 24-hour helpline: other services must put in place. We should have a drop-in house, as they have in Dublin, where people affected can contact, for example, local churches. There must be a joined-up approach; people affected should be able to consult ministers or external councillors. All those services must be available to support patients when they come out of hospital and when they are away from their doctors. Things to do should also be organised. When the Committee visited Scotland, we saw how walking groups and reading clubs had been formed. Such activities take people’s minds off problems, and provide a focus. That type of approach is crucial: I urge the Department to consider seriously such activities, in addition to its general approach.

The Chairperson:

The house in Dublin, which Alex mentioned, is called Pieta House. It is a model with which all Committee members are very impressed. If you have not visited it, you should make a date to see it. It is community-led, but all the relevant professionals are on hand. It is hoped that it can be turned into a 24/7 service. People presenting at accident and emergency units can be taxied to the house and treated immediately. They are followed and supported throughout their recovery until they are able to cope. Of the 1,100 people who have crossed the threshold, not one has been lost to a completed suicide, which is amazing. It is an excellent model that should be rolled out in every trust area.

Mr Martin Bell (Department of Health, Social Services and Public Safety):

I may be able to provide some more information on the community aspects. With respect to Ms Ní Chuilín’s question, working with communities and bereaved families has been one of the most the most rewarding aspects of the strategy.

In ensuring that representation is as it should be, we have not always got it right. That is something that we are learning, and getting better at. For example, local communities and bereaved families have substantial representation on the regional suicide strategy implementation body, and they play an important part in oversight of the whole strategy. A reflection of the importance that we attach to that issue is that in 2008-09, over £2 million, of the £3 million budget, will be allocated as part of a community-support package for local health boards, to help local communities to develop initiatives that will help to tackle suicide and self harm.

We are still learning, but we are keen, and the Minister has given a commitment that communities and bereaved families will be at the heart of everything that we do. Where we have got that wrong, we will change it; we have done so in the past. We are open to making those changes.

With respect to the helpline number, we are aware of the present lack of publicity. As we speak, a substantial advertising campaign is being developed, which will soon go live. Interestingly, prior to the formal announcement of the helpline, Contact Youth, which conducted the pilot scheme, received up to 100 calls per day. Caller activity has increased to between 200 and 250 calls per day, and that is before the advertising campaign has begun. It is clear that knowledge of that helpline has spread by word of mouth. However, we are aware of the need to have a formal campaign, and that will go live shortly.

Mr Easton:

We were told that groups such as the PIPS project had to apply for funding a year at a time, and had to spend most of their time trying to obtain funding from different sources. Is it possible to introduce three-year funding cycles to make it easier for such projects to spend more time on their strategies and work, and spend less time chasing after funding?

The Chairperson:

We are now in April. What is the situation regarding the funding of the voluntary sector? Are there moneys in place to allow voluntary organisations to continue?

Mr A Elliott:

The Department looks to the boards to let organisations know as soon as possible about their funding. There is a reasonable degree of certainty now as a result of the completion of the CSR. There are opportunities, if we move quickly, to get things working. The finance division of the Department has examined the issue of one-year funding, which causes uncertainty until the following year. There are mechanisms evolving through which we can consider the possibility of two-year funding. Boards will be given a little more flexibility in that regard. I understand completely the frustrations created by one-year funding. It not only affects suicide prevention projects, it has an impact across a range of areas, and it provides a real challenge.

The Chairperson:

We must always recognise the sterling work carried out by voluntary groups, and how they contribute to the well-being of the communities that they serve.

Dr Deeny:

I wish to thank all four of you for meeting the Committee. I have had an interest in these matters not just politically but also as a health professional for some years. Sadly, I have had to deal with suicides and the family devastation that follows. Mr Elliott mentioned the number of people who have mental-health problems. I believe that the number is even higher. Any GP will tell you that 25% to 30% of their consultations are about mental health. Even though that is the case, sadly, some of our patients can, in the space of six months or a year, become actively suicidal and take their own lives. In other countries, as well as our own, there are people who put the rope around their necks, so to speak, even before they have seen a health professional, which is very worrying.

Having been a doctor for some years now, I believe that there is a vulnerable period when a person can become actively suicidal. That is the challenge that we face. How do we get to those people, or get them to the appropriate person during that vulnerable period, before they commit suicide?

The Chairperson made reference, as we did in the previous presentation, to the facility that we saw outside Dublin. As a doctor, that is the best facility that I have ever seen. It is a community-based, friendly centre. It was not an old psychiatric institution with a threatening atmosphere that carried a stigma, which sometimes makes a situation worse; nor did it have a waiting list. We have a waiting list that goes way beyond the vulnerable period. The facility gave immediate access to relatives and friends, accident and emergency departments, GPs and the police. I was glad to hear Dr Stuart mention that, because GPs have been admitting for some time that they have had to prescribe anti-depressants because they do not have access to talking therapies. That is a major problem, so it is good to hear that some of the money that is to be made available as a result of the Bamford Review’s recommendations will be used for the talking therapies. We need well-trained counsellors, and I am glad to hear Dr Stuart say that those therapies will be of an acceptable standard. That is what we saw in Dublin. The Chairperson mentioned that 1,100 people had passed through that facility, which was so friendly, and did not look like a hospital or a health centre at all. As far as I know, not one of those people has committed suicide, which, as a doctor, is a staggering fact for me to hear.

