Northern Ireland Assembly Flax Flower Logo
Session 2007/2008
Third Report

The Committee for Health, Social Services and Public Safety

Report on the Inquiry into
the Prevention of Suicide
and Self Harm

Volume One
TOGETHER WITH THE MINUTES OF PROCEEDINGS AND MINUTES OF EVIDENCE
RELATING TO THE REPORT

Ordered by The Committee for Health, Social Services and Public Safety
to be printed 1 May 2008
Report: 27/07/08R Committee for Health, Social Services and Public Safety

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Committee for Health, Social Services
and Public Safety
Membership and Powers

The Committee for Health, Social Services and Public Safety is a Statutory Departmental Committee established in accordance with paragraphs 8 and 9 of the Belfast Agreement, section 29 of the Northern Ireland Act 1998 and under Standing Order 46.

The Committee has power to:

The Committee has 11 members including a Chairperson and Deputy Chairperson and a quorum of 5.

The membership of the Committee since 9 May 2007 has been as follows:

Mrs Iris Robinson MP (Chairperson)
Ms Michelle O’Neill (Deputy Chairperson)
Mr Thomas Buchanan
Mrs Carmel Hanna
Rev Dr Robert Coulter
Dr Kieran Deeny
Mr Alex Easton
Mr Tommy Gallagher
Mr John McCallister
Ms Carál Ní Chuilín
Ms Sue Ramsey

Table of Contents
Volume One

Executive Summary
Summary of Recommendations

  1. Introduction
  2. Background
    Suicide
    Self Harm
  3. Trends
    Northern Ireland
    International Comparison
    Self Harm
  4. Strategic Approach to Suicide Prevention
    Implementation Structure
    Evaluation and Review
    Funding
    Targets
  5. Stakeholder Involvement
    Development of the Strategy
    Ongoing involvement through SSIB
    Families and Community Groups
    Cross-Departmental Role
    Role of Schools and Colleges
    Role of Churches
    Role of Sport and Exercise
    Role of Local Authorities
  6. Services and Support
    Training
    ASIST Training
    Training for clergy and church workers
    Training for PSNI
    Telephone Helpline
    Self Harm Service
    Talking Therapies
  7. Experience Elsewhere
  8. Other Issues
    Role of Media
    Public Information Campaign
    Chill Out Room
    Card Before you Leave
    Communication
    Support for Frontline Staff
  9. Conclusion

Appendix 1:
Minutes of Proceedings

Appendix 2:
Minutes of Evidence

Volume Two
Appendix 3

Written Submissions

Appendix 4

Other Evidence Considered by the Committee

Appendix 5

List of Witnesses who Gave Oral Evidence to the Committee

Executive Summary

The number of suicides in Northern Ireland has been increasing in recent years. Currently, about 195 people take their own life each year while a further 4,500 people are admitted to hospital having attempted suicide or inflicted serious injury from engaging in deliberate self-harm. Launched in October 2006, a national suicide prevention strategy entitled Protect Life: a shared vision has been developed within the context of a rise in the number of people dying by suicide and engaging in self-harm. Protect Life represents a major step forward in the efforts to reduce this needless waste of life. However, suicide is not a matter of figures or statistics but each person who takes their own life is a life prematurely cut short and a tragedy and a trauma beyond words for the family, for their friends and relatives, and for society as a whole.

The Committee has examined the scope and appropriateness of the strategy and its implementation to date. The level of engagement, particularly with community groups and families bereaved by suicide, in drawing up the strategy has been extensive and lessons have been learned from international best practice. Throughout its Inquiry, the Committee discovered a substantial level of commitment and endeavour in delivering the full implementation of the strategy and ensuring improvements in levels of support for those affected by suicide.

The Committee identified a number of areas where it believes the strategy can be strengthened and enhanced. These include the following:

The Committee learned of many excellent services throughout Northern Ireland, provided by local community groups and others, that aim to prevent suicide and self-harm, to deal with those who may attempt suicide, and to cope with the aftermath of suicide and provide support to bereaved families. The Committee also saw exemplary models of counselling and other services in operation in Dublin and in Scotland and would urge the Minister to explore how these could be replicated in Northern Ireland by building on existing experience and capacity.

It is well recognised that the media can play a positive role in raising awareness of issues relating to good mental health and can have an impact in combating any associated stigma. At the same time irresponsible reporting of suicides can increase the risk of copycat suicides. Increasingly concerns have also been raised about the influence of the internet and the prevalence of social networking sites that are used to promote suicide among young people. The Committee commends the efforts being made by the Minister to engage with the local media and with internet service providers.

The awaited response by the Department of Health, Social Services and Public Safety to the recommendations in the Bamford Review of Mental Health and Learning Disability provides a unique opportunity to develop and strengthen links between the suicide strategy and the provision of mental health services. This is particularly important in relation to the development of child and adolescent mental health services.

Summary of Recommendations

1. The development of the Protect Life suicide prevention strategy has been a major step forward in the battle to reduce the incidence of suicide in Northern Ireland. We recognise the benefits of the dual population and targeted approach but we believe that the focus of the targeted approach needs to be re-examined and redefined to include other priority groups, such as older people and those living in rural areas. (Paragraph 35)

2. We have major concerns that the current structure lacks a dedicated directorate to manage and act as a central focus for the implementation of the suicide prevention strategy. We call on the Minister to establish a designated suicide prevention directorate as part of the proposed new Regional Public Health Agency. (Paragraph 41)

3. It is of the utmost importance that robust review and evaluation arrangements are in place to examine the key elements of the strategy and learn lessons as the strategy develops. While provision for such review and evaluation was built into the strategy we have major concerns that this has not yet taken place. We call on the Minister to commission an urgent independent, time-bounded evaluation of the key elements without further delay and to take account of the findings of this Committee Report in the review of the strategy. (Paragraph 44)

4. We note the overall level of funding for implementation of the strategy and recognise that it compares favourably on a per capita basis with Scotland and the Republic of Ireland. We strongly urge the Minister to ensure that this funding remains ring-fenced for a number of years to sustain and implement the Protect Life strategy and that there is full transparency, accountability and scrutiny of how this funding is used.. (Paragraph 50)

5. We commend the sterling work carried out by community groups and we fully recognise the vital importance of their involvement in the strategy to reduce suicide and support bereaved families. The assurance by the Department that over £2 million in 2008-09 is being allocated to support community initiatives is welcome. However, we are greatly concerned at the ongoing uncertainty and insecurity caused for those groups by single year funding. This must be addressed urgently. We call on the Minister to provide funding support for community groups on a minimum of a three yearly basis. (Paragraph 51)

6. We fully recognise the difficulties involved in measuring suicide rates, the dangers of putting too much emphasis on a single year’s figures, and the arguments for and against setting specific targets. We note the target of a 10% reduction by 2008 and we urge the Minister to review the targets when figures for 2008 become available and to consider setting targets for the reduction of self-harm. (Paragraph 56)

7. We fully appreciate the first hand knowledge and understanding that bereaved families bring to bear in the efforts to deal with suicide and the positive contribution that they have made to the development of the strategy. We commend the many families who have come together to set up Family Voices and we urge the Minister to ensure that their views are taken into account. (Paragraph 66)

8. We welcome the establishment of the Ministerial Co-ordination Group on Suicide Prevention chaired by the Health Minister and involving a number of other Ministers. We urge the Executive to acknowledge that suicide prevention is not solely a health issue and to examine how the role of the Ministerial Group can be further developed to secure a greater commitment and involvement by all Departments. (Paragraph 69)

9. We welcome the introduction of the independent counselling support service in post primary schools and call on the Minister for Education to extend this service to the primary sector as soon as possible. We also welcome the work that is underway to develop a Pupils’ Emotional Health and Wellbeing Programme for the post primary sector. However, we believe that developing coping skills and building young peoples self esteem should begin at an early age and we call on this programme to be extended to all schools. (Paragraph 76)

10. We welcome a number of useful initiatives linked to the prevention of suicide and self harm currently being undertaken by the Department for Employment and Learning. These include the services provided by Opportunity Youth and Include Youth to young people on the Jobskills and Training for Success Programmes. We also recognise the value of the Bytes Project, jointly supported by the Department of Education, which targets ‘hard to reach’ young people who are not in education, employment or training. We call on the Department for Employment and Learning to review its contribution to implementing the Protect Life strategy and, in particular, to ensure that initiatives taking place in some FE colleges are available to all in that sector. (Paragraph 78)

11. We welcome the commitment by the leaders of the four main churches in Northern Ireland to play their part in tackling the issue of suicide and self harm. We urge greater collaboration with the Suicide Strategy Implementation Body in the development and delivery of training for all clergy in dealing with people who may be at risk of suicide and in supporting families and communities in the aftermath of a suicide. (Paragraph 84)

12. The positive role of sport and exercise in combating stress, anxiety and depression is well established and widely recognised. We urge the Minister to explore how the prescribing of an exercise regime can be developed and promoted for use as an option by GPs in appropriate circumstances. (Paragraph 91)

