COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY

OFFICIAL REPORT

(Hansard)

Inquiry into the Prevention of Suicide and Self-Harm in Northern Ireland

 15 November 2007

Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Ms Carál Ní Chuilín
Ms Sue Ramsey

Witnesses:
Mr Tom Black ) British Medical Association in Northern Ireland
Mr Danny Lambe )
Mr Ivor Whitten )

The Chairperson (Mrs I Robinson):
I welcome Dr Tom Black, the deputy chairperson of the Northern Ireland general practitioners’ committee (NIGPC) of the British Medical Association in Northern Ireland; Dr Danny Lambe, the deputy secretary of BMA(NI); and Mr Ivor Whitten, who is the Assembly and research officer for BMA(NI). I invite the witnesses to make a five- to 10-minute presentation. We will then have questions from Committee members.

Mr Danny Lambe (British Medical Association in Northern Ireland):
I will say a few words, but first I would like to correct you, Chairperson — it is “Mr”, not “Dr”, Lambe.

I am the deputy secretary of the BMA in Belfast. The BMA is the professional association and trade union for doctors in the UK. Across the UK, more than three out of four practising doctors and the majority of medical students are members of the association. In Northern Ireland, the BMA represents approximately 4,000 members from every branch of the medical profession.

As I have said, we are the recognised trade union for doctors, and we negotiate on behalf of the Government on contracts and on terms and conditions. We produce a range of publications on health matters and medical ethics, and we also produce the ‘British Medical Journal’, which is an internationally renowned medical publication.

Dr Tom Black (British Medical Association in Northern Ireland):
Thank you very much for this opportunity to appear before the Committee, Chairperson. The Committee has already received our submission, so I will not read through it.

Given that the Committee has seen a great deal of information on the subject of suicide and self-harm, I am sure that it will appreciate that it is one of the most intractable and difficult problems that we face. Earlier, Sue Ramsey discussed the case in Omagh, and as she was saying, every case is a dreadful tragedy. No two cases are the same — each has its own story and background. Each suicide appears to be a single event that is similar to others, in that it is an end point. However, the stories that lead up to each suicide are different. It is a bit like asking whether we can find a cure for cancer. That cannot be done unless we must look at the different types and causes of cancer. Dealing with suicide is as complex a problem as that. Therefore, it is a multilayered and multifactorial problem, and we need complex and holistic solutions — all the buzzwords are there.

I would like to hit a few of the targets that I see as a GP who works at the coalface. The first is, obviously, prevention. We are looking at ways in which to raise awareness; training issues; ways in which to help bereaved families; and risk factors, such as alcohol and drugs. A huge amount of work is being done on the matter, so, needless to say, I have spent the past three weeks reading everything that has ever been written in Northern Ireland on the subject. The amount of work and training that already goes on would knock members down. For example, in the Foyle Health and Social Services Trust, which covers the Derry area, 600 people trained on suicide awareness alone. That is an amazing number, and that pattern is replicated throughout Northern Ireland.

Secondly, we must also recognise depression early, and provide treatment. We must consider the number of psychiatrists that we have, as well as the number of available beds in psychiatric units, and strike a balance between treating patients through drugs and through talking therapies. Cognitive behavioural therapy (CBT) is the one most commonly used.

A third area, which is close to my heart, is emergency assessment. The speed of response for somebody who is in crisis is crucial. They must be assessed on the day, and, if necessary, brought to a safe place.

Self-harm is the fourth area that I wish to highlight. Although suicide is a huge problem, self-harm is 30 to 40 times greater. The key relationship between the two is that 51% of suicide victims have self-harmed before their death. That means that, were self-harming dealt with, 51% could be caught.

Admittedly, not every person who self-harms will go on to commit suicide. In the year after a self-harm incident, there is a 1% possibility of a person’s attempting suicide, but that percentage rises to 3% to 4% within five years. Therefore, we should focus on the self-harm group and ensure that they receive follow-up care. Everyone who self-harms is offered follow-up care, but 60% do not receive it. It is important to ensure that those individuals undergo psychosocial assessments and that a care plan be devised for them. We must work really hard and focus on those who are most vulnerable, and then consider the number of psychiatric beds and psychiatrists available.

