COMMITTEE FOR HEALTH, SOCIAL SERVICES AND PUBLIC SAFETY
OFFICIAL REPORT
(Hansard)
Inquiry into the Prevention of Suicide and Self-harm: Health and Social Services Councils
13 March 2008
Members present for all or part of the proceedings:
Mrs Iris Robinson (Chairperson)
Mrs Michelle O’Neill (Deputy Chairperson)
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr John McCallister
Ms Sue Ramsey
Witnesses:
Mr Noel Graham - Northern Health and Social Services Council
Ms Maggie Reilly - Western Health and Social Services Council
The Chairperson (Mrs I Robinson):
I would like to apologise to Noel and Maggie from the health and social services councils for having to cancel an evidence session that they had previously been due to attend, and for cancelling it very late in the day. We had to postpone it because of the Committee’s consideration of the clostridium difficile issue. However, you are here now, and I would like to welcome you on behalf of the Committee. I invite you to make a five- to 10-minute presentation, and then we will allow up to an hour for discussion between members and yourselves on any issues that they may wish to raise.
Mr Noel Graham (Northern Health and Social Services Council):
Thank you for inviting us to give evidence on behalf of the health and social services councils to Committee’s inquiry into the prevention of suicide and self-harm. Our response is on behalf of the four health and social services councils. My name is Noel Graham, from the northern council, and my colleague Maggie Reilly is from the western council.
I will first provide some background on the health councils. They were set up in 1991 as statutory bodies charged with representing the views and opinions of the public. The councils are based in four local offices — in Belfast, Broughshane, Lurgan and Omagh — and are independent from those who plan, manage and provide health and social care.
The subject under discussion today is something in which individual councils have taken a keen interest. We submitted a written response some time ago, following a joint council forum that was held on 25 October 2007, which discussed the Protect Life strategy. Before discussing that issue, members of the four health councils heard presentations from Colm Donaghy, who chairs the regional strategy implementation body, a GP, a suicide awareness co-ordinator from the western area, and Ann McGarrigle of the Families Forum.
Councils have raised concerns in the past about the lack of a co-ordinated approach to suicide prevention, and the most recent phenomenon of suicide clusters among young people in Northern Ireland.
We note that there are four main points in your terms of reference, and we hope to address those in turn. The first is about assessing the scope and appropriateness of ‘Protect Life: A Shared Vision’. Prevention of suicide and self-harm is not just a health or social care issue. The strategy is led by the Department of Health and Social Services and Public Safety, but implementation of most of the actions will depend largely on working in partnership with other agencies. We strongly believe that the strategy should have had a wider cross-departmental authorship and, perhaps, could have been championed through the Office of the First Minister and deputy First Minister (OFMDFM), as was the child poverty strategy.
We welcomed the population and the targeted approach that was used in the strategy. The first section deals with population approach. We feel that, in that section, there needed to be a specific action for children and education: after all, children spend anything between 12 and 17 years in education. Regarding the action-area dealing with communities, we endorse the public information campaign that has begun, but we want ongoing action, not just a short-term approach. We agree that public policy has the potential to have an adverse effect on the mental health and well-being of local communities. The strategy encourages all statutory public bodies to carry out health impact assessments on their policies, but we ask how that will be monitored and who is responsible for carrying it out.
In principle, we agree with the actions identified in the strategy in relation to the family. However, we question whether, in practice, such support-mechanisms are in place, and we are concerned that the success of the support and interventions proposed will depend on the capacity of , and the funding available to, the voluntary and community sectors.
The next action-area dealt with children and young people. We are concerned that the level of investment required for children and adolescent mental-health services, as envisaged by the Bamford Review, has yet to be realised. The current target for outpatient waiting is 13 weeks, which is not being met, and is far too long for children in crisis to have to wait for appropriate intervention. We want to see a greater priority in developing and implementing practices, protocols and referral pathways, to smooth the transition from youth to adult health and social services.