13. We are disappointed that Sport NI and the main sports bodies in Northern Ireland have not been directly involved in developing and delivering the strategy to prevent suicide. We call on the Minister for Health, Social Services and Public Safety to explore with the Minister for Culture Arts and Leisure how Sport NI and other sports organisations can fully participate in delivering the suicide strategy. We strongly commend the Scottish model of involving sporting icons and using major sporting occasions to raise awareness of the issue and to encourage young people, particularly young men, to seek help. (Paragraph 92)

14. There is clear potential for local authorities to play a significant role in the ongoing development and delivery of the Protect Life strategy. We urge the Minister to explore with local authorities how solid partnerships can be developed. We believe that this should include full participation in the Suicide Strategy Implementation Body and other structures. (Paragraph 96)

15. The importance of training and development in suicide awareness, in identifying early warning signs and in knowing how to respond to those signs has been incorporated into the strategy. The merits of the ASIST (Applied Suicide Intervention Skills Training) programme are widely recognised. We believe that the time is right to examine the progress of the training programme to date and identify any gaps. (Paragraph 107)

16. We have major concerns that the decision to extend the pilot telephone helpline in north and west Belfast into a regional helpline at this time was rash. We believe that a number of key issues should have been fully addressed before any decision was taken to go live. These include

We believe that the regional helpline should have an easily identifiable title, such as ‘lifeline’ and that the launch should have been accompanied by a high profile media awareness campaign. However, we would now urge caution about a high profile publicity campaign until an assessment of the adequacy of existing referral and support services has been carried out. (Paragraph 117)

17. We are greatly concerned about the lack of focus on providing psychosocial assessment and follow-up care for those who self-harm. We welcome the pilot self-harm service in north and west Belfast and call for it to be evaluated urgently and extended to all A&E departments. (Paragraph 122)

18. There is an urgent need for greater access to talking therapies to treat people with depression and anxiety disorders. We welcome the assurance of a significant investment in psychotherapies and the development of a psychotherapy strategy and we call for this to be implemented without delay. (Paragraph 128)

19. We welcome and recognise the value of co-operation between countries at a strategic level on issues relating to the prevention of suicide. The Committee fact finding visits to Scotland and the Republic of Ireland also highlighted that there are often many lessons to be learned from ground-breaking and innovative services that are pioneered and developed at a local level. We call on the Minister to consider, perhaps through the Five Nations Forum, how information on innovative activities at a local level can be shared between countries. (Paragraph 132)

20. We strongly recommend that the Minister set up a separate dedicated Protect Life website, similar to the Choose Life website in Scotland and the Reach Out website in the Republic of Ireland. We believe that this would provide a key resource to augment implementation of the strategy. (Paragraph 133)

21. We strongly support calls for more responsible reporting of suicide and related issues in the media and we welcome the action taken by the Minister to engage with the local media. We particularly welcome and support the initiative by the Minister to tackle the issue of internet sites that promote suicide. We call for a Northern Ireland version of Headline, a media monitoring programme, to be established and implemented as soon as possible. (Paragraph 139)

22. We recommend that the current general mental health media campaigns be subjected to a robust evaluation and that urgent consideration be given to how the specific issue of suicide and self harm can best be addressed through a public media campaign. (Paragraph 142)

23. We recognise the critical opportunity that is provided to influence the lives of people who present in crisis at A&E departments of hospitals. We call on the Department to require Boards and Trusts to carry out an urgent examination of ways in which a chill-out room can be provided in or adjacent to all A&E departments in hospitals. (Paragraph 145)

24. We recommend the urgent introduction of a ‘card before you leave’ system to provide people at risk of suicide or self-harm who attend A&E departments or who are discharged from hospital with a definite follow-up appointment. (Paragraph 147)

25. We are greatly concerned that lessons about the need for better communication highlighted in a number of reports have not been implemented. We fully support the recommendations in the O’Neill Report in relation to communication. (Paragraph 149)

26. We recognise that healthcare and other frontline staff are themselves at increased risk of suicide and we recommend that urgent consideration be given to the establishment of a structured system of care and support similar to that in place in Ayrshire and Arran NHS. (Paragraph 151)

Introduction

1. The number of suicides in Northern Ireland soared from an average of 150 between 1999 and 2004 to 291 by 2006.The Committee, conscious of the serious and growing concerns about this increasing incidence of suicide, set aside other scheduled work to examine the current strategic approach to the prevention of suicide and self harm in Northern Ireland.

2. This report sets out the results of the Committee examination of:

3. In undertaking the Inquiry the Committee wrote to a wide range of organisations and groups within Northern Ireland and further afield inviting written submissions. Notices were also placed in the main newspapers. The Committee recognises that tackling suicide and self harm is not an issue for one Department and is conscious of the recently established Ministerial Co-ordination Group on Suicide Prevention. The Committee, therefore, invited views from all Departments and Assembly Committees. Visits to Edinburgh, Ayr and to Dublin were undertaken to learn from the experience in Scotland and the Republic of Ireland where comprehensive strategies have been in place for some time. The Committee also visited a Self Harm Service based in north and west Belfast organised by the Belfast Health and Social Care Trust. The Committee took formal evidence from many organisations both in Parliament Buildings and at various locations throughout Northern Ireland. We are grateful to all those who helped us with this Inquiry, including those who provided oral or written evidence. We are particularly grateful to the families of those bereaved by suicide for sharing their views and concerns with the Committee.

Background

Suicide

4. “Suicide itself is not an illness or a condition, … it is an act that can occur as an outworking of various factors. … Suicide is a final act which always arises as a consequence of a great complexity of issues.”[1]The evidence produced during the course of the Inquiry demonstrated beyond doubt that there is no single reason why someone takes their own life and the risk factors associated with suicide are exceedingly complex and multi-faceted. As well as mental health issues the factors highlighted to the Committee that may be linked to suicide ranged from social pressures, low self esteem, lack of opportunity, limited education and employment opportunities, limited access to mental health support, lack of communication and interpersonal skills, to sectarianism, intimidation or involvement with paramilitaries. Other factors highlighted were the impact of bullying or of being subjected to physical or sexual abuse, the impact of alcohol or drug misuse, long term medical conditions and post natal depression.

5. Particular groups or sections of society may be subject to specific influences. Age Concern stated “Depression is the leading cause of suicide in older people. Other risk factors include sleep problems such as insomnia, and alcohol consumption, particularly in men.”[2] The Rural Community Network reminded the Committee that farmers and farm workers have been identified as a high risk group for stress, depression and suicide and suggested that “Restructuring of farming, crises such as BSE and Foot and Mouth have placed immense strain on farmers and farm families struggling to make ends meet.”[3]

6. The National Union of Students identified the pressures facing students while Youth Action NI highlighted that “Young men aged 15-18 years are extremely vulnerable and it is in this period that they may begin to experience the stress, bullying, confusion, pressure etc which impacts on their later decision to attempt suicide or self harm.”[4] NIACRO pointed out that “Asylum seekers and other ethnic minority prisoners may be at heightened risk of self harm or suicidal behaviour.”[5] Raymond Craig, Oakleaf Rural Support Network highlighted that “There is a seriously high suicide rate in the gay and lesbian community — it is in crisis.”[6] The views of a group of young people were reported to the Committee by VOYPIC (Voice of Young People in Care). The young people ranked the following in order of importance as the issues of greatest concern in relation to suicide: “i. bullying- this could occur in the work place, school or where person is living; ii. alcohol and drugs, this could be use by parents or self; iii. stigma– included mental health and being seen as different because of clothes, music, sexuality; iv. no family contact; v. low self esteem; and vi. loneliness”[7].

7. Professor Hugh McKenna, University of Ulster, told the Committee that “Suicide and self harm are much commoner in younger people (15 – 24) than in other age groups. … Issues such as bullying, sexual orientation and difficulty in relationships frequently are often at the root of suicide and other related behaviour. The empirical literature suggests that young people have difficulty with problem solving or coming to terms with complex issues in life.”[8]

8. At the outset of the Inquiry, the Chairman of the Royal College of Psychiatrists described the factors that influence suicide prevalence as falling into three broad categories, namely mental illness; emotional or psychological factors; and socio-cultural factors. The Law Centre NI pointed out that “There is an established link between mental ill health and suicide. According to the World Health Organisation mental disorders (particularly depression and substance abuse) are associated with more than ninety percent of all cases of suicide.”[9] This assertion was further strengthened by Professor Kevin Malone, University College Dublin, who told the Committee that “All the international studies clearly demonstrate that a significant component of suicide deaths is associated with varying degrees of mental illness.”[10] The Eastern Health and Social Services Board concluded that “Whilst there are a range of factors which give rise to an increased risk to suicide … the single greatest predictor of future suicide is previous suicide attempts.”[11]

9. Concerns were also expressed that sensationalist media reporting of suicide and irresponsible internet sites can have a detrimental influence. Rt Rev Dr John Finlay told the Committee that “we are concerned that the prevalence of suicide in an area — especially among teenagers — can, sadly, create a copycat culture. We fear that the situation is exacerbated by the media and by the influence of soaps.”[12] Dr Tom Black, BMA, said that “one of the main problems with suicide is that it is contagious. People talk about ‘imitation’ and ‘copycat’ behaviour. … I prefer the word ‘contagious’. Suicides then happen in clusters, as we have seen in Northern Ireland”[13]. Mr Colm Donaghy, Chairman of the Suicide Strategy Implementation Body, also argued that “the media and the internet have big impact on our young people. Some 6% to 7% of suicides are copycat suicides, and that is primarily due to the impact of the media on young people. In Northern Ireland terms that equates to 20 young people. Those would be eminently preventable suicides if we could ensure that our media reported responsibly on suicide”[14].

