Informing best practice and policy change to transform services for people who have self-harmed

Suicide and non-fatal self-harm are major safety concerns in specialist mental health services, in hospital emergency departments and in primary care. Hospital attendance following non-fatal self-harm occurs commonly. Services for self-harm vary greatly and risk of dying by suicide subsequently is greatly raised among these patients.

In collaboration with NHS England, the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), and the Manchester Self-harm Project, we developed and implemented a national Commissioning for Quality and Innovation (CQUIN) for psychosocial assessments following self-harm (April 2022-April 2023). We also delivered a programme to improve services for people
who have self-harmed (via the NHS Long-Term Plan). The completed programme enhanced patient safety by improving access to psychosocial assessment and aftercare interventions following self-harm. NHS England have now funded a further programme to improve assessment processes and culture-of-care in inpatient services nationally (2024-2026).

Problem

Self-harm is an important patient safety issue as over 200,000 episodes are treated in hospitals annually. Clinical guidelines recommend the provision of psychosocial assessments and aftercare to reduce the likelihood of further non-fatal and fatal self-harm. Our research on psychosocial assessments, risk assessment, and psychological therapies has highlighted major gaps between evidence and practice in the receipt of optimal care following an episode of self-harm. Marked variability across NHS services is evident in the provision of psychosocial assessments. Only half of people receive an assessment following self-harm, and only a minority receive referrals to aftercare services. Services are often reported as being disjointed, resulting in substantial unmet and heightened risk. Our investigations have revealed important reasons why some people do not receive an assessment when they attend hospital following self-harm, whilst also highlighting the barriers to and facilitators of accessing appropriate aftercare and psychological therapies.

Impact of the research

In collaboration with NHS England, we developed and implemented the national Commissioning for Quality and Innovation (CQUIN) for psychosocial assessments following self-harm (April 2022-April 2023). We also delivered a national programme to improve self-harm via the NHS Long-Term Plan and NHS Mental Health implementation Plan. The work resulted in improved patient outcomes, changes in service delivery, and policy influence. For example, the CQUIN programme resulted in a 10% increase in the number of patients receiving a psychosocial assessment nationally. This translates to a real-world improvement for ~10,000 ED presentations following self-harm, with those patients now receiving high-quality, evidence-based care. Impacts included: increasing assessment rates, enhanced care pathways; improved documentation (e.g., GP/patient letters);national training programmes for North West Ambulance Service; local trust training; and inclusion in healthcare staff knowledge hubs. All 42 ICSs in England developed a self-harm support offer. Over 1900 stakeholders engaged in the ‘Improving community services for self-harm’ events (2020-2023).

Contribution of NIHR infrastructure

LQ and NK are funded by the NIHR GM PSTRC and they led the research programme that contributed to the development of the national CQUIN for psychosocial assessments and the programme of work on improving community services for self-harm. Our studies and dissemination strategies are co-designed with members of the NIHR GM PSTRC PCIE panel. Our PCIE partners also contribute to the Expert Reference Panel and shared learning events (see ‘Evidence’). Our research on psychosocial assessment, risk assessment, and access to aftercare forms part of the evidence base that we feedback to clinical teams as part of our programme of work focussed on improving community services for self-harm and the CQUIN on psychosocial assessment.

Awards

• 2024: Making a Difference Awards, Outstanding Benefit to Society through Research, Highly Commended Award. University of Manchester. Title: Improving care for people who have self-harmed: Translating evidence into practice via engagement with patients & carers, clinicians and NHS England. 
• 2023: British Psychological Society, Northeast Branch, Best Public Engagement Award for Excellent Communication of Psychology.

Resources

Suicide Prevention Strategy
• See ‘progress to date’ for overview of our QI work:

NHS England and NHS Improvement national CQUIN for psychosocial assessments:
• CQUIN Indicator

NHS England and NHS Improvement: Improving community services for self-harm (includes videos)

NICE guidelines for self-harm
NICE self-harm guideline. Professor Nav Kapur was the topic expert for the NICE self-harm guideline, which also includes our risk assessment work, previously funded by NIHR.
• NICE (2022). Self-harm: assessment, management, and preventing recurrence. In development [NG225] 

PPIE website:
• Mutual Support for Mental Health-Research (MS4MH-R)