Regarding the action-area concerning health and social services, we fully support the suicide and depression awareness training, as a priority for all front-line staff dealing with people in distress — particularly for GPs, primary care and accident and emergency (A&E) staff in the health and social services. We have some concerns about the varying levels of uptake by GPs of this training: uptake in some areas has been slow. We want to see evidence that, where one GP from a practice has been trained, knowledge has been cascaded to other staff in the practice, or that it has impacted upon working practices. We are concerned that the development of clinical guidelines for health and social services staff who deal with people who are at risk of self-harm has a medium-term timescale. Greater priority should be placed on that work.
In the action-area concerning churches and religious bodies, we support the need for suicide and depression awareness training for all church and religious leaders. In addition, we endorse the actions proposed in relation to the media.
Sections B and C relate to targeted approach and overarching actions, and we fully endorse all the actions in both sections. We repeat that, without the full and active involvement of all the delivery partners, the strategy is unlikely to be fully implemented.
The second area in the terms of reference was about examining the level of stakeholder involvement. Chapter 3 of the strategy recognises and indeed highlights the need for the stakeholders to work together to achieve the aims of the strategy. However, we noticed that, within the taskforce membership, two thirds, or 20 of the 32 members, come from a health and social care background. Only three of the members are from the education sector; six from the community and voluntary sector background; one from the Department of Social Development; and one each from Prison Service and the juvenile justice service.
We were disappointed to an extent that neither the family nor the survivor voice was represented on the task force. One of the guiding principles of the strategy on engagement is continuing consultation with bereaved families, survivors, carers and their representatives. Through speaking to family representatives, we are aware that they were consulted, but that does not always equate to real engagement, which must recognise and support bereaved families who are faced with their own difficulties at such a vulnerable time. They may be endeavouring to support their own family or other bereaved families. Perhaps they are involved in fundraising for, and the running of, local services, as well as contributing to strategic discussions about the future planning and delivery of services. Further work must be done on the best way of supporting families in shaping the delivery of services and contributing to the strategic direction of the strategy. The health councils feel that the opportunity should have been taken to have greater involvement and input from people who have attempted suicide and survived.
Ms Reilly :
The third point on the terms of reference was on the level of services and support that are available. Provision of timely services is a long way from being in place. Urgent attention must be paid to the provision of a broad range of services, to which GPs can refer individuals.
Young adults, in particular, are not as quick to engage with traditional mental-health services. Therefore, the design of future services must include new and innovative ways of engaging with young people. The previous speakers explained some of those ways, and we fully endorse what they said. Priority must be given to the early identification of people who are at risk. There are recognised suicide-risk factors, such as the increase of alcohol and drug use, depression, separation and bereavement. GPs and educators are often the first points of contact for people who are at risk. More resources must be directed at primary care and the education sector. Parents need information and support to enable them to recognise and deal with risk-taking behaviour in their children.
In summary, the strategy can succeed only if it becomes genuinely cross-departmental and is driven by the Assembly as a political priority. It is worth examining the possibility of having OFMDFM drive the strategy, similar to the way in which it has driven the strategy for children and young people and the child poverty strategy. It should ensure that housing, social security, education and local government are integral to delivering on the strategy.
There must be regional co-ordination of local plans and cross-departmental activity. Further research is needed to assist communities in answering the big question of why suicides happen. That would support the development of preventative services and help to counter the ripple effect of suicide and attempted suicide.
There must be an increasing understanding that suicide and self-harm are not solely a threat to young people. The needs of people of all ages must be built into the strategy. We note that figures in the consultation document, ‘Protect Life: A Shared Vision — The Northern Ireland Suicide Prevention Strategy and Action Plan 2006-2011’, show that around 20% of deaths by suicide involve people who are under 25, but that 67% are in the 25-to-54 age bracket.
The central role of GPs must be strengthened by further training and increased engagement with the strategy. More resources must be made available to primary care, including training in early detection for at-risk patients and for patients who are accessing counselling and support that is delivered by trained professionals who work with GP practices. Health and social care trusts should be required to put a family-support service in place that is capable of providing intervention to a bereaved family within 48 hours.