Self-Harm

10. The Royal College of Psychiatrists defines self harm as “a deliberate non-fatal act, including overdosing, cutting and attempted hanging, done in the knowledge that it is potentially harmful”[15]. The British Psychological Society states that cutting and burning are the most common forms of self-harm, but it also includes scratching, head banging, poisoning, skin picking, hair pulling, interfering with wound healing, asphyxiation and biting. Self-harm is often seen as a means of coping with particular problems or situations. However, the Western Health and Social Services Board told the Committee that “Numerous studies have found that engagement in deliberate self-harm (DSH) is the strongest predictor of future suicidal behaviour, both fatal and non-fatal. It is estimated that at least one third of all suicides have a history of deliberate self harm.”[16] Dr Tom Black, BMA, told the Committee that “the key relationship between the two is that 51% of suicide victims have self-harmed before their death”[17].

11. The Royal College of Nursing urged the Committee to note that “the DHSSPS strategy seeks to address the issue of self-harm as well as suicide. The two issues are broadly linked but not necessarily mutually inter-dependent.”[18] Dr Rory O’Connor in his evidence to the Committee noted that “self-harm is the key predictor of completed suicide” but he also pointed out, in relation to the Scottish Suicide Prevention Strategy ‘Choose Life’ that it “is not a self-harm prevention strategy”[19].

12. The Royal College of Psychiatrists pointed to recent research which “suggests that full assessment of self-harm case is possibly the most important suicide prevention measure that can be taken. Of those who self harm, 1% are likely to complete suicide within the next year, an increase in risk of 100 times. This is clearly an easily identifiable group of people who are at risk and who can and should be offered thorough assessment and, if necessary, follow up”[20]. The Royal College also pointed out that the NICE (National Institute for Health and Clinical Excellence) Guidelines require every patient to be given a full psychosocial assessment after self–harm.

13. Dr Philip McGarry, Royal College of Psychiatrists, expressed concern “that 10% of those who self-harm and attend hospital departments are adolescents, and we do not have the appropriate follow-up or back-up services there”[21]. He also pointed out that “most psychiatrists who see self-harming patients in general hospitals would reckon that, in over 50% of cases, alcohol has been taken. In many of those cases, had those individuals not taken alcohol, they may well not have harmed themselves”[22].

Trends

Northern Ireland

14. While there has been a prevalence of suicide among the young adult population for many years, the number of registered suicides in Northern Ireland has effectively doubled since 2004. During the period 1987 to 2004, there were 2,732 registered deaths from suicide in Northern Ireland. This number peaked in 2000 at 185 deaths, while the lowest number of suicides during this period was in 1987 when there were 122 registered deaths.

15. The average number of suicides per annum between 2000 and 2004 was 163. However, the 2005 figure registered a 46% increase rising to 213 deaths (167 males and 46 females)[23] while 291 suicides were recorded (227 males and 64 females) in 2006, representing a 37% rise in the number of registrations on the 2005 figure.[24] The figures for 2007 just published highlight a reduction in the number of registered suicides to 242. While the reduced figure for 2007 is important, the overall average between 2000 and 2007 has increased to approximately 195.

Table 1: Suicide and Undetermined Deaths for Northern Ireland 2000-2007[25]
...

2000

2001

2002

2003

2004

2005

2006

2007

Year Registered

185
158
183
144
146
213
291
2421

Year Occurred
(186)
(181)
(196)
(157)
(220)
(206)
 
 

Male/Female
140
45
132
26
142
41
112
32
105
41
167
46
227
64
175
67

16. The Committee noted that when a suicide death is referred to the coroner, as is the protocol in all instances of suspected suicides, there is quite often a delay between the actual death and date of registration. For example, a significant number of suicides registered in 2006 occurred in the preceding years. Of the 291 deaths by suicide registered in 2006, 52 occurred in 2004, with 37 occurring in 2003 or earlier.[26] In Table 1, the figures in brackets highlight the number of suicides and undetermined deaths in the year that they actually occurred.

17. While the overall suicide rate is 11.4 per 100,000 persons, there are considerable variations in the prevalence of suicide across Northern Ireland. One of the ways in which Protect Life highlighted the large differences in suicide rates was through comparison of local Parliamentary Constituencies. In their submission to the Inquiry, the Department reaffirmed the fact that the North and West Belfast constituencies continue to experience the highest rates of suicides where currently the rate is 20 and 15.3 per 100,000 persons respectively.

18. Table 1 above clearly demonstrates that suicide is much more prevalent among males than females. Figures 1 and 2 below also illustrate the fact that suicide is more prevalent in young adults and supports the view that suicide is more prevalent in urban and economically deprived areas. It is also worth noting the findings of a recent piece of longitudinal research conducted by O’Reilly et al from Queens’ University Belfast which concluded that ‘differences in rates of suicide between areas are predominantly due to population characteristics rather than to area-level factors…suggesting that policies targeted at area-level factors are unlikely to significantly influence suicide rates.’[27]

Figure 1: Average suicide rate per 100,000 persons by rurality and age band[28]

Figure 1: Average suicide rate per 100,000 persons by rurality and age band

Figure 2: Average suicide rate per 100,000 persons by economic deprivation and age band[29]

Figure 2: Average suicide rate per 100,000 persons by economic deprivation and age band

International Comparison

19. The situation in Northern Ireland is congruent with the wider global trend of a growing number of people dying by suicide in almost every region of the world. The scale and pervasiveness of the problem is reflected in the fact that for some time suicide has been the third biggest cause of “years of lives lost” after cardiovascular disease and cancer. An estimated 877,000 lives were lost prematurely worldwide due to suicide in 2002.[30] According to the World Health Organisation (WHO), around one million people worldwide currently die from suicide each year and 10 to 20 times more attempt suicide. This represents an average of one death every 40 seconds and one attempt every 3 seconds.[31] In 2005, 6,045 suicides and undetermined deaths were registered in the United Kingdom and the Republic of Ireland[32] with approximately 5,000 deaths registered in England alone.[33] Alongside these deaths, there are a very large number of people, estimated to be as many as 142,000 who are admitted annually to Accident and Emergency (A&E) departments because they have harmed themselves non-fatally. Among admission to A&E departments for non-fatal self-harm, the majority involve self-poisoning. Between 10% and 15% tend to be cases of self-injury, with most of these involving cutting.[34]

Figure 3: European Union total population suicide rates per 100,000 persons[35]

Figure 3: European Union total population suicide rates per 100,000 persons

20. The overall suicide rate in Northern Ireland, currently 11.4 per 100,000 persons (as of April 2008), is higher than the rates in England, Wales and the Republic of Ireland but less than the rate in Scotland. It is important to note that this figure is based on a rolling average between 2002 and 2006. It represents a rise in the original figure of 9.7 per 100,000 persons outlined within the Protect Life strategy which itself was based on a rolling average between 2000 and 2004.[36]

Figure 4: National suicide rates per 100,000 persons in England, Scotland, Wales, Northern Ireland and the Republic of Ireland[37]

Figure 4: National suicide rates per 100,000 persons in England, Scotland, Wales, Northern Ireland and the Republic of Ireland

Self-Harm

21. As set out in Protect Life, the average rate of admissions to hospital each year in Northern Ireland as a result of self-harm is 280 per 100,000 persons[38] or almost 4,500 admissions each year. However, the seriousness of the problem and the need to tackle it alongside the increasing prevalence of suicide is only partially reflected in the recorded statistics. This is because deliberate self-harm continues in many respects to be a ‘hidden problem’ involving young people who often only present themselves to Accident and Emergency departments when such behaviour has resulted in serious injury. Moreover, the figures are furthered distorted by the fact that only a proportion of those individuals who have self-harmed and present themselves for medical attention at Accident and Emergency departments are admitted to hospital.

22. The Department’s submission indicates that, ‘the term self-harm covers a wide range of behaviours including ‘parasuicide’[39] and habitual self-cutting and poisoning which involves differing degrees of risk to life and differing degrees of suicidal intent.’ Incidents of self-harm which result in admissions to hospital are recorded in the DHSSPS Hospitals Inpatients System (HIS) which uses the same International Statistical Classification of Diseases and Related Health Problems (ICD) used in the classification of deaths.[40] The latest hospital admission figures relating to self-harm are illustrated in Table 2.