Can the Department see a situation where, given the financial help for talking therapies and by working along with the Northern Ireland Local Government Association , councils, and, indeed, the new commissioning groups, a building could be provided in each of the five trusts that would be immediately accessible to people who are feeling suicidal?

I believe genuinely that, as we saw in Dublin, the telephone helpline provides virtually immediate access, and that service must be provided. A person may not be able to wait over a weekend for support, and may have hung themselves by the Sunday. That is the big challenge. I must admit that I do not know the details of the telephone helpline service, although I should know. Does it have a name? For example, everyone — certainly children — knows about Childline, so perhaps it should be called something such as “Lifeline”, something catchy that people will know about. It should also have a short number, and people should be able to get through to an operator quickly, and, perhaps, be directed to one of the centres. If a person is genuinely feeling suicidal, he or she should be able to lift the phone and speak to someone who will advise where in the trust area he or she can go immediately to receive support. If we can meet that challenge, we will save lives.

Mr A Elliott:

In relation to the final point, we see the launch of the telephone helpline as being an opportunity to raise its profile, and to create something that, at least as far as telephony is concerned, is available 24/7. The helpline service should be something that people know about, with a recognisable name, and those aspects are being planned. It is interesting that Dr Deeny mentioned the name “Lifeline” because that is one of the names that is being considered for the telephone helpline. We must make the service something that everyone everywhere knows is available, in case they find themselves in a position where they need it. Bernie will discuss the buildings.

Dr Stuart:

As I said earlier, we are looking at developing a psychotherapy strategy. We have the money for that. We have not got as far as spelling out exactly what the community infrastructure will be, but our response to the Bamford Review states that it is not enough to say that we do not need as many hospital places — we need a community infrastructure, and we are working on how that will be implemented. I am interested in exploring how Pieta House in Dublin operates, to see whether something similar to that could be one of the options.

However, we recognise the importance of immediate access to care. As members know, the crisis intervention teams that are in place are all operational to a certain extent but they are not fully staffed yet. Those teams are only working from nine to five but, where possible, we are planning to extend that, in conjunction with the work that we are doing on emergency access with accident and emergency departments. I agree that it is vital that community infrastructure is available to match the need for it, and that matter will be considered more closely.

Mr A Elliott:

The thinking about some of the therapies, particularly the talking therapies, is potentially very positive. Some of the work from Scotland that I have seen shows that the benefits of those therapies may extend beyond mental health. If we can successfully find the interventions that build resilience in people, there are potentially significant benefits to be had in reducing cancer, cardio-vascular disease, and a whole range of issues that we deal with. Those interventions are likely to be high quality talking therapies; however, getting from talking therapies to high quality talking therapies is itself quite a big step. Much work must be done to ensure a meaningful delivery of that service in Northern Ireland.

The Chairperson:

Unfortunately, we seem to live in a society where people lack coping skills, particularly younger people. Of course, the breakdown of the family unit is an additional problem. However, I hope that you will visit Pieta House and take cognisance of that model, as I suspect that, when you see what it is achieving, you will come back as enthused about it as we were.

Mr Buchanan:

Obviously, a lot of work remains to be done between the statutory and community sectors in order to put the jigsaw together and provide the required services for these vulnerable people. That may well leave a vacuum in the short term. Have we fully trained staff in every accident and emergency department in Northern Ireland who can recognise and deal with a suicidal individual who comes through the hospital doors?

Dr Stuart:

I will have to come back to members on that. All accident and emergency departments should recognise a serious case. However, we must examine interventions in borderline cases — when it is not clear that somebody is suicidal.

Mental-health disorders do not always show themselves in the same ways. For example, mental-health disorders in young people do not necessarily show themselves in the same ways that they do in adults.

In theory, the answer is yes — we have staff in every accident and emergency department who can recognise and deal with suicidal people — but there are sad cases when people leave accident and emergency departments and commit suicide. There is more work to be done on that.

The qualifications of the staff are not in question; they have the ability to cope with people with serious mental-health problems in a hospital. We want to consider borderline cases, and early intervention, to prevent situations becoming worse.

The Chairperson:

We all welcome the ongoing project in north and west Belfast. The sooner that we get those programmes rolled out in east and south Belfast, and within rural constituencies, the better. Indeed, the need can be greater in rural settings due to the isolation that people can suffer.

We all aim to achieve the same objective — a first-class service for those who require it, from the mildly depressed to those who present with very serious psychotic problems.

I thank you all for coming along and for your help. It has been a pleasure working alongside you and seeing you on the number of occasions that we have. No doubt we will see you again soon