We strongly believe that the proposals of the Bamford Review should be fully implemented. The Protect Life strategy’s overall aim is to reduce death by suicide by 15% by 2011. However, it does not clearly define how the implementation of the 62 separate action areas will be measured in order to achieve that. In order to understand what was successful and unsuccessful about the strategy, those measurements would have to be clearly defined.
The health councils have welcomed the opportunity to reflect on the strategy and, as part of our continuing role to represent the public interest in health and social care, we will continue to scrutinise and comment on the implementation of the strategy. I thank the Committee for the opportunity to give our views today.
The Chairperson:
Thank you, Maggie and Noel. Before members put their questions to you, in case you are not aware, representatives of the four main Churches have given evidence to the Committee, which was a useful exercise.
Mrs O’Neill:
I thank the witnesses for coming to give evidence today. Your submission refers to the need for the establishment of a co-ordinating office, the main function of which would be to establish and co-ordinate local plans and regional activity. When Committee members visited the Dáil, we met staff from the National Office of Suicide Prevention. Are there merits in establishing such a structure here?
Ms Reilly:
We heard talk of examining the issues of suicide throughout the 32 counties. There are some merits to establishing such a body here. We are concerned that the implementation body seemed to be a misnomer — the body remained as an advisory body to the Department rather than an implementation body. There was, therefore, a potential gap in ensuring that the actions were implemented in a co-ordinated fashion. As a subject, suicide has tended to be quite bitty, so it would be worth investigating the possibility of a similar structure here.
Mrs O’Neill:
Your submission refers to the lack of uptake by GPs of training on suicide. In the absence of making training compulsory, have you any ideas about how to increase the uptake?
Mr Graham:
The figures that we saw were lower in some board areas than in others. However, in some cases, when a GP or individual from a practice had attended the training, the practice was included in the number of practices who had taken part. Some calculations were based on the number of practices that had taken part, rather than on the number of GPs out of the total number who could have been involved. I do not know the detail of the level of training that is provided, but I read in the media that there has been some criticism, and perhaps some GPs felt that it was targeted at too low a level. Therefore, some discussion with GPs is required on the content of the training.
Mrs O’Neill:
The level of training was highlighted in several submissions to the Committee. Perhaps the training should be ongoing or pitched at a different level.
Ms O’Reilly:
In the Western Board area, there was a 99% uptake of training. We checked to ensure that the figure of 99% applied solely to GPs. The Western Board addressed the issue of training by closing practices and introducing out-of-hours emergency care to provide services, so that GPs got protected time to train. Consequently, the uptake was extremely high, and we encourage other boards to consider following that lead.
Dr Deeny:
Welcome, Noel and Maggie. I am glad that you are here today.
Thank you for mentioning those figures, Maggie, because that is exactly what happened in the Western Board area. The reason that so many GPs in the west trained in suicide awareness is because we pressed the local medical committee for protected time to train. For half a day every two or three months, the out-of-hours cover ensures that GPs are free to train.
As you said, you represent the public and patients, which is an honourable role. I wonder how the new plans for healthcare in Northern Ireland will affect how we try to put in place health services from the bottom up, based on what we know the patients need. How will you work with the local commissioning groups? After all, you are the patients and the public’s representatives. The five local commissioning groups will be part of a regional commissioning body — there have been so many changes that I forget its title.
I have heard you on the radio, Maggie, and you have probably heard me, but we have seldom met. However, I often wonder how the people whom you represent approach you.
I could not agree with you more that whether the condition is epilepsy, diabetes or whatever, no one can speak better and teach others about the subject than the patients who have suffered from it. Therefore, families who have experience of suicide must be involved, as must patients who have come through periods of feeling suicidal. That point was made earlier by people who suffer from chronic ill health, and they had been asked to represent their fellow sufferers to the public, who may not have any knowledge of the condition.