Table 2: Number of hospital admissions as a result of self-harm (2002/03-2006/07)[41]

Year

2002-03

2003-04

2004-05

2005-06

2006-07

Total

Admissions as a result of self-harm

4,591

4,517

4,704

4,494

4,112

22,418

All admissions

487,518

508,824

521,123

532,670

537,193

2,587,328

% of all admissions

0.94%

0.89%

0.90%

0.84%

0.77%

0.87%

Strategic Approach to Suicide Prevention

23. Professor Hugh McKenna, University of Ulster, pointed out that “many eminent researchers will agree that preventing suicide in its totality is near impossible. Nonetheless, many will also agree that the reduction of suicide and other related behaviour such as self harm can be achieved. This type of thinking requires a mind shift by Government. Much of the current research focuses too much on causative factors and how people commit or attempt suicide. There is a need to focus on factors that have helped people to regain their will to live.”[42]

24. The development of a regional strategic approach to the prevention of suicide and self-harm is a relatively recent method of tackling the issue. Dr Rory O’Connor, a leading chartered health psychologist and member of the International Association for Suicide Prevention, explained that “the first national suicide prevention strategy was developed in Finland and launched in 1986 and has influenced national strategies throughout the world. It was a ten year strategy and it has been evaluated internally and externally. It has been seen largely as a success. … A number of other countries, Norway, Sweden, New Zealand, Australia, United Kingdom, Netherlands, Estonia, France and the South of Ireland have all got suicide prevention strategies.”[43]

25. Dr O’Connor also told the Committee that suicide prevention strategies across the world tend to be made up of six components. These are: undertaking education and awareness; screening those at risk; providing treatment for psychiatric disorders; restricting access to lethal means of carrying out suicide; developing guidelines for dealing with media reporting; and undertaking research.

26. In 2005 an increase in the number of suicides, particularly among young people, led to the establishment by the Department of a multi-sectoral taskforce charged with the development of a suicide prevention strategy for Northern Ireland. In drawing up the strategy the taskforce undertook a very extensive engagement process which included meetings and consultation workshops with a wide range of sectors and stakeholder organisations throughout Northern Ireland. Bernie McNally from the Belfast Health and Social Care Trust commended the process saying “It is the Trust’s view that the development process of the Protect Life Strategy was an example of effective stakeholder involvement across the statutory, community, and voluntary sectors.”[44]

27. The resulting ‘Protect Life: a shared vision’ suicide prevention strategy, published in October 2006, includes all six components identified by Dr O’Connor and it also incorporates a number of important guiding principles including, the development of links to others relevant strategies such as Investing for Health, the mental health strategy, the alcohol and drug strategy, and the children’s strategy, the recognition of the need for joined-up working at Government level, and the need for ongoing engagement with primary stakeholders particularly bereaved families.

28. The strategy has adopted a dual population and targeted approach. As explained in the strategy document “The population approach seeks to tackle the issue of suicide in a wider generic context, with actions aimed at protecting the general population of Northern Ireland. The targeted approach seeks to tackle the issue by focusing action on those who are most at risk.”[45] The document stresses that the dual approach is complementary.

29. Mr Francis Rice, Southern Health and Social Care Trust explained that the action plan is also divided into two different approaches. “The first is a population-based approach under which we have specific objectives and targets that deal with communities; families, children and young people; health and personal social services; workplaces; emergency services; Churches; and the media. We then move on to more specific, targeted approaches that have objectives with specific outcomes and deal with areas such as self-harm and mental illness; drug and alcohol misuse; young males; those bereaved by suicide; survivors of sexual, physical and emotional abuse; marginalised and disadvantaged groups; high-risk occupations; and prisoners.[46]

30. Professor Hugh McKenna, University of Ulster, described the Strategy as “probably the most important document that has been produced in recent times in Northern Ireland … This document has a number of well made points with regard to suicide. Its proposed strategy of targeting vulnerable populations is to be commended. It identifies young males and those bereaved by suicide as being particularly vulnerable”[47].

31. However, a number of respondents expressed some unease that the emphasis on tackling the suicide risks among young people could detract from the needs of other groups or sectors. The Northern Health and Social Care Trust stated “A concern would be that in focussing so strongly on the very real needs of younger people the strategy may play down the needs of older people who also sadly suffer high rates of suicide.”[48] Age Concern argued that “suicide and self-harm is also an issue in later life, with suicide rates across the UK remaining high for both older men and women, especially those aged 75 and over. …Older people should be identified and included as a priority group within the scope of the strategy.”[49] Professor Hugh McKenna, Queens University Belfast, also drew attention to suicide among older people and concluded that “ a pre-emptive approach to older suicide is needed”[50].

32. Mr Iain McGowan, on behalf of a multi-disciplinary group of clinicians, stated “we hold that the focus [of the strategy] on young males and those bereaved by suicide limits its scope. It would be damaging to set to one side other demographic categories in which suicide is a notable issue, for example, suicide in pregnant women and new mothers, in those who struggle with sexual identity and in those over the age of sixty-five”[51].

33. The Niamh Louise Foundation argued that one size does not fit all and stressed the need for a different approach in urban and rural areas. The Foundation stated that “this does not seem to have been included in the development of the strategy and the principle that one method works well in all areas should be readdressed and special attention given to how to create awareness and response mechanisms in the aftermath of a suicide in our rural areas”[52].

34. Research by Dr Dermot O’Reilly, Queens University Belfast, presented to the Committee found that ‘differences in suicide rates are predominantly due to population characteristics rather than area-level factors’. It suggests that once ‘individual characteristics and household factors (i.e. marital status, household composition, socio-economic and employment status and baseline health status) are adjusted for, the association between suicide risk and area deprivation and levels of social fragmentation disappeared.’ Dr O’Reilly told the Committee that the lesson for the suicide strategy was that “While the current efforts focus on the need for support for individuals and especially for younger people …, it ignores the wider social background to suicide risk. Our research clearly shows that suicide risk is greatly increased amongst those not in employment and those individuals living in disadvantaged circumstances. … factors which improve the levels of employment and increase the social wellbeing of the population are likely to have a significant impact on suicide risk for the Northern Ireland population. As is often the case, the factors that most impact on our health lie outside the caring and curative services.”

35. The development of the Protect Life suicide prevention strategy has been a major step forward in the battle to reduce the incidence of suicide in Northern Ireland. We recognise the benefits of the dual population and targeted approach but we believe that the focus of the targeted approach needs to be re-examined and redefined to include other priority groups, such as older people and those living in rural areas.
Implementation Structure

36. Following publication of the Suicide Strategy the Department set up a Suicide Strategy Implementation Body (SSIB) “to oversee and drive forward the implementation of the Strategy”[53]. The SSIB, with a membership of more than 40, comprises very wide ranging representation from, inter alia, health related organisations, bereaved families, PSNI and various Government Departments. The SSIB meets bi-monthly and the secretariat is provided by the Department.

37. STEER Mental Health argued that “If suicide prevention is to be recognised as a priority by all relevant Government Departments, the Suicide Strategy Implementation Body should be located within the Department of the First and the Deputy First Minister.”[54] This was a view supported by the Health and Social Services Councils. North Down & Ards Community of Interest group queried “how progress can be made on so many actions, given that ‘lead’ partners are not clearly identified and much of the responsibility for driving action lies with the DHSSPS.” The group also pointed to the “danger of services being driven via DHSSPS and the potential therefore to ‘medicalise’ the solutions to the issue”[55].

38. The co-ordinator in the South Eastern Trust expressed concerns that “a robust system of communicating the progress of SSIB to the local community level is lacking” and also that “there is a feeling that while SSIB members are given due respect and a hearing that major decisions taken at the inception of the strategy cannot be easily influenced”[56]. The Health and Social Services Councils were concerned that the Suicide Strategy Implementation Body was a misnomer and that it had “remained as an advisory body to the Department rather than an implementation body”.[57]

39. Mr Seamus McCabe, PIPS, said “The strategy is a bottom-up strategy, and it was put in place as a result of lobbying that bereaved families carried out. … when work reaches a certain level, the Department takes ownership of it, and we are cut off. The community groups take the work as far as they can, and the Department then takes over.”[58]

40. In the Republic of Ireland a National Office for Suicide Prevention [NOSP] has been established within the Health Service Executive to oversee the implementation of ‘Reach Out’ the National Strategy for Action on Suicide Prevention. NOSP in a submission to the Committee suggested “It would be helpful if there was a similar organisation to the NOSP in NI as this would allow for one contact point for this office. Also in our experience the establishment of the office has provided a national focus for all our initiatives as well as a central coordination role. For government it provides a single channel through which Department of Health and Children funding and policy monitoring can take place. We would urge you to establish a team within the health/ social care statutory set up to undertake this work.”[59] Health and Social Services Councils agreed that there were merits in establishing a similar body in Northern Ireland. Speaking about another issue Pat McGreevy, Coordinator South Eastern Health and Social Care Trust said “Unlike Scotland and the Republic, we do not have a designated suicide prevention office to get the message out.”[60]

41. We have major concerns that the current structure lacks a dedicated directorate to manage and act as a central focus for the implementation of the suicide prevention strategy. The SSIB, which is charged with overseeing and driving forward the strategy, provides a vital structure to bring together the many stakeholders and to help develop policies. However, with more than 40 members we believe it is too large and unwieldy to undertake the role of driving forward the strategy. We call on the Minister to establish a designated suicide prevention directorate as part of the proposed new Regional Public Health Agency.