I have also spoken to a number of child psychiatrists and adult psychiatrists to try to tease out the issues involved. Where I work, there are many problems with suicide. The public come to see us to express their concerns, one of which concerns the issue of detention. For example, some people may tell us about a relative in crisis who was admitted to hospital, only to sign himself or herself out after a few days.

That issue must be examined, particularly for those people with a personality disorder. Under current legislation, a personality disorder is not classed as a mental illness. Therefore, people with a personality disorder can undergo an assessment, yet they are allowed to discharge themselves because they are not considered mentally ill. Only people who are deemed mentally ill in law can be detained. Issues will arise in future as a result of the Bamford Review of Mental Health and Learning Disability. We will be able to consider mental capacity instead of mental ill health in an effort to detain people who are a risk to themselves but who may be assessed as having a personality disorder rather than a mental illness. However, I acknowledge that that will raise human-rights issues.

Finally, I want to emphasise the huge amount of work that is being carried out in the voluntary sector. I could rhyme off a list of acronyms of organisations from now until tomorrow, all of which are doing very good work. We have already heard about how schools are involved in that work. Again, I do not want to talk about specific cases, so I will try to talk in general terms. If a schoolchild has had a particular experience, one could perhaps go to the school to ensure that it offers the counselling required and that the child can access the necessary services and expertise through the local health board and the health trust.

If it suits the Committee, I will end my presentation there and take questions.

The Chairperson:
You may be aware that the Committee has just returned from a visit to the Scottish Parliament, where we looked at its model of care for suicide prevention. The Executive’s strategy and action plan, ‘Choose Life’, which was introduced in 2002, seems to be at a fairly advanced stage. Has BMA(NI) looked at that model or at any of the materials that it has made available to target self-harmers in particular? Have you done anything to replicate Scotland’s efforts? Have you made any proposals that would reflect how well the Scottish Parliament has succeeded in preventing suicide? There has been a significant turnaround in Scotland — 117 suicides were prevented between 2000, when records were first kept, and 2006. There was a drop in the number of suicides in Scotland in that period.

Dr Black:
Scotland has a big problem with suicide. It has an incidence of 17 suicides per 100,000 people. I have no intimate knowledge of the Scottish model. I recommend the huge amount of work that is being carried out on the suicide prevention strategy by boards and trusts. Much good work is being done here.

My reading of international information is that, if we do all the right things and work very hard on awareness and intervention, the initial result will probably be an increase in suicide rates in the first two years. That appears counter-intuitive, but it is the international experience. In five to 10 years, however, information suggests a decrease in instances of suicide of somewhere between 15% and 20%. That is a quite disheartening statistic. We must appreciate that, even if we do all the right things, a problem with suicide in Northern Ireland will remain. We still need to do all the right things and try to achieve that 15% to 20% reduction, if only to stem the tide. Northern Ireland’s target is a 15% reduction in suicides by 2011. It will be difficult to achieve that target.

The Chairperson:
The Committee has discussed young people who present in distress at A&E units. More often than not, their behaviour is erratic, so security guards tend to remove them. Such behaviour is obviously a cry for help, but those young people go off into the night and, unfortunately, proceed with suicide.

What is your view on having dedicated areas in A&E units in which voluntary groups, such as the Samaritans, could be in attendance on a rota basis? They could help to settle that young person. The necessary clinical expertise that is required to help them could then be provided, on another rota basis, that might prevent that young person from going off into the night distressed and possibly taking his or her life.

Dr Black:
I have worked in A&E units, out-of-hours services and general practice, so I deal with such issues daily. I work in a deprived area of Derry, the Bogside, which has faced problems similar to those being faced in parts of Belfast. We must be more receptive and display an open-arms attitude to those young people, particularly to young men, because they are the most vulnerable group. The male to female ratio of suicides in people of that age is 10 to one. We must have that open-arms attitude and take those young people down a different path, because they often present in crisis, often with what we might consider to be behavioural problems and often with alcohol consumed. Dedicated areas in A&E units would be a good idea.