Finally, you are quite right — GPs do not have enough access to alternative therapies. I admit that, often, we have no option but to prescribe antidepressants when we know that talking therapy would be much more effective. The benefit of exercise was mentioned earlier; it, too, should be prescribed more often.
The Committee has discussed the lack of facilities in Northern Ireland — not just for adolescents and young people who are under 18 years of age, but for young mothers who have post-natal depression. There is absolutely nothing. I could not agree with you more on that issue. I have had to deal with it for years. Young people would feel threatened by, and may run away from, treatment in an old-fashioned mental institution. They would respond better to talking therapy, which could be rolled out through the provision of counsellors in the new general practices and health centres of the future. People who are trained in talking therapies could be available to offer those services. What do you think of that idea?
Ms Reilly:
I will deal with those points in sequence. People approach us in a variety of ways. For example, if we speak on the radio, a plethora of people flood to us for help. Obviously, we would be better known if we were better resourced. We support people in making complaints, raising issues and act in an advocacy role on their behalf. The more work that we do, the more people promote the council as being able to help. People become aware of us through word of mouth. We also use various PR methods.
The council has 24 members. Those 24 members represent the council in the communities that they represent. The public know those representatives and through them, approach the council. Therefore, knowledge of our activities is spread through word of mouth. Awareness is not as good as it ought to be. We hope that in the new world, when there is a new patient/client council, it will be better resourced in order to allow us to deal with a greater number of the public. Frankly, however, if more people were to come to us at present, we would not have the resources to cope with them. That is a major concern.
Mr Graham:
One of the difficulties that we have been burdened with from the start is our name — the Northern Health and Social Services Council — partly because people think that we are a health and social services board and, in some cases, they confuse the social services bit with social security. Quite a number of people have contacted us about benefit issues. We have tried to get the message across in the telephone directory, in which we run a half-page advertisement. That has had a downside, because we get loads of enquiries from people who cannot find their trust or local services and ring the council to find out the information that they need. However, because we are in contact with them we can redirect them or signpost those other services.
As you are probably aware, there are two options for the new structure of the patient-and-client council body. Recently, after the consultation started, we were involved in a joint workshop with council members. We plan to hold another one on 1 May. However, in the meantime, we are engaged with community groups, and we hope to engage with local politicians as well within the timescale — taking account of Easter — that is available. When that concludes, we hope to produce a joint response from the four councils on how the new body might operate most effectively.
Ms Reilly:
I want to return the issue of mental health that was discussed earlier. I am glad that post-natal depression was mentioned. This morning, I listened to the Chairperson’s comments, which were a powerful testimony on how women relate to the issue. It is absolutely scandalous that there is no service for women. We are talking about the baby blues that occur for a few days after the birth, right through to the much more serious scale of post-natal depression that has been discussed on ‘The Stephen Nolan Show’. It is a scandal that a service has not been provided.
In a previous life, I used to talk to women’s groups about good mental health. I spoke to young women and was shocked to discover that some of them were already single parents, were isolated, and had all the problems that go with being in that situation. They were quite intelligent women, and declared quite openly to me that they had found ways to get round the system so as not to let health visitors know that they might be depressed, because their greatest fear was that social workers would come and take their babies from them.
Something needs to be done about that; those were vulnerable young women. Afterwards, I put them in contact with the appropriate people, and assured them that that was not how such business should be conducted; rather that it should provide help and support. However, that is how those young women viewed the system generally, and they would tell their friends the same. There is a tool that asks a series of questions in order to determine the level of post-natal depression; those women would answer those questions in such a way as to keep their depression hidden. They knew how to tailor their answers so that it would not look like they were depressed, and yet they were significantly depressed. Something needs to be done about that. I am glad that you are inviting Breda Hughes to come along to address that issue because it falls under the mental-health continuant.
The Chairperson:
I could not agree more with what you have said.
Mrs O’Neill:
I have gone to tribunals where people seeking incapacity benefit have been turned down because of their reluctance to admit that they have mental-health problems; they do not want to admit to it for fear of losing their children. That is a massive problem that we must challenge.