Evaluation and Review

42. The Department advised that the Strategy will be reviewed on an annual basis and that the first review is due to be completed “by end of March 2007”[61]. The review will consider the actions, timescales, structures etc and make recommendations. In its submission to the Committee the Department stated that it had commissioned the Institute of Public Health in Ireland (IPH) “to develop a monitoring and evaluation framework that will assist with the future assessment of key elements of the Strategy’s implementation. … IPH is currently consulting with key stakeholders on the development of this framework, and it is anticipated that this work will be completed by the end of November 2007”[62].

43. When the Committee met representatives of families and community groups one of their main concerns was the absence of any evaluation to date. Michael Doherty, West Belfast Suicide Awareness and Support Group, said “the strategy was 12 months old in September 2007. It is now January 2008, and no adequate evaluation of the strategy has been carried out. A lot of money has been spent on it, and perhaps another £3 million will be spent this year, but we want an adequate evaluation that considers whether the actions that were planned for the first year have taken place and, if so, what the outcomes have been. We must learn from those outcomes in advance of moving into the second year of the strategy.”[63]

44. It is of the utmost importance that robust review and evaluation arrangements are in place to examine the key elements of the strategy and learn lessons as the strategy develops. While provision for such review and evaluation was built into the strategy we have major concerns that this has not yet taken place. We call on the Minister to commission an urgent independent, time-bounded evaluation of the key elements without further delay and to take account of the findings of this Committee report in the review of the strategy.
Funding

45. The Department provided funding of £1.9 million in 06/07 and £3.06 million in 07/08 to implement the Strategy. Approximately £0.95 million in 06/07 and £1.8million in 07/08 of this was allocated as part of a community support package. In addition in January 2008 the Minister announced the establishment of a Regional Suicide Prevention Helpline and stated that it will cost approximately £3.5million each year to run the helpline. The Minister stated “this development means that a total of over £6million has now been allocated each year to implement the suicide prevention strategy.”[64]

46. The level of funding provided was acknowledged by the Samaritans as “generous in relation to the other administrations and the size of population”[65]. In Scotland “£12 million was made available … in 2003-2006 and a further £8.4 million was made available for 2006-2008”[66]. During the visit to the Republic of Ireland the Committee was told that the total funding available there to support suicide prevention initiatives in 2007 was €8 million (£6.78m approx[67]) and this level of funding continues into 2008. An additional €1.2 million (£1.02m) was allocated in 2006 and a further €1.85 million (£1.58m) in 2007 to develop and implement national training programmes and to provide self-harm services through A&E departments.[68]

47. Dr Rory O’Connor pointed to the experience in Scotland where funding was earmarked “for local projects, for local development and local skills, so in each of these areas, there was someone who was designated as a lead person to develop the strategy.”[69] He stressed that “having ring-fenced money is particularly important.”[70] However, during the visit to Scotland the Committee learned that ring-fenced funding for the Choose Life Strategy was likely to cease in 2008 and that future funding for the suicide strategy would be included in the overall allocation to Boards. The importance of ring-fencing funding for suicide prevention was also stressed by colleagues in the Joint Committee on Health and Children in the Republic of Ireland.[71]

48. Community groups expressed grave concerns about the level of funding and the uncertainty for their groups after April 2008. Michael Doherty, West Belfast Suicide and Awareness Support Group told the Committee “When the strategy was first launched, people lauded it and the additional money that came with it. However, funding has been totally inadequate, as well as the manner in which it has been handled. … funding must be for a three-year period. …the funding that we have been allocated is inadequate, and we do not know what funding we have beyond March 2008”[72]. Phillip McTaggart, PIPS, said “I constantly hear about £3 million that is being invested in suicide prevention. However, the real figure for the money that goes to work on the ground is only £1·3 million”[73]. When questioned about the funding issue in April 2008 Martin Bell, DHSSPS, assured the Committee 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”[74].

49. On the issue of providing sustainable funding over a longer period Andrew Elliott, DHSSPS, said “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 mechanisms evolving through which we can consider the possibility of two-year funding. Boards will be given a little more flexibility in that regard”[75].

50. We note the overall level of funding for implementation of the strategy and recognise that it compares favourably on a per capita basis with Scotland and the Republic of Ireland. We strongly urge the Minister to ensure that this funding remains ring-fenced for a number of years to sustain and implement the Protect Life strategy and that there is full transparency, accountability and scrutiny of how this funding is used.
51. We commend the sterling work carried out by community groups and we fully recognise the vital importance of their involvement in the strategy to reduce suicide and support bereaved families. The assurance by the Department that over £2 million in 2008-09 is being allocated to support community initiatives is welcome. However, we are greatly concerned at the ongoing uncertainty and insecurity caused for those groups by single year funding. This must be addressed urgently. We call on the Minister to provide funding support for community groups on a minimum of a three yearly basis.
Targets

52. The Department in its submission states that “the Strategy sets a target of reducing the overall Northern Ireland suicide rate by 15% by 2011, from a baseline of 12.6 in the three year rolling average period of 2004-2006”[76]. Others highlighted that the target is 10% by 2008 with a further 5% by 2011. Dr Rory O’Connor felt that these were “really ambitious targets”[77] and he pointed out that some countries have set targets while others have not. He raised concerns about the implications for the strategy if targets are not met and particularly how it might affect morale or be viewed in the media.

53. The Department argued that progress in reducing the stigma surrounding suicide might mean that more deaths are officially recorded as suicide and thereby artificially increase the recorded suicide rate. It concluded that “if this occurs it should not be interpreted as a failure of the Strategy to achieve its goals”[78]. Dr O’Connor welcomed the fact that “the Northern Ireland Strategy has looked at this and identified secondary targets”[79].

54. In the Republic of Ireland the Reach Out strategy sets clear targets for reducing suicide levels. The Director of the National Office for Suicide Prevention pointed out “While we originally did not set targets due to concerns over the reliability of data we have now done so ... We have taken the view that a target does allow us all to focus our efforts and be accountable for actions taken. … we have also set a target for the reduction in the rate of repetition of self harm”[80].

55. STEER Mental Health believes that “Suicide rates are an unknown quantity and an accurate system for recording suicide statistics must be developed as a priority”[81] so that progress can be measured. The Northern Ireland Commissioner for Children and Young People, while accepting that reducing the suicide rate will be very difficult, argued that “a 10% reduction is too low, and would suggest a target rate of 33%”[82].

56. We fully recognise the difficulties involved in measuring suicide rates, the dangers of putting too much emphasis on a single year’s figures, and the arguments for and against setting specific targets. We note the target of a 10% reduction by 2008 and we urge the Minister to review the targets when figures for 2008 become available and to consider setting targets for the reduction of self-harm.

Stakeholder Involvement

Development of the Strategy

57. A number of respondents agreed that there had been widespread consultation with the community and voluntary sector and with bereaved families during the initial development of the draft strategy. The Rays Crisis Centre, for example, told the Committee that “bereaved families generally felt that they had been listened to, and that their opinions, experiences and concerns had been taken on board.”[83] However, this does not appear to have been maintained. ZEST stated “From a community perspective there are concerns in relation to equal partnership and, in particular, equality in the decision-making process.”[84] This sentiment was supported by Youth Action Northern Ireland which stated “There was no follow up after this point to engage with us as an agency and how the strategy was being implemented on the ground.”[85]

58. The Rays Crisis Centre reported that “the families felt that a significant number of issues had been omitted from the draft version of the strategy ... The Families had been informed but feel they have had no real consultation: as their ideas and inputs were not included in forming the final outcomes of the strategy.”[86] Another community group STEER stated its belief that “stakeholder involvement is merely a ‘box ticking’ exercise by some agencies”[87]. Youth Action Northern Ireland concluded that “Involvement of all stakeholders is key to the success of the strategy and more needs to be done to share the learning and experiences from other projects”[88].

59. Mr Iain McGowan, University of Ulster, argued that “There has been a lack of local academic input into the suicide prevention strategy. As far as I am aware, no one from any of the three higher education institutes was a member of the strategy group. We accept that there were eminent academics and suicidoligists providing quality assurance, but it would have been useful to have had someone with local knowledge as a member of the group”[89].

Ongoing involvement through SSIB

60. The level of stakeholder involvement was commended by some “given that there are 35-40 groups and organisations represented at the Suicide Strategy Implementation Body”.[90] The Southern Health and Social Care Trust stated “Given the multi-sectoral nature of the strategy at regional, area and local levels, coordination is vital. ... Representation on these groups by service providers, commissioners, individuals and communities is critical in ensuring firstly that responses are targeted at addressing the needs of those who have experienced first hand the effects of suicide and self harm and secondly that these responses are multifaceted in nature thus ensuring a holistic response to need.”[91]

Families and Community Groups

61. The Department pointed out that “bereaved families played a key role in the development of the Strategy and are represented on the SSIB. A Families Forum (now Family Voices) was established in August 2006 to ensure that they continue to have a powerful voice in the implementation process.”[92] There were mixed views on how successful the engagement with bereaved families has been. North Down & Ards Community of Interest Group, for example, told the Committee that “there is limited engagement at present locally from families bereaved by suicide and this may take time to develop”[93].