The Chairperson:
As you have said, there are higher suicide rates among young men. In Scotland, cards are distributed at football stadia that state that it is OK to talk. That is a worthwhile strategy. There is a macho image of men being incapable of opening up in the same way in which women will in the hairdressers’, over coffee or in shopping centres. Women are good at talking. Men are also good at talking but not about personal health issues or depression.

The Scottish strategy of targeting masses of young men at football matches was innovative. The cards that were handed out were fantastic. They made it clear that it is right to talk and that it is right to contact someone. The cards also provided emergency contact numbers. That idea could equally effective if rolled out here.

Dr Black:
The first poster that people see as they enter my surgery is titled “If your head’s away, just say”. They then come across is an image of John Duddy, the famous boxer from Derry, who supports the Samaritans. We also have cards bearing his image. Those posters represent attempts to identify that group of people to which you refer. However, that is difficult to do, as young men often do not self-harm or suffer from depression — they just present without any warning and leave their families devastated.

Mrs O’Neill:
What are your views on the GP uptake of training in suicide and self-harm prevention? Does more need to be done to attract more GPs to it? How successful has the Department been in getting GP buy-in to the Protect Life strategy?

Dr Black:
There were some initial problems, but the good news is that one third of all GPs have already been trained. Next week, Dr Deeny and I will go to our training in the Western Health and Social Services Board where we will be training every GP.

Ms S Ramsey:
Did Dr Deeny not take up the training?

Dr Black:
He is going for the second time. We will cover every GP in the Western Board, so more than half of the GPs will have then been covered. I would rather give you that piece of good news than say that there was some bother at the beginning.

A GP will come across a patient who takes his or her own life only every six years, so it is a rare occurrence for a GP. It will happen about once every one or two years in a practice. We have bought into the training, because self-harm is common. We carry out assessments, and, at times, we need to then take a psychiatric assessment of a patient. However, we still go home at night with that worry in the back of our minds.

Mrs O’Neill:
There is a tendency to refer to the next level those children who have emotional difficulties. Is putting more resources into primary care the way in which to deal with the problem? For example, should children be referred in order that they might be treated with talking therapies, and so forth?

Dr Black:
Sure Start is great; health visitors are brilliant. a great deal of work is being done in that area, and we hope that it is targeted at the areas in which it is needed.

Child and adolescent psychiatry is a difficult area. Doctors might wait a couple of years, or write numerous letters and make many telephone calls, to get a referral, while knowing fine well that children who are in a worse condition than their own patients are blocking the system. During the week, I spoke to a psychiatrist who deals with children, and I asked her whether she had any suggestions. She said that more funding and more jobs were necessary. However, she also said that even though a funded job is currently available, it cannot be filled. Therefore, whoever gets that job will have to be trained.

Interestingly, that psychiatrist also said that children have to be reached before they are five years old. However, psychiatrists who work with adults tell me that patients need to be reached before adolescence. That is what Sure Start does, and it is well funded for that purpose. I congratulate the Assembly for pushing lots of money on to that project. We hope that it works, as it is certainly getting a great response.

Ms Ní Chuilín:
You said earlier that 51% of suicide victims self-harmed before their death. That is very concerning. Although I am not saying that everyone who self-harms goes on to end his or her life, that figure is an indicator, and, somewhere along the line, it is being ignored. Even certain professionals, such as those in the veterinary, dental and medical professions, are at a high risk of suicide.

You mentioned out-of-hours surgeries. Were you referring to a service that is similar to the Association of Belfast Doctors-on-Call (BELDOC), or to an out-of-hours surgery for people who are suicidal? We have all raised that issue. A&E is great for treating a broken finger, but it is not great for people who have mental-health problems. It is too busy and chaotic, and it deals with acute complaints. As Iris pointed out, people need to go somewhere that is separate from A&E if they are under the influence of drugs and alcohol. Out-of-hours surgeries need resources in order to make them safe. People do not use a Monday to Friday, 9.00 am to 5.00 pm surgery to ask for help but often go to after-hours surgeries. New Lodge and Ardoyne are in my constituency, which is a stone’s throw away from here. There are terrible incidences of suicide and self-harm in those areas. I feel sorry for A&E staff, because some youngsters go to the hospital who, if they are not seen right away, walk out. Could more be done to provide for a better out-of-hours service? Could such a surgery be provided beside an A&E unit, even if it were separate?