The Chairperson:
There should not be a stigma attached to mental-health problems.
Dr Deeny:
Do you see yourselves as the future patient and client council — whether that is one or five —working along with the local commissioning groups and planning healthcare? Do you think the best way forward is to have councillors in less-threatening environments, such as modern health centres, rather than patients having to attend old mental institutions?
Ms Reilly:
We will not have a future at all unless we can engage with local commissioning groups; that is where the decision-making process is at. It is our job to present knowledge of, and background to, what local people say that they need, and where they feel there are gaps in the system.
However, we are not the proxy patient, nor are we going to be put into that position. It is important that the voices of the real patients are heard. We can assist the capacity-building for individuals and communities to have their voice heard. However, it is imperative that we work closely with local commissioning groups on this matter.
Dr Deeny:
What are your thoughts on patients being able to visit councillors in health centres rather than having to go to mental-hospitals?
Ms Reilly:
I absolutely agree with that idea. There is a stigma associated with the traditional mental-health services; young people simply will not engage with mental-health teams. There should be a system whereby the GP can see Johnny, for example, in the health centre — a non-threatening environment — and then send him two doors down to speak to the councillor for 20 minutes, an hour, or whatever. That scenario would not have the same stigma attached to it as the current process of attending a particular building that everybody knows is a mental-health institution. If a real difference is to be made, that system must be changed.
Mr Gallagher:
You have both referred to serious gaps in the mental-health service. Is there a lack of proper referral services everywhere, or do those vary depending on the postcode?
Ms Reilly:
No, the board does not particularly see the problem as varying according to postcode.
Mr Graham:
We would not be aware of the postcodes – it is a more general problem.
Ms Reilly:
I was aware of a lack of psychology services in the western area, but my colleagues in the other councils informed me that that was also an issue for them. There was a difference between the terms and conditions for psychologists in the various board areas but that has, to some extent, been ironed out by the Agenda for Change. There is a lack of investment in talking therapies per se, and there has not been enough recognition of the importance of that role.
The Chairperson:
It is coming to the fore that talking therapies are preferable to arming people with so much medication that they literally become zombies.
There are a number of concerns relating to funding, and inadequate service provision, among community-based and families groups involved in suicide prevention, such as PIPS, RAYS, Families Voices, West Belfast Suicide Awareness and Support. What role do the councils perform in voicing those grievances with the national and local implementation bodies involved in the Protect Life strategy; do you speak up as an advocates grouping on the subject?
Mr Graham:
It is only because we concentrated on the strategy when it came out and heard from organisations such as Family Voices that we became aware of the services and support mechanisms that are out there. We visited the local branch of the Samaritans in our area to find out what they did. They would like to have some involvement with accident and emergency departments at local hospitals, because they felt that people who presented there with attempted suicides or other issues could be referred to them and could be helped. They do not have that role at the moment. I am not sure, however, that the Samaritans would have the capacity and the funding to carry out that role.
Ms Reilly:
We genuinely believe that what has happened in the community traditionally is that the community and voluntary sector has been put upon to provide services. Sometimes, when there is a lot of media attention, particularly around the clusters of suicides of young people, there have been knee-jerk reactions and the demand that somehow, the community had the answer. However, the resources did not follow, and tremendous pressure was put on local groups who had people coming to them.
At every opportunity, whether it is with the Children’s Commissioner or with the Department, we are raising that issue and saying that these are core services that the Minister and the Department should be funding. They should not rely on the community and voluntary sectors to do that work. Those sectors have an important role to play, and perhaps can provide a quicker service that is more flexible towards the needs of the population than that provided by the statutory sector, but they must be funded to do that.
The Chairperson:
I am delighted that you are conveying that opinion at every opportunity. It is a serious area of concern, and we must ensure that we have an outcome that will deliver to the people who are affected. Thank you all for coming along. It has been a very interesting session.