62. The Committee met with a number of representatives of bereaved families and community groups from across Northern Ireland and were greatly impressed by their courage, passion and energy. As Bobby Cosgrove, Family Voices, told the Committee “We do not come at the issue from a professional background; the only hidden agendas that we have are lying in graves. That is where we are coming from. With our hearts and souls, we want to help people through what we went through and to try to make life easier for them. We see the horrors that are happening, and we believe that we can make an impact.”[94] Mr Cosgrove also said “Nineteen years ago, my son took his own life. I had absolutely no one to turn to. I went everywhere. I just wanted answers to simple questions to make sure that I was not going insane. No support was available to me. Twelve years ago, Ann’s son did the same thing. Again, there was no support. Over the past five years, the families have made massive changes. It is the families who have made those changes.”[95]

63. Mr Seamus McCabe, PIPS, explained that the organisation “Family Voices is the result of a lot of families getting together from across the Province, and it allows us the opportunity to share information. It meets on a regular basis.”[96] Anne McGarrigle, Family Voices, told the Committee “We are trying to include all suicide-prevention groups, and we have appealed to all of those groups to be part of Family Voices. It is difficult and tiring for bereaved people to talk about their story, but we need to know the issues and act on those as a collective bunch.”[97]

64. The Minister in evidence to the Committee acknowledged the important role of families. He said “Families who have been bereaved by suicide play a key part in the suicide strategy implementation body, … There are a number of key stakeholders, but the representatives of bereaved families and communities play a very important role, because they have intimate first-hand knowledge of the consequences of suicide — not just of the event but of living with it afterwards.”[98]

65. Colleagues in the Republic of Ireland saw Family Voices as perhaps a model to be emulated. The National Office for Suicide Prevention told the Committee “We have been impressed by the work of the Families Forum in NI and whilst we have similar families groups in the South they do not yet meet together as a national grouping. There is an opportunity in the future to establish an all island network of bereaved families.”[99]

66. We fully appreciate the first hand knowledge and understanding that bereaved families bring to bear in the efforts to deal with suicide and the positive contribution that they have made to the development of the strategy. We commend the many families who have come together to set up Family Voices and we urge the Minister to ensure that their views are taken into account.
Cross-Departmental Role

67. There is a recognition that implementation of the Strategy is not solely a matter for the Department of Health, Social Services and Public Safety. Four other Departments, Education, Agriculture and Rural Development, Employment and Learning, and Social Development, are represented on the SSIB. In addition, the Executive has established a Ministerial Co-ordination Group on Suicide Prevention chaired by the Health Minister and including the Education Minister and the two junior OFMDFM Ministers. The Minister accepted a suggestion from this Committee that the Minister for Employment and Learning should also be part of the Group. He said “I shall discuss that matter with the ministerial group and with the Minister for Employment and Learning. That is a good suggestion, bearing in mind the link between suicide and young males, and DEL’s role in further and higher education — as well as the link between employment and self-esteem.”[100]

68. The Royal College of Nursing was critical of the level of involvement by other Government Departments, saying “the leadership and personal commitment being shown on this issue by the Minister for Health, Social Services and Public Safety is exemplary. … However, and despite the fact that the broader issue of suicide arguably touches upon the responsibilities of every single Stormont department, there is no discernible evidence of the inter-departmental commitment that the strategy envisages. It is difficult to avoid the conclusion that the Northern Ireland Executive appears to regard suicide and suicide prevention solely as a health issue, when it is in fact far broader.”[101] The Committee for Social Development also called for greater cross-departmental involvement saying “The Committee recognises that other departments and agencies should be involved in education campaigns, particularly the Department of Education and the Department for Employment and Learning, and would encourage strong cross-departmental working.”[102]

69. We welcome the establishment of the Ministerial Co-ordination Group on Suicide Prevention chaired by the Minister for Health, Social Services and Public Safety and involving a number of other Ministers. We urge the Executive to acknowledge that suicide prevention is not solely a health issue and to examine how the role of the Ministerial Group can be further developed to secure a greater commitment and involvement by all Departments.
Role of Schools and Colleges

70. A number of respondents, including the NI Commissioner for Children and Young People (NICCY) and BMA NI, pointed to the important role that schools have in helping young people to build self esteem, resilience and develop coping skills. NICCY stated that this was particularly important “in relation to young males who may find it difficult to articulate and deal with their feelings.”[103] BMA NI stated that “the educational sector is in an important position in the delivery of these much needed skills”[104].

71. Sharon Sinclair, Aware Defeat Depression, also highlighted the need for “action to equip people with the skills in problem-solving, conflict resolution and building self-esteem. Those skills can effect a significant change in help-seeking behaviour by those in psychological distress and can help to avoid the kind of progression into hopelessness that will often prompt suicidal behaviour. Again, we feel that such work must begin at school age and on a widespread basis.”[105] Aware Defeat Depression and Action Mental Health gave details of their work in schools which includes a depression-awareness programme for young people between the ages of 14 and 16. Colin Loughran, Action Mental Health, told the Committee “It used to be difficult to get into schools because teachers were afraid of the consequences of recognising the issue. However, there has been a significant increase in the number of schools that are prepared to allow organisations with expertise to conduct sessions and support their pupils.”[106]

72. The Committee noted a recent call by the Ulster Teachers’ Union for suicide awareness training for teachers ‘as they face a growing epidemic of mental health issues among pupils[107]. However, a representative of Family Voices cautioned that “child-protection issues put teachers in a delicate position. Often, when a child indicates that something is wrong, we cannot ask questions — the matter must immediately be passed on to designated personnel in the school. In many ways, teachers’ hands are therefore tied. As professionals, we often feel that we would like a little more scope to deal with situations. The pastoral system that is up and running in many schools is patchy and varies between schools. The action that is taken by a school depends on its principal and policies.”[108]

73. The Department of Education in its submission emphasised the priority it places on developing the emotional health and wellbeing of pupils and stated that work is underway to develop a ‘Pupils’ Emotional Health and Wellbeing Programme’ with the focus on the post primary sector. An independent counselling support service has been made available to all post primary schools from September 2007 with funding of £1.8m from the Children and Young People’s Funding package. Contact Youth was appointed in October 2006 to provide this counselling support to schools and the Department indicated that 95% of post primary schools have taken up the service. Other schools continue to use existing counselling services. The Department also stated that “A strategy for the provision of counselling is being provided and it is hoped that the service may in time be extended to primary schools to address issues with younger children, where appropriate”[109].

74. NICCY called for counselling services to be made available in all schools and emphasised that “it is essential … that any service is developed in consultation with children and young people to ensure that the service is designed to meet their needs”[110].

75. Rt Rev John Finlay said that the experience of pastoral care would indicate that “people are not coping in the same way as past generations may have done.”[111] This was borne out in other responses. NIAMH referred to a conclusion reached by number of international suicidologists that “by teaching young children how to cope with difficulties they should be able to handle problems and crises in adolescent and adult life. ….. Such an approach is essentially different to the pathogenic approach which seeks to identify children who have mental health problems or who are perceived as being especially vulnerable”[112].

76. We welcome the introduction of the independent counselling support service in post primary schools and call on the Minister for Education to extend this service to the primary sector as soon as possible. We also welcome the work that is underway to develop a Pupils’ Emotional Health and Wellbeing Programme for the post primary sector. However, we believe that developing coping skills and building young peoples self esteem should begin at an early age and we call on this programme to be extended to all schools.

77. The Department for Employment and Learning affirmed its full commitment to the Protect Life strategy and to continue to engage with the SSIB. The Department provided examples of initiatives that contribute to the mental wellbeing of students in further education and indicated that universities and teacher training colleges provide a counselling service for students.

78. We welcome a number of useful initiatives linked to the prevention of suicide and self harm currently being undertaken by the Department for Employment and Learning. These include the services provided by Opportunity Youth and Include Youth to young people on the Jobskills and Training for Success Programmes. We also recognise the value of the Bytes Project, jointly supported by the Department of Education, which targets ‘hard to reach’ young people who are not in education, employment or training. We call on the Department for Employment and Learning to review its contribution to implementing the Protect Life strategy and, in particular, to ensure that initiatives taking place in some FE colleges are available to all in that sector.
Role of Churches

79. The Committee for Social Development highlighted the fact that “Faith leaders are in a key position to provide guidance to those who present with suicide and self-harm tendencies and influence societal attitudes.[113]” This view was echoed by Mr Iain McGowan, on behalf of a multi-disciplinary group of clinicians, who stated “We strongly advocate the involvement of ministers and religious leaders and representatives of voluntary sector organisations in discussions about mental healthcare provision and suicide prevention work”.[114] Health and Social Services Councils also supported “the need for suicide and depression awareness training for all church and religious leaders”.[115]

80. When churches in general failed to respond to a request for written views on suicide prevention the Committee invited the leaders of the four main churches in Northern Ireland to give evidence. Bishop Patrick Walsh told the Committee that clergy are involved in three areas relating to suicide, “they are among the first to be called out to a suicide incident, which is a very harrowing experience. Secondly, they are then involved with the care of the families, and that is a most important part of pastoral ministry for all our churches. Thirdly, they are, very often, the first port of call for someone who is contemplating suicide, or who has indulged in some sort of self-harm. …. we are all very conscious of the need for them to be trained.”[116]

81. Rev Roy Cooper said “The Church’s role in suicide prevention may include as many efforts as possible to develop experiences of community. Indeed, for many in town and country, the Church is their basic community. There may be other initiatives, including co-operative working and being prepared to talk openly about suicide, thereby giving opportunity to challenge its perceived role as a solution to problems.”[117] Rev Cooper indicated that depression “headed the list of the most important issues the Church had to deal with”[118] and he highlighted the problem of isolation for young and old alike in rural areas.