Dr Black:
I am talking about GP surgeries and the out-of-hours surgeries in the Western Health and Social Care Trust, which before that were known as Foyle Doctors-on-Call (FOYLEDOC). We tend to have patients who ring to say that they have suicidal ideation or intent and that they have a history of depression. We bring them to the surgery, do an initial assessment with the community psychiatric nurse (CPN) to whom we have access to ascertain whether the person needs to be formally admitted to hospital. That works well. Many people use the out-of-hours surgery; probably about two or three times more than use A&E make use of the out-of-hours surgery. That represents an interesting shift, because the perception is that A&E catches all types of patients. As we know, suicide involves no single issue; therefore, A&E catches a different patient profile, such as those who present with overdoses, because that is the appropriate place for them. A&E also takes in people who have been knocked unconscious through inebriation or through the inappropriate use of illegal drugs. Therefore, those patients get a different profile. That means that both types of profile need to be covered.

Given that GPs know their patients and their history, they should be the first port of call. Histories for patients such as those about whom we are talking are repeated. Without going into individual cases, patients who self-harm do not disappear but come back repeatedly. Their GP may refer them to many places, but they do not follow up on one appointment, do not attend others or discharge themselves from hospital. A GP can see a crescendo building as the patient’s life deteriorates. Of course, they do not all commit suicide — perhaps only one in 20 does so.

Dr Deeny:
I welcome Danny, Tom and Ivor. I, too, have a great professional interest in those aspects of health provision.

Chairperson, I read your newspaper article on talking therapies. Those certainly seem to be the way forward. We certainly do not have enough provision. Tom referred to the fact that it is so frustrating for a GP who is confronted with such illnesses, particularly in a young person. I tell people that I wish I could have them seen next week, but I cannot do that. Sometimes, therefore, a GP is forced into prescribing medication that may or may not be appropriate. That is a terrible tragedy.

I must mention something that is important for Tom, the whole medical profession and, indeed, for society. I worry that everything is being medicalised — every behaviour seems to be considered a medical condition these days. Personality disorder has been mentioned. It is a most frustrating problem. Some people will be referred to in the community as having psychopathic or sociopathic personalities; however, they do not have a mental illness, according to the criteria. There are no powers available to force them into hospital or to keep them there, yet they are liable to do anything. That is a major problem for society. However, one cannot medicalise everything or make every behaviour a medical condition.

My question, addressed to all the witnesses, but to Tom in particular, is as follows. A macho culture is a serious problem here, as I am sure is true of Scotland as well. All health professionals must play their part; however, the education authorities and the Churches have a major role to play in placing the value of human life back of on the agenda. People seem to think nowadays that taking their own life is an option.

We have seen an awful event this week in Omagh. I do not intend to highlight that case alone, but if that case is as it appears to be, not only has a person decided to take his own life, but he has decided to take his whole family with him. That is an awful situation. We must liaise with the Churches and the education authorities in stressing the value of human life to children from an early age.

Perhaps I am asking this question of the wrong people, and I should be asking the Department, but has this situation arisen due to a lack of funding? Is it about under-resourcing, or bad resourcing? Witnesses have mentioned that there should be wider access to talking therapies. As doctors and members of the Committee, everyone here agrees on that. Every one of us supports better funding for mental-health services. Is the money all going in the wrong direction? We need more people to do the talking and the counselling.

That is the frustrating thing that Tom described well. In my time as a practitioner, I have come across two young fellows who gave no indication of sinking into depression, yet, without warning, they killed themselves. We had no means of predicting that that might happen. If they had had somewhere to go to talk through their problems, or to get rid of their macho image, that might have made a difference.

