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Self-Harm Care Pathway Overview

In early 2017, The Gloucestershire Health and Wellbeing Board raised concern about one of the Public Health Indicators – hospital admissions for self harm.  Public health, part of the Gloucestershire County Council Prevention, Wellbeing and Communities hub, undertook a deep dive to look at the reasons behind this.  In depth interviews were carried out during 2017 with a wide range of professionals working within mental health, acute and emergency care, social care, education, supported housing, and the Voluntary and Community Sector.  People with lived experience also contributed their views and experience.   All contributors had direct experience of working with people who self harm, and were asked for their views on what is working well in Gloucestershire, what needs improving, and what are their top 3 priorities for change.   The results from all of the interviews were summarised and presented at a workshop in December 2017, which resulted in an Action Plan to improve pathways across Prevention, Access to care and support, quality of care and support, and recovery from self harm.  The most recent statistics on emergency hospital admissions for intentional self-harm continue to show a downward trend, however local rates in Gloucestershire are still significantly higher than the national average.

                                              

Source: Public Health England, Public Health Profiles https://fingertips.phe.org.uk/search/self%20harm#page/4/gid/1/pat/6/par/E12000009/ati/102/are/E10000013/iid/21001/age/1/sex/4 [accessed 25.10.18]

The “Preventing Self Harm Action Plan” aims to improve the experience of people who are self harming, and to help more people  get the help they need to manage emotional distress, in order to stop or reduce self harming.   The finalised Action Plan has since been reviewed and approved by the Mental Health and Wellbeing Partnership Board and the Mental Health Clinical Programme Group.  One of the actions within the Action Plan is to improve the information and support available to GPs, which has resulted in this pathway. 

The majority of people who self harm are not suicidal.  However, self harm is a risk factor for suicide.  The most recent Gloucestershire Suicide Audit published in 2017(2013-15) shows that there were 148 cases of death by suicide during the period 2013-15. .  25% of these people had a history of self harm.

 Audit data from GP surgeries is available for 112 of these cases, and shows that:

  • 61% visited in 12 months before death
  • 31% visited in month before death
  • 12% visited in week before death

Please see the Clinician Education section for the Executive Summary of the 2016 Gloucestershire Suicide.

Self-harm is a coping mechanism. An individual harms their physical self to deal with emotional pain, or to break feelings of numbness by arousing sensation.

Self-harm is any deliberate, non-suicidal behaviour that inflicts physical harm on the body and is aimed at relieving emotional distress. Physical pain is often easier to deal with than emotional pain, because it causes 'real' feelings. Injuries can prove to an individual that their emotional pain is real and valid. Self-harming behaviour may calm or awaken a person. Yet self-harm only provides temporary relief, it does not deal with the underlying issues. Selfharm can become a natural response to the stresses of day-to-day life and can escalate in frequency and severity.

Self -harm can include but is not limited to, cutting, burning, banging, bruising and scratching. Self-harm is often habitual, chronic and repetitive; it tends to affect people for months and sometimes years.

People who self-harm usually make a great effort to hide their injuries and scars, and are often uncomfortable about discussing their emotional inner or physical outer pain. It can be difficult for young people to seek help from the NHS or from those in positions of authority, perhaps due to the stigma associated with seeking help for mental health issues. Self-injury is usually private and personal, and it is often hidden from family and friends. People who do show their scars may do so as a reaction to the incredible secrecy of their emotions and feelings which they are unable to share, and one should not assume that they are attention seeking, although attention may well be needed.

Please click the relevant flowchart to be taken directly to textual information

Red Flags
Urgent concern (if the patient);
  • is considered to be an immediate risk to themselves or others
  • is actively suicidal, has a current suicide plan
  • has deteriorating personal circumstances exacerbating their mental illness
Children
  • If any urgent concern consider GP led pharmacological intervention, discussion and referral to CYPS - Send urgent fax to 01452 894301 and accompanying telephone call to: 01452 894300  
  • Please also refer to the Safeguarding - Children's pages on G-care.
Adults
  • If any urgent concern consider GP led pharmacological intervention, discussion and referral.  Referrer Information for Mental Health Services - Gloucestershire including the Contact Centre, Crisis Resolution and Home Treatment Teams can be found here.
  • 2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here.
  • Please also refer to the Safeguarding – Adults pages on G-care.
Presentation

Self harm is a behavioural response to emotional distress, which the person finds effective in helping them to cope.   It can sometimes mask an underlying psychological trauma. 

