An award-winning service earns the confidence of people who self-harm with empathetic care. Stuart Shepherd reports on how it is improving the lives of vulnerable people
People who self-harm do not necessarily think of themselves as health service users.
The stigma they feel directed against them is not, in their experience, confined to college, work or society at large. Distressingly, it seems to spill into the attitudes of staff at the nearby accident and emergency department, one of the places they might otherwise turn to for help. So a lot of the time, rather than using the service, they avoid it.
By not engaging with health professionals, people who self-harm often deny themselves access to support that could help them reduce and eventually stop the behaviour.
The consequences reverberate at many levels. Large areas of prominent scar tissue can develop. Deep or misplaced cuts come not just with the risk of a life-threatening blood loss, but also of tendons being severed and loss of limb function. Infection can lead to serious complications, even death.
Evidence also suggests that while self-harm is not a predictor of suicide, the risk of suicide is higher in the year following a self-injury.
Concerned with the lack of suitable provision for what is in truth an unknown but potentially large number of people who self-harm - a recent study found levels as high as 11 per cent in 16-year-old girls - a team at Bradford teaching primary care trust decided to find out what the kind of service that could make a difference might look like.
The primary care management model the team went on to develop, based on small-scale preliminary results from an extended pilot phase, was described by the 2007 HSJ Awards as trailblazing, transferable and a challenge to underlying misconceptions. So impressed was health secretary Alan Johnson that he highly commended the service. A visit from Professor Louis Appleby, national director for mental health, is also planned.
"We knew from the literature that because of negative attitudes and long waits at casualty, there was an unmet need," says clinical psychologist Gillian Proctor. "So we put out questionnaires to people who had used A&E, asking them about their experience, how it could be improved on and what kind of training they thought professionals could benefit from."
National Institute for Health and Clinical Excellence clinical guidelines on self-harm also informed the emerging picture of a new type of provision.
As well as calling for people who self-harm to be involved in the commissioning, planning and evaluation of services, NICE recommendations also include dedicated staff training and supervision, collaboration towards properly integrated services, a comprehensive evaluation of need and risk, and physical treatment regardless of acceptance of psycho-social or psychiatric assessment.
Dr Proctor and her colleague Eleanor Longden, service user development worker and trainer, supported by nurse practitioner Stephanie Lawrence, then worked together to pull into shape the pilot scheme for a 24/7 primary care based service in north Bradford.
In October 2006 - after 18 months of consultation, negotiation and preparation with potential service users and partners in A&E, the ambulance trust, the voluntary sector and across GP practices and nursing teams - the service was ready to deliver.
People wanting to use the service call a centralised number and are offered an appointment for treatment, provided from a nearby surgery or community hospital, within three hours. When nobody is free to suture a wound, arrangements have been made with casualty for direct access.
From 9am-5pm, the mixed team offering care consists of district and practice nurses, nurse practitioners and a GP, all of whom, with little previous similar experience, put themselves forward for the work. Outside office hours, the service is provided by a community intervention nursing team.
Before things got up and running, Dr Proctor and Ms Longden - who has personal experience of self-harm - organised training for the health professionals. This helped them understand some of the reasons behind self-harm and the value of a non-judgemental and empathic approach.
"People felt more confident about talking with service users after the training," says Ms Longden, "rather than worrying that what they said might make things worse. They could see how important it was to complement medical interventions with dignity, compassion and respect rather than anything complex or psychotherapeutic."
The original six-month pilot was extended to a year to allow for a more thorough formal and independent evaluation by the University of Central Lancashire.
Comparisons of the experience of the self-harm service with A&E were overwhelmingly positive, with the primary care model scoring 80 per cent for satisfaction against 25 per cent at A&E. All the service users who completed the evaluation questionnaire said they would use the service again and felt the staff to be understanding.
"I find it really difficult asking for help, but because I know the people who treat me respect me and know about self-harm, I would use this service again," wrote one respondent.
"I have used this service sometimes as a means of trying not to cut, by talking over the phone, which has helped," wrote another.
This feedback shapes how the service develops. The scheme is now being considered for the whole of Bradford teaching primary care trust's catchment.
"So far, other than a small spend on posters and flyers, there have not been any cost implications," says Dr Proctor. "However, a formalised service across Bradford and Airedale, using the same model and with dedicated management time, would need resourcing. There are significant savings to be made, though. At a conservative estimate, it is likely to divert 250-300 people a year from the area's two casualty units."
Extending the service beyond north Bradford, where 94 per cent of the population is white, will bring a new set of challenges.
"We will have to look at issues within the black and minority ethnic population in much more detail," says Dr Proctor.
"Self-injury is particularly prevalent among South Asian women, so we will want to work alongside the services that support them to be sure they can find out about what we do, trust us and gain access."