I am also concerned about the state of paediatric medicine. The way that society is going means that everyone is worried about being sued. My brother is a solicitor, and I often tell him that his profession is destroying our world. Everyone talks about suing. It seems to me that that has resulted in fewer doctors wanting to study paediatrics and to become child and adolescent consultants. They have concerns about working with children, because of the possibility that something unfortunate might happen. That is a sad situation. Tom mentioned an example of an available child-psychiatrist post, and it worries me that there has been difficulty in filling it. In Northern Ireland, GPs wait for a year or more for appointments and homes for their young patients.

Does Tom want to see money redirected from wastage in the Health Service into those services? In particular, does he want to see a concentration on talking therapies and on child and adolescent mental health?

Dr Black:
I will take those points in order.

One of the main problems with suicide is that it is contagious. People talk about “imitation” and “copycat” behaviour. I do not like those terms — I prefer the word “contagious”. Suicides then happen in clusters, as we have seen in Northern Ireland. A problem that then develops is that communities lose faith in us, the public servants — in health, in the community and in politics — to whom they look for resolution of the situation. Kieran is correct. It is not a medical model that is required but an integrated one.

One hears about multidisciplinary teams, but the community, the Churches, the police, the schools, the voluntary sector and everyone must be involved. The more that I consider this problem and the more BMA presentations that I give, the more I sound like my granny. Young people must drink less and be home at an earlier hour. They must do as their parents tell them. They should be going to a church of some sort so that they develop a moral spine and core values. That all sounds very Victorian, but it would be good for them and good for us. We are all part of the community, so this is not a medical model; it is an integrated model.

I give two types of interview every year. One interviewer starts from the premise that GPs prescribe too many antidepressants; and the second interviewer starts from the premise that GPs are not prescribing enough antidepressants — that we are under-diagnosing. There is always a gap between these interviews, but sometimes the gap is as little as two weeks. The situation lies somewhere between those two extremes. My practice has a 50% above average rate for antidepressants, because of the location in which I work and also because my patients have to wait three to six months for access to CBT. The access that I have is group therapy, and that does not suit young men. It would be great to have better access to CBT.

The tension between medical and legal aspects is well founded. It does not affect GPs too much at the moment, because the relationship between the GP and the patient is based on continuing care. Most people are still with the same medical practice that they started with — I am. A bond of trust builds up between a patient and the GPs who have been in that practice for 20 or 30 years.

However, the medical/legal issue is an increasing problem in hospitals. The recent Queen’s Speech contained an announcement that the standard of proof required to take a complaint against a doctor to the GMC will be changed from the standard of proof in criminal cases — “beyond reasonable doubt” — to the civil standard of proof — “balance of probabilities”. That means that doctors will now lose cases on a 51% probability. When that provision becomes law, people should expect defensive medical practice.

I will make a brief point here, although I should not really do so on this occasion. That issue will come to the Assembly, which has legislation rights on medical regulations, so Members can make up their own minds. The situation will get much worse. We do everything like the Americans do, although we are 10 years behind them. In many parts of America, people are unable to obtain the services of an obstetrician, because it costs obstetricians $300,000 to pay for legal defence, so they are unable to work.

I am sorry: I digress.

[Laughter.]

The Chairperson:
You may as well make the most of your opportunities.

Ms S Ramsey:
I thank the witness for his presentation: there is a lot of common sense in it, so I do not mind his digression.

Committee members visited Scotland recently. The Committee is conducting an inquiry into the issue of suicide and self-harm, and I hope that, when it is finished, members will be able to make recommendations. I assume that the Committee will have the co-operation of two other Departments besides the Department of Health, Social Services and Public Safety, because a joined-up approach is necessary.

I was interested to hear your comments that suicide is contagious, presents in clusters and affects the community in that it loses faith in its leaders. For a long time in the medical profession — in hospitals, social services and among GPs — the right hand did not know what the left hand was doing. I do not mean to be negative, because the Health Service is making progress. Will the amalgamation of Health Service trusts, and hospital trusts, make a difference in that various sectors will communicate better? Young people present themselves at hospitals with a multitude of issues, but the relevant community services did not know what was happening to them. I hope that the services will use a joined-up approach to provide individual packages of healthcare to people who present.