                                                                                        

If you think that a patient is self harming, ASK them as this may be a timely opportunity for them to receive an intervention that will help reduce harm and improve coping ability.

  • A deliberate act of self injury
  • May include cutting,  burning or otherwise harming the skin; self poisoning, head banging, self strangulation, insertion of objects
  • The patient may present with an injury which you think has been caused deliberately, or they may tell you it was deliberate
  • You may notice signs (e.g.  recent scars) during the course of an examination or consultation, that suggest self harm
  • You may also suspect that the patient is self harming, if they seem low in mood, anxious, or have difficulty coping. 
  • Many people self harm without suicidal intent.  However, self harm is a risk factor for suicide – see Red Flags section.
  • Look for other harmful behaviour (over exercising / drug and alcohol misuse)

  • As a way of coping with or relieving unmanageable emotional distress
  • To make emotional pain real and tangible
  • As a way of punishing oneself
  • To avoid doing something more harmful, or manage suicidal feelings
  • May be a response to a particular situation or event, or part of an ongoing emotional state which the person is finding difficult. 
  • As a coping strategy it can be very effective, and become a habit
  • Alternative coping  strategies  are needed before someone can reduce or stop their self harming behaviour

  • People of all ages self harm, often without seeking help
  • Young people aged 11-25 are more likely to self harm with an average age of onset age 12
  • Some people with mental health disorders including Eating Disorders, Personality Disorders, anxiety and depression
  • Children in care
  • People who are lesbian, gay, bisexual or transgender
  • People who have autism and/or a learning disability
Differential Diagnosis / Conditions Associated with Self Harm

 Please consider the following as differential diagnoses/associated with self-harm;

Initial Primary Care Assessment

Immediate steps in primary care:

  • LISTEN non judgementally.  You may be the only person the patient confides in.
  • For children and young people under 18 use the HarmlessGlos tool to help guide your conversation and plan a course of action.

Assessment

  • ASK :
    • Have you harmed yourself?
    • In what way did you harm yourself?
    • Did something happen to cause you to harm yourself?
    • Have you harmed yourself more than once?
    • Are you getting any help with how you are feeling?
  • Urgently establish the likely physical risk, and the person's emotional and mental state, in an atmosphere of respect and understanding
  • Assess for risk, which should include identification of the main clinical and demographic features and psychological characteristics known to be associated with risk, in particular depression, hopelessness and continuing suicidal intent
  • Full mental health and social needs assessment
Initial Primary Care Management

ACT:

For children and young people under 18 use the HarmlessGlos tool to help guide your conversation and plan a course of action

Encourage the use of alternative self-management strategies:

Consider referral to or signpost patient to Gloucestershire’s Community Drug & Alcohol Recovery Service

  • Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be first step

Follow up

A telephone call is often sufficient to check in on how the person is coping OR ask them to make a follow up appointment. Re-assess at this stage in order to decide whether further action or more watchful waiting is required.

Practice Point

Children and Young People (upto 18 years):

CYPS Practitioner Advice line is available Mon - Fri 9am-5pm
Tel: 01452 894272

Adults (18 years plus):

The Contact Centre may be contacted for advice at any stage:
Tel: 08000 151 499
Email: 2gnft.FPCC-Admin@nhs.net
Fax: 01452 894418
Address: Tri Service Centre, Waterwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP

Make appropriate onward referrals based on the risk of serious harm or suicide, accompanying mental health or physical health problem, age or vulnerability.

Mental Health Referral Guidance

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with GHC, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform GHC as soon as possible. This will allow GHC to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, 2HCNHSFT)

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