This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.
Adults who go to hospital after harming themselves may struggle to access the care they need afterwards (aftercare). A study explored the barriers they face, from the perspective of clinicians who refer them for aftercare (liaison psychiatrists). The authors suggest potential strategies for improvement.
Researchers interviewed mental health professionals from 32 services for people who had presented to hospital following self-harm. Access to aftercare varied across services. The study found that referrals for talking therapies in primary care were often rejected due to concerns about the perceived risk of suicide. Staff also reported difficulties in gaining access to secondary care (crisis teams, for example), some of which viewed their service as being reserved for people with severe ongoing mental illness.
Interviewees said that providing good quality and prompt aftercare following self-harm, could contribute to improved patient safety and wellbeing. They described strategies that improved access to aftercare following self-harm.
For information and support on self-harm, visit the NHS website.
What’s the issue?
People who present to hospital for self-harm may be at highest risk of dying by suicide in the year after their discharge from hospital, particularly in the first month. Timely access to appropriate care can prevent suicides.
In liaison psychiatry services, clinicians care for people attending hospital with a wide range of mental health issues. They commonly see people who have self-harmed, and often struggle to access the aftercare that patients urgently need. The barriers to accessing aftercare are not well-understood.
In this study, researchers interviewed staff in liaison psychiatry services about accessing care and talking therapies for people presenting to hospital following self-harm.
What’s new?
Researchers interviewed 51 staff members, including liaison psychiatrists, mental health nurses, and team managers, from 32 liaison psychiatry services in England.
Interviewees described challenges in finding appropriate aftercare for people who had self-harmed. Patients could be considered too well for hospital care but too high a suicide risk for primary care. Clinicians felt as if they were “between a rock and a hard place.”
Secondary care services (like crisis and home treatment teams) were seen to be reserved for people with severe ongoing mental health conditions, clinicians said. Access was further reduced by long waiting times, bed shortages, and bureaucratic processes. A lack of collaboration could mean that assessments carried out by one department were repeated by another. These barriers set up a cycle of despair, which left both the person who had self-harmed, and their clinician, feeling helpless. Clinicians felt this increased the risk both of further self-harm and clinician burnout.
NHS Talking Therapies (known at the time of the study as the Improving Access to Psychological Therapies programme) often excluded people who had self-harmed. According to one clinician, “as soon as you mention that somebody is self-harming, that’s it, they’ll just reject it, and then they’ll refer it on to the community service.”
Interviewees described broad strategies that could increase access to care after self-harm.
Improve assessments and care plans
- Good quality psychosocial assessments (of individual needs and risk) can be therapeutic in themselves; staff need time and support to improve the quality of these assessments.
- Care plans and referral letters may be improved by input from skilled staff from different disciplines (including occupational therapists, pharmacists, community mental health staff, psychologists and liaison psychiatrists).
Negotiate boundaries between services
- Carefully crafted referral letters that provide enough detail, and are adapted according to the service may be more likely to be accepted.
- Addressing concerns about self-harm at an early stage, in person, if possible, may help staff feel more confident in working with people who have self-harmed.
- Senior staff can advocate for a patient’s access to services; they can also mediate interpersonal conflicts between services. "Pull the consultant card", one interviewee said.
Build relationships
- Stronger relationships within and between departments, and between hospital and community care, could improve access to aftercare. Greater integration could be achieved through information-sharing between services, and cross-team working.
- Clear communication and referral criteria may improve access to aftercare.
- Routine out-patient appointments, and talking therapy from liaison psychiatry services, could formalise aftercare and improve patient safety.
Why is this important?
NICE guidelines on self-harm recommend that people should receive follow-up within 2 days of their initial psychosocial assessment and that access to therapy should not be determined by diagnosis, age, drug misuse or co-existing conditions. However, this study suggests that many people do not receive follow-up during this high-risk period. The researchers were concerned that risk assessments sometimes became barriers to talking therapy and to hospital care, which goes against current guidelines.
The study team explored the views of service users in a related study. Like the staff, participants called for better access to compassionate aftercare after self-harm. Other recommendations included better communication about talking therapies, less stigma around self-harm, and more support in navigating services.
What’s next?
Despite clinical guidelines, access to talking therapies after self-harm is variable. Good quality aftercare exists, but is not widely available. The researchers are working with healthcare professionals and patients to identify and implement interventions for people who present to mental health and primary care services after self-harm. Improved access to aftercare could reduce inequalities, improve patient safety, and enhance staff wellbeing.
The researchers are working with the National Confidential Inquiry into Suicide & Safety in Mental Health Services and the Manchester Self-Harm Project on projects to improve NHS community services for self-harm in England.
As part of this work, the researchers held workshops based on these findings for more than 800 NHS staff and Integrated Care System colleagues. The workshops aimed to improve integration between services. The focus was on diversity, inclusion, and reducing inequalities in access to healthcare after self-harm.
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This Alert is based on: Quinlivan L, and others. Liaison psychiatry practitioners’ views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study. British Journal of Psychiatry Open 2023; 9: 1 – 8.
A related study about patient experiences of accessing psychological therapies: Quinlivan L, and others Accessing psychological therapies following self-harm: qualitative survey of patient experiences and views on improving practice. British Journal of Psychiatry Open 2023; 9: 1 – 10.
More information about the team’s ongoing work to improve services for people who have self-harmed.
Funding: this study was funded by the NIHR Greater Manchester Patient Safety Translational Research Centre.
Conflicts of Interest: no relevant conflicts were declared.
Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.