Dr Black:
Communication among primary care, secondary care, community care and the voluntary sector is the key. The last time that I spoke to Ms Ramsey, we talked about the Hayes Report, which dealt with the integration of social care, healthcare and community care. The logic is that it should work better. One cannot fail, when considering the report, to realise that it is the sensible model to adopt. I hope that that is the case and that it does improve matters. Generally, GPs are of a mind that a community psychiatric nurse (CPN) should be attached to their practice, so that he or she can deal with the patient’s family. At my surgery, the health visitors are brilliant. They know what happened to a child with whom they dealt five years ago, and what has happened to his or her cousin, and so forth. The BMA thinks that a CPN should probably be attached to a GP’s surgery. Most of those services are attached to areas or patches. However, that is a different argument.

Ms S Ramsey:
As the Committee is now coming to the end of its inquiry, I am trying to tease out matters so that they may be addressed in our proposals. You mentioned suicide clusters — or that suicide is contagious — and said that the community is losing faith. In my opinion, the reason that communities are losing faith is because they were not inundated with help or support, whether that be from GPs, CPNs or people in the community. That is the point which Kieran and the Chairperson made earlier. There must be a proactive approach to whatever is happening in the community, and the recent fire tragedy in Omagh relates to that. Rather than waiting for things to happen, society should be proactive. Do you think that society has been proactive, up to the point where the professionals — in a community and a medical sense — are on the ground and targeting whatever issues are there in an effort to try to stop the contagion of suicide?

Dr Black:
That is a good point. The reason that I raised that issue is because I am a member of my community. I will try not to mention specific cases — because there have been quite a few in Derry recently — but I will say that I talk to people, and they will ask me why a particular patient was not detained? Why was that patient unable to access that service? What has been done about that matter? I have tracked those complaints.

Last Friday, I had a meeting with the deputy chief executive of the Western Health and Social Care Trust, Joe Lusby, who is the director of planning and performance. I discovered that a lot is going on in the background. I also talked to the co-ordinator of the suicide intervention group, who is working with schools, and to the psychiatrist who is dealing with the issue of detention for people with personality disorders. A lot of work is being done behind the scenes that is not being publicised and explained to the community. I wonder if that is a good or a bad thing because, as we all know, there are consequences if we raise too high an awareness of the issue. Obviously, a balance must be found. Therefore, GPs and local politicians have a role to play by going to the media and saying that the matter is being dealt with, that counselling is available in such and such a school, that we will consider the issue of detention for people with personality disorders, and so forth. We need to build up the community’s confidence. However, a huge amount of work is being undertaken by many people.

Mr Easton:
Drugs and alcohol play a role in some suicides or affect some of the people who have presented to you with mental-health issues. Do you feel that Northern Ireland is falling behind in the provision of services for people with alcohol or drug addictions, and that — even when we do have those services — we fail to follow up on mental-health issues that are derived from those addictions? I am also keen to explore whether the media has a role to play in a suicide prevention strategy and in the comments that they make — at times — in their reports?

Dr Black:
Alcohol has a huge part to play in the matter. It exerts, perhaps, four times the influence of that of drugs. The BMA has a policy that states that an increase in the price of alcohol will lead to a decrease in access to it. If access to alcohol is decreased, the consequences are similarly decreased. Personally, I would like to double the price of alcohol tomorrow. I would like to do that because it is 40% cheaper than it was 15 years ago. If the price were doubled tomorrow, that would constitute a 20% increase in the price of alcohol when compared with that of 15 years ago. That is all that would happen. Therefore, if the price of alcohol were doubled, that would improve matters. I realise that that is another issue, and that my solution is rather simplistic.

In the Western Board area, there are 90 registered agencies that deal with alcohol and drug treatment. Our problem is that young men who have alcohol problems have tried at least six of those agencies. I sometimes wonder whether there is too much choice. They go into the Northlands Treatment Centre, and they either like it or do not like it. They may go into an addiction treatment unit, which, again, they might or might not like. Then they might go down to Sister Consilio at Cuan Mhuire. There is a lot of choice about access to treatments.