82. Rt Rev Dr John Finlay told the Committee that “We are always willing and desirous to be a comfort and counsel to those who have suffered, especially the families. Perhaps our concern and our frustration is that, more often than not, people who take their own lives are very peripheral to our membership and association with the Church”[119].

83. Archbishop Harper spoke of his concern that “Societal change also includes problematic substance and alcohol abuse. There is significant evidence that that may be directly correlated with mental-health issues. When I speak of mental health, I do not want to suggest that suicide is merely a matter of mental ill health. It is not. To deal with it simply as a mental-health matter will address some, but by no means all, of the issues.”[120]

84. We welcome the commitment by the leaders of the four main churches in Northern Ireland to play their part in tackling the issue of suicide and self harm. We urge greater collaboration with the Suicide Strategy Implementation Body in the development and delivery of training for all clergy in dealing with people who may be at risk of suicide and in supporting families and communities in the aftermath of a suicide.
Role of Sport and Exercise

85. The beneficial effect of regular exercise, whether through organised sport or otherwise, on both physical and mental well-being is well established. Dr Kremer, Queens University Belfast, pointed out that “there is a positive correlation between exercise, self-esteem, self-efficacy, well-being in general and cognitive functioning; and a negative correlation with anxiety, stress and depression”[121]. He said “Critically, in relation to self-harm and suicide, there is an emerging literature that suggests that those who exercise are less prone to suicide attempts”.[122]

86. Dr Kremer explained that “Mood state, for example, responds well to certain types of exercise. ….. it is now well established that an effective treatment for depression — and most especially for clinical depression — is regular exercise. ... Anxiety has also been shown to respond well to exercise, especially programmes that last longer than 20 minutes”[123]. But he cautioned “it would be over-egging the case to say that exercise provides an answer to all the problems. It is more likely that exercise can act in combination with other interventions to help to stop people who are already heading down a suicide route.”[124]

87. Professor McCartan, Sport NI, advised the Committee that “there is clear empirical evidence … that GPs are prescribing exercise and physical activity as a remedy to deal with depression, anxiety and the continuum that leads to self-harm and suicide, rather than simply prescribing pills.”[125] But Dr Kremer pointed out that “A major culture shift is needed to recognise that GPs using exercise as a form of treatment is not a second-class option or a poor cousin. In a well-maintained and well-managed environment, that can be a long-term solution to many of those problems”[126].

88. Another issue identified by Dr Kremer is that those who are most likely to benefit from exercise are also likely to be those who are least inclined to take exercise. He argued that “Fresh thinking is needed to consider how to engage with those hard-to-reach, marginalised people. They need to be encouraged to engage in activities that they may well have been put off at an early age.”[127]

89. During the visit to Scotland the Committee learned that well-known sports personalities are being used there to encourage people, particularly young men, to talk about their feelings and to overcome the stigma relating to depression. Major sports occasions are also used to distribute literature encouraging people to talk about the issue. Professor McCartan, Sport NI, told the Committee that “The Scottish Parliament allocated sportscotland around £13 million from the health budget to help in the development and promotion of such programmes. We would seriously consider developing such a programme and promoting it at major international football matches in Windsor Park, at major rugby and Gaelic matches and at the North West 200. They are probably our four biggest crowd-pullers.”[128]

90. The Committee was concerned to learn that sports organisations were not involved in drawing up the suicide strategy and are not involved in the SSIB. Professor McCartan, Sport NI, told the Committee “To the best of my knowledge, we were not consulted on the strategy, but we are aware of it”[129].

91. The positive role of sport and exercise in combating stress, anxiety and depression is well established and widely recognised. We urge the Minister to explore how the prescribing of an exercise regime can be developed and promoted for use as an option by GPs in appropriate circumstances.
92. We are disappointed that Sport NI and the main sports bodies in Northern Ireland have not been directly involved in developing and delivering the strategy to prevent suicide. We call on the Minister for Health, Social Services and Public Safety to explore with the Minister for Culture Arts and Leisure how Sport NI and other sports organisations can fully participate in delivering the suicide strategy. We strongly commend the Scottish model of involving sports icons and using major sporting occasions to raise awareness of the issue and to encourage young people, particularly young men, to seek help.
Role of Local Authorities

93. Anne Donaghy, Antrim Borough Council, acknowledged that “Local government takes a keen interest in the Protect Life strategy” but when asked about the extent of local government involvement in developing the strategy she said “we could have added more. We submitted a paper, but we would have welcomed more open discussion”. Heather Moorhead, NILGA, told the Committee that “There is a massive role for local authorities, but their work is piecemeal”. Heather Moorhead summed up the involvement of District Councils in suicide prevention initiatives by saying that “some local authorities are doing a lot; others are doing something, while some are not doing anything”.

94. Anne Donaghy, Antrim Borough Council, spelt out what she saw as the important role for local Government saying “We can help to target resources and to ensure that those that are set aside for suicide prevention can be used more effectively. … local government has the ability to co-ordinate a streamlined partnership approach, in which we can connect organisations and individuals, such as the Churches and health professionals, who have an important role to play”[130]. She also identified specific ways in which existing local Government services could be used to help reduce suicide saying “We have rural connections; rural suicide is as big an issue as it is anywhere else, and it affects young and old. … We can channel our sports and leisure and community development resources”[131].

95. Anne Donaghy stressed that “local government wants to be involved in the implementation and evaluation of the Protect Life suicide strategy. We want to channel the capacity that exists — and the resource that is paid for — to the community and address the issue.”[132] NILGA called for a more proactive approach and proposed the setting up of a “working group with some of the other key providers … We want to define the type of role that we believe that local authorities could be playing and the things that we could be doing.”[133] She stressed that suicide “is not just a health issue: it is a societal public-health issue, and a solution cannot be arrived at with only a health mindset; a broader mindset is required”[134].

96. There is clear potential for local authorities to play a significant role in the ongoing development and delivery of the Protect Life strategy. We note the position in Scotland where local authorities are major partners in delivering the strategy and have appointed suicide co-ordinators in each area. While current participation is described as piecemeal many District Councils are keen to play their full part. We urge the Minister to explore with local authorities how solid partnerships can be developed. We believe that this should include full participation in the Suicide Strategy Implementation Body and other structures.

Services and Support

Training

97. The taskforce set up by the Department to draw up the suicide strategy identified the need for training and development, firstly for frontline health and social care staff, secondly additional training for others including health professionals, clergy, and those whose occupations may bring them into contact with people at risk of suicide, and thirdly the introduction of coping skills in schools. Subsequently the need “to provide appropriate training for people dealing with suicide and mental health issues” was identified as one of the key objectives of the strategy. The need for additional or improved training for all those who may come into contact with people at risk of suicide was a recurring theme of many of the submissions to the Committee.

ASIST Training

98. Dr Philip McGarry, Royal College of Psychiatrists, explained that “In the workplace, a great deal of work has been done using ASIST, which is Applied Suicide Intervention Skills Training, and that started in Canada, 20 years ago. … The two-day course is geared towards people such as youth leaders, community workers, police officers, fire services, and so forth. It educates people on how to identify any early warning signs shown by an individual and how to deal with that person. That training continues, and the voluntary and statutory sectors are doing good work rolling it out.”[135] Pat McGreevy, South Eastern Health and Social Care Trust, compared ASIST to CPR and said “Youth club leaders, teachers, bus drivers and the police have all been trained, and that training is continuing to spread. Those people are not therapists; they are first-aiders in suicide. The ASIST programme has been running for five years, and we must keep rolling it out.”[136] However, while much progress has been made it is clear that more is needed. Marie Osbourne, West Belfast Parent and Youth Support Group, told the Committee “My group has taken part in training with front-line medical staff in the Royal Group of Hospitals. Training must be provided, not only to doctors, but to receptionists, nurses and so on. The way that people are treated in the Mater Hospital is abominable.”[137]

99. Many respondents expressed concern about the uptake of training by GPs. For example, Rays Crisis Centre said “the GP education and training programme to increase detection of depression seems to be inadequate … Many GPs have been resistant to the ASIST training”[138]. The Niamh Louise Foundation put it bluntly saying “It is distressing that GPs are unwilling to avail of the training made available to them at present especially when they are the gatekeepers from the community to the mental health care system”[139]. At the outset of the Inquiry in September the Minister told the Committee “To date, 161 GPs have received training, and approximately another 200 will have received training before December 2007. In addition, 71 practice managers and nurses have received related training”[140].

