Institute takes on hostile NHS reception for self-harmers

There is an epidemic in our midst: every year, 170,000 people in
England and Wales seek hospital treatment after deliberately
harming themselves. Of these, an estimated 80,000 never receive a
psychological assessment or follow-up despite their risk of suicide
being 100 times greater than the average.

Invariably, self-harming results from immense psychological
distress and is particularly prevalent among young people. Last
week the National Institute for Clinical Excellence (Nice) issued
guidance on how primary and secondary care providers should
effectively treat and care for this group of vulnerable people
(news, page 9, 29 July).

The need for such guidance is in itself an admission that the
health service is failing to meet the needs of self-harmers.

Louis Appleby, the national director for mental health, admits that
not all hospital accident and emergency departments provide
appropriate services.

“My impression over the past 10 years is that some emergency
departments have done a lot of these things but some haven’t,” he

Mental Health Foundation chief executive Andrew McCulloch goes one
step further.

“It’s an indictment of our services that necessary basic humane
treatment needs to be spelled out in this way,” he says, expressing
surprise at the length of time it has taken for guidance to emerge,
given the seriousness of the problem.

Sue Millman, director of Advance Support, adds: “It is
disappointing we are in a situation where this advice needs to be
given at all.”

One of the key suggestions in the guidance is to offer people who
self-harm a psychological assessment at triage, or at the initial
assessment in primary or community settings, once they have

McCulloch says he is not aware of this happening in many A&E

Mind policy director Sophie Corlett says that, although some
medical professionals do adhere to good practice with this group,
people who self-harm commonly face hostility and lack of

She adds that successful implementation of the Nice guidance
depends on health trusts and individuals changing their systems and
their practices. “This is achievable,” she says. “These are not
overly complicated things to deliver.”

Appleby agrees it is up to local organisations to behave
responsibly and adopt the guidance. He believes the new Healthcare
Commission has a critical role to play in making sure local trusts
follow clinical guidance. “We should be leaning heavily on local
services to make sure they do the right thing. But we have to
balance that with letting them have local autonomy.”

Although there is no money earmarked to help implement the
guidance, Appleby insists that primary care trusts’ yearly
allocations include funding to support all Nice guidance. “Training
systems need to pick up on self-harm,” he says.

Millman calls for organisations to reprioritise their existing
training budgets to offer self-harm training involving self-harmers

Corlett adds that, in the long run, the resource implications of
rejigging training budgets would be less significant than not
tackling self-harm at all.

Whether health organisations and medical professionals do decide to
tackle the issue remains to be seen. The Nice guidance is, after
all, just that: guidance.

But Millman argues that enforcing it with legislation would not be
helpful either.

She says:”Giving this guidance teeth would merely curb the worst
excesses. It is about changing professionals’ attitudes and that
can’t be done by rules.”

The Guidance

The key recommendations from Clinical Guideelines 16,
available from, are:

  • Treat people who self-harm with the same care, respect ann
    privacy as any patient.
  • Provide appropriate training for staff coming into contact with
    people who self-harm.
  • Offer ervyone who has self-harmed a preliminary psychological
    assessment triage.
  • Assess everyone who has self-harmed for future risk of
    self-harm or suicide.

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