Alcoholism is an intractable problem and the success rate is low. Much work has been done on alcohol treatment; however, in considering suicide prevention, it is a key area. At the time of committing suicide, 37% of people have taken alcohol. I sound like my granny again in suggesting that the price of alcohol should be increased. That message is not popular, and one sounds like an old fuddy-duddy who is ruining everybody’s fun. There would be a huge improvement in healthcare if ordinary people who drink a bit too much were persuaded to drink less. That would not address the problem group, but consumption could be reduced by such a general proclamation.

The media have a huge role to play, and people in the media have undertaken suicide awareness training and are careful in how they treat the subject. Nowadays, the news of many suicides is passed by word of mouth, and, because the media is so careful, one does not hear about them on the media.

The Chairperson:
An exception to that was the news of the three young boys who took their lives. I thought that that coverage was insensitive and sensationalist.

Mr Buchanan:
You mentioned the huge amount of behind-the-scenes work. How is that work being integrated? What could the Department do to assist those people at the coal face who are attempting to improve services for people with mental-health problems?

Dr Black:
If you ask a GP a question, you will get a GP answer. People attend various hospitals, A&E departments, community psychiatric nurses and psychiatric services. Therefore, because records of any such visits come back to a patient’s GP, GP records are the only integrated healthcare record that is available. It worries me a little that some voluntary-sector services do not provide GPs with records. If a person with alcohol or drug-abuse problems enters a voluntary-sector institution for six weeks, perhaps his or her GP should know about that. However, that raises issues of confidentiality, and so forth. The general practitioner should be the single integrated point of record. GPs have the primary-care responsibility and are often the person that the patient comes to see. People who commit suicide have, on average, seen their GP in the previous two months.

My answer on how the Department could help is probably the wrong one. There is no single thing that the Department can do. Assistance is multilayered and multifactorial, and the Department’s focus should be on the voluntary sector, communities, schools — on everything — and not just on cognitive behavioural therapy. The worst thing is that there might be some improvement only if everything is done correctly.

The Chairperson:
Although you felt that you were beginning to sound like your granny, I am a granny, and I believe that you are absolutely right. Society has lost many core values, and the solutions to its problems will not simply come from the statutory and voluntary sectors; they must also come from the community — particularly from the Churches, the police, schools and educational institutions.

If nothing else, we must get across to people that they must seek out others in order to talk and explore what is going on in their heads. Perhaps, that will cut the number of tragedies that families across Northern Ireland are experiencing. As Kieran mentioned, rural communities must also deal with a lack of infrastructure, and people there are isolated.

Age Concern’s submission to the Committee highlighted suicide statistics for older people and stated that the leading cause of suicides in that age group is depression. The document also states that nearly half of the older people who take their lives visit their GP in the month before they commit suicide. What more can GPs can do to detect and treat older people who may be at risk?

Dr Black:
Much has been done about making connections. When a house in Galliagh burnt down, I discovered that the local community group phoned 300 old people in the area every morning. I never knew that, even though many of my patients live in the area.

Ms S Ramsey:
That project is called Good Morning Galliagh; I know about it, even though I live in Belfast.

Dr Black:
So much good work is being done. GPs see each elderly patient about 12 times a year, so they probably would see them in the last month of their lives. The keys are recognising social isolation and the early diagnosis of depression. So many symptoms of depression can be construed as symptoms of old age, and we must keep an open mind about that. I hate to say it, but we have been seeing an increase in the diagnosis of depression among elderly people recently. I have no doubt that I will be interviewed about that soon. GPs have a definite role to play in preventing suicide among elderly people.

The Chairperson:
Thank you for giving the Committee your time, for your very interesting presentation and for answering our questions. It is fair to say that the Committee is very much with you in trying to deal with the dreadful issue of suicide and finding a means for its prevention. The Committee has a lot more work to do, and it cannot be complacent. Thank you, Tom, Danny and Ivor, for coming today.