100. Noel Graham, Northern Health and Social Services Council, highlighted the crucial importance of suicide and depression awareness training for all front-line staff dealing with people in distress, particularly GPs. He said “We have some concerns about the varying levels of uptake by GPs of this training: uptake in some areas has been slow”[141]. His colleague, Maggie Reilly, Western Health and Social Services Council, pointed to the 99% uptake among GPs in the Western Health and Social Services Board area and explained that “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”[142].

101. Dr Maria O’Kane, Royal College of Psychiatrists stated that “ASIST is an excellent programme for the voluntary sector. Health professionals have told us that it is extremely good, but that they would like the next stage. One of the reasons that GPs find ASIST difficult to take up is that, like everything else, there are competing needs”[143]. Dr Tom Black, on behalf of the BMA admitted that “There were some initial problems, but the good news is that one third of all GPs have already been trained. … 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.”[144] The BMA in its written submission also expressed disappointment that medical professionals had not been involved in designing the awareness training programme.

102. Mr Colm Donaghy, Southern Health and Social Care Trust, explained that “The outcome of the General Practitioner Training programme provided through the Health Promotion Agency is as yet unclear. There is a need to assess the relevance, appropriateness and therefore uptake of the current training provision and to explore more fully if it is indeed addressing the real needs of General Practitioners. It is vital that General Practitioners are made more aware of what services are currently available in their respective communities and as a result encouraged to make referrals to these services for more sustained and longer term support.”[145]

103. Ms Sharon Sinclair, Aware Defeat Depression, stressed the need for on-going training in the longer term. She said “To appropriately support people at risk, targeted efforts are needed to enhance depression and suicide awareness among professional groups in health, education, human resources, the criminal justice system and so on. In the voluntary and community sectors, those initiatives need to be continued. A commitment to skills development of the kind that we have seen over recent years is equally important so that people can access appropriate training, including depression awareness, mental-health first aid, and ASIST (Applied Suicide Intervention Skills Training) programmes. In our view, they must remain as part of the long-term strategy.”[146]

104. Mr Colin Loughran, Action Mental Health, said “An evaluation has been completed for the Southern Health and Social Services Board area. ASIST was evaluated as a part of that. The indications are that ASIST is appropriate and helpful to front-line practitioners, but, for the general population, it may not be the most effective source of training. Something pitched at a lower level, aimed at a general understanding of mental and emotional health, would be more effective for the wider public.”[147]

Training for clergy and church workers

105. The Church Leaders agreed that training of clergy and church workers was a very significant issue for all of them. The Most Rev Alan Harper, Church of Ireland, pointed out that a survey of clergy a couple of years ago indicated that suicide was a major issue and many clergy felt “they were seriously under-resourced in dealing with it. … they needed to know how to recognise the signs of self-harming or suicidal behaviour, and to help subsequently in dealing with the outcomes, whether that involved dealing with survivors or bereaved families”[148]. Rev Harper also said that the clergy training programme was receiving a radical overhaul at the moment and that “Suicide awareness will be a significant component in that. However, that is only a forward projection. We have some structures in place, but they are insufficient for upskilling the clergy to deal with an issue that many of them will not have encountered face to face”[149]. Rev John McClure reported that funding for the Churches to train new and existing clergy was available through the SSIB.

Training for PSNI

106. Mr Pat McGreevy, South Eastern Health and Social Care Trust, highlighted that “Working with the police is crucial because, being the first on the scene, their attitude can affect a bereaved family and how they feel about help, and hope, in general. If a family experience an insensitive reaction from those first responders, it can put them off seeking help at all, so it is crucial that the police are aware of, and sensitive to, the needs of families”[150]. Mr McGreevy indicated that “A couple of initiatives are already in place in the Eastern Board area. We have developed a training programme for police officers that raises awareness about suicide, considers what can be done to intervene with people at risk and also deals with the issue of responding to bereaved families in a sensitive manner.”[151] Brendan Bonner, Western Health and Social Services Board, pointed to work taking place there with PSNI “to ensure that all officers likely to attend the scene of a suicide undertake ASIST training”[152]. Melanie McClements, Southern Health and Social Care Trust, said that engagement with PSNI in the Trust area had resulted in “the idea that we will influence the foundation training for new officers on the necessary skills. … The PSNI is working with us on inter-agency protocols, from the first response, to the media, funeral directors, the PSNI and our own service”[153].

107. The importance of training and development in suicide awareness, in identifying early warning signs and in knowing how to respond to those signs has been incorporated into the strategy. The merits of the ASIST (Applied Suicide Intervention Skills Training) programme are widely recognised. The range of people who will benefit from such training is extensive and includes not only frontline health and social care staff but also other health professionals, clergy, police and other emergency services, and those whose occupations could bring them into contact with people at risk of suicide. Many issues about training were raised during the Inquiry including concerns about the uptake of GP awareness training and calls for training to be extended to other groups, for example, clergy, teachers and all staff who work in A&E departments. We believe that the time is right to examine and evaluate the progress of the training programme to date and identify any gaps.
Telephone Helpline

108. The Department launched a pilot 24/7 suicide prevention telephone helpline in October 2006 in North and West Belfast and explained that it “specifically targets young people and is supported by additional peer mentoring and counselling services”[154]. There was a general recognition from respondents that the helpline was “an important and accessible contact in providing an initial crisis response”[155]. The Southern Health and Social Care Trust argued that it needed to be “more widely targeted at addressing the needs of all communities across the province and not just those within one specific geographical area. In addition, it is essential that these services establish more effective links with local service providers thus improving their ability to signpost those in need to appropriate, locally based services”[156]. Some including the Committee for Social Development called for it to be “extended throughout Northern Ireland as a matter of urgency”[157].

109. However, others including Pat McGreevy, Suicide Coordinator in the South Eastern HSC Trust, urged caution. He argued that “A 24/7 suicide helpline should become a regional resource for people of all ages but only when a proper review of the pilot has been undertaken and if no other alternative models are considered to be more effective”[158]. The Niamh Louise Foundation also urged care saying “it is important to rethink how it can be rolled out in the rural areas and how the advertising and follow up procedures are addressed”[159].

110. On 31 January 2008 the Minister announced the launch of a regional suicide prevention helpline across Northern Ireland and described it as “a key element in meeting the objectives of the Suicide Prevention Strategy’ and stated “I will ensure that the helpline is evaluated during its first year to ensure that it is meeting its objectives”[160].

111. Representatives of community groups and bereaved families expressed very serious concerns that the helpline had been expanded without an evaluation of the north and west Belfast pilot and that proper back-up services are not yet in place. Michael Doherty, West Belfast Suicide Awareness and Support said “We are asking for the back-up services that are needed in the community. … the Minister went ahead and tendered for a new regional helpline in the absence of a proper evaluation. I know that the helpline does good work, but concerns about it have been raised constantly. However, those services do not exist. A strategy must be adopted to ensure that adequate services will be set up. Let us not build up people’s expectations”[161].

112. Philip McTaggart, PIPS, supported this position pointing out that 15 months after the pilot was set up no evaluation has been carried out. He said “I am not suggesting that that helpline does a bad job. It has good elements, but it also has weaknesses. …. Had an evaluation of the pilot scheme been carried out, weaknesses might have been discovered and corrected. … We are finding that, after taking a call, the helpline will ring us and refer a client to us for help. We already have waiting lists; we are snowed under.”[162] Vincent Donaldson, West Belfast Suicide Awareness and Support, said “The helpline is not ready to go regional yet …We are in favour of a 24-hour helpline, but it has to be properly managed. If it is not, death will be the result. ... The problem that we had with it was that there were a lot of faults during the pilot period, and, all of a sudden, before it has been evaluated, it is being expanded.”[163]

113. The Samaritans stated that the pilot itself was announced “against the advice of Samaritans in the early days of the action plan. It duplicates much of our own long established and respected service and for Samaritans this is a disappointment. Having come forward early in the development of the strategy to offer our support and with the benefit of our 50 plus years of experience we feel that there is little benefit to the NI population by creating another helpline”[164]. Suzanne Costello, Samaritans, told the Committee “The phone line … has aspects that our service does not provide, but there are significant areas of overlap and there could be better synergy if we were able to work more closely with the Department”[165].

114. The Minister in a written response to the Committee explained that he “decided to establish a regional 24/7 crisis response helpline because of the high volume of calls to the pilot, which was receiving in the region of 100 calls per day. Approximately half of these were from outside the N&W Belfast area, which clearly indicated the growing demand from elsewhere in Northern Ireland. … My judgement was that action was needed at a regional level”[166].

115. The launch of the regional helpline has been relatively low key and witnesses attending the Committee after the launch, including local suicide coordi