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Co-creation of national policy and practical resources for preventing deaths by suicide

1. Summary of the impact

In the UK, over 6,000 people die by suicide each year.  Research by Professor Owens on the prevention of suicide in public places has enabled all of England’s 152 public health teams to deliver the national suicide prevention strategy, with 78% including specific actions to reduce suicides in public places; directly informed the 2018 NICE Guideline on preventing suicide in community and custodial settings; and informed Highways England’s strategy and training of all 2,000 of its traffic officers in preventing suicides on the road network. The research-based leaflet ‘ It’s safe to talk about suicide’ has been used by at least nine local authorities, five universities, the RNLI and the Fire Officers Association, and directly shaped national public health campaigns empowering lay people to play an active part in suicide prevention.

The research has therefore informed national public health policy; supported changes to practice in public and private organisations; and directly contributed to national public health campaigns related to suicide prevention in the UK. Whilst it is hard to quantify, feedback from organisations that Prof Owens advised show they believe it has had a major impact on reducing the risks of suicide.

2. Underpinning research

Many people who die by suicide have had no recent contact with health services, so there is limited opportunity for clinical intervention. Research led by Prof Owens and her team has focused on community-based approaches and is firmly rooted in a public health perspective.

2.1 Informing public health policy and supporting local authority practice.

In 2013 responsibility for public health, including suicide prevention, was transferred from Primary Care Trusts to local authorities. Prof Owens and her team have worked closely with Public Health England (PHE) to ensure that the 152 local authority public health teams in England have clear, practical guidance based on the best available research evidence.

**2.1a Preventing suicides in public places. In 2014, we won a PHE contract to revise the 2006 NIMHE guidance for the newly created Local Authority public health teams. We reconceptualised the problem from a community-based and systems perspective, reviewed scientific and grey literatures [3.1], consulted public health teams with experience of managing sites frequently used for suicide, and interviewed people who have tried to take their own lives at such sites. We synthesised these diverse findings to produce a guide for local authorities and piloted it in partnership with the public health team responsible for a frequently used suicide location in England [3.2].

2.1b Evaluating the utility of suicide audit. Effective suicide prevention at a local level relies on the systematic analysis of local data (a practice known as suicide audit) in order to inform local action planning. In an NIHR CLAHRC-sponsored study, we surveyed all public health teams in England to find out how they were conducting suicide audit and how the resulting data were being used. We found that many teams were investing large amounts of time and effort in collecting data but were unable to show how it informed their suicide prevention plan, or that it had resulted in specific actions [3.3].

**2.1c Review of local suicide prevention plans. Leading on from Study 2.1b, in partnership with Samaritans we won a contract from PHE to conduct an analysis of all 152 local authority suicide prevention plans, identify good practice and areas requiring improvement, and develop a set of quality standards. We showed that, whilst there was a high level of ambition and commitment on the part of local authorities to address all areas of the national strategy, many of them were struggling to implement their action plans, especially in the context of local budget cuts and a lack of centralised resources [3.4].

2.2 Helping everyone play a part in preventing suicides.

It is widely acknowledged that “Suicide prevention is everybody’s business”, but little is known about the part that lay people can play in it or the skills and resources they need in order to do so. Our research has filled this gap. We first sought to understand the difficulties people experience in recognising and responding to a suicidal crisis within different social settings. We then used the findings to develop a new generation of public health messages that take account of the everyday contexts in which people live, and we evaluated these.

**2.2a Developing and evaluating a public education leaflet:It’s safe to talk about suicide’. Exeter research has shown that family members and friends of those who were suicidal struggled to pick up warning signs; and when they did, they judged intervention to be highly risky and avoided talking about suicide for fear of triggering adverse reactions and damaging relationships. Working with The Alliance of Suicide Prevention Charities (TASC) and a panel of people bereaved by suicide (2013-14), we developed a public education leaflet that specifically addressed these fears. In partnership with our local public health team, we distributed 15,000 copies throughout Devon via a wide range of community agencies, and followed these up to evaluate its utility, acceptability and perceived safety [3.5]. The evaluation showed the leaflet was filling an important gap in public information provision and was eagerly embraced by frontline staff and volunteers, who were passing it on to clients, using it for their own education and development, or using it as a teaching aid [3.5].

**2.2b The role of passing strangers in preventing suicides in public places. Previous research on preventing suicides in public places has mainly focused on the effectiveness of installing physical barriers at high-risk sites. In 2015, we formed a new strategic partnership with Jonny Benjamin MBE, maker of the award-winning Channel 4 documentary, The Stranger on the Bridge. In an MRC-funded study (2017-18; £122,959.00; PI: Owens) we examined the role of passing strangers. We interviewed 12 people who had been prevented by a stranger from taking their life in a public place, and 21 who had intervened to prevent someone from doing so. From this study we identified the core components of an effective intervention and developed a set of clear public education messages to empower people to recognise and reach out to someone in crisis in a public place [3.6].

3. References to the research

(Exeter researchers are shown in bold text)

  1. Cox G, Owens C, Robinson J, et al. Interventions to reduce suicides at suicide hotspots: A systematic review. BMC Public Health 2013; 9(13):214. DOI: 10.1186/1471-2458-13-214

  2. C; Hardwick RJL; Charles NT; Watkinson G. 2015. Preventing suicides in public places: A practice resource . London; Department of Health. https://www.gov.uk/government/publications/suicide-prevention-suicides-in-public-places [synthesising evidence from: a systematic review (Ref. 1), review of international guidance and grey literature, survey of Directors of Public Health, and interviews with survivors]

  3. Owens C; Roberts S; Taylor J. 2014. Utility of local suicide data for informing local and national suicide prevention strategies. Public Health, 128(5):424-429. DOI: 10.1016/j.puhe.2014.03.004

  4. Chadwick T; Owens C, Morrissey J. 2019. Local Suicide Prevention Planning in England: An Independent Progress Report. London; Samaritans, 2019. https://www.samaritans.org/about-samaritans/research-policy/national-local-suicide-prevention-strategies

  5. Owens C; Charles N. 2017. Development and evaluation of a leaflet for concerned family members and friends: 'It's safe to talk about suicide'. Health Education Journal, 76(5):582-594. DOI: 10.1177/0017896917706601

  6. Owens C; Derges J; Abraham C. 2019. Intervening to prevent a suicide in a public place: a qualitative study of effective interventions by lay people. BMJ Open 2019;9: e032319. doi:10.1136/bmjopen-2019-032319. DOI:10.1136/bmjopen-2019-032319

4. Details of the impact

Our REF2014 impact case study presented the development of the first national guidance on the prevention of suicides in public places (Guidance on action to be taken at suicide hotspots. NIMHE, 2006) and its subsequent global impact. The current impact case study is based on both new research and entirely new claimed impacts that have occurred since August 2013.

In the UK, over 6,000 people die by suicide each year. It is a leading cause of death for young people, has higher rates among those from deprived backgrounds, and devastates the families and communities of each individual who takes their own life.

4.1 Informing national public health policy and supporting local authority practice.

**4.1a Preventing suicides in public places. Owens’ national guidance [3.2] has been used to inform the management of high-risk suicide locations. In 2015, this national guidance on preventing suicides in public places, was distributed to every public health team and local planning department (n=152] in England along with a letter from the Secretary of State for Health [5.1]. The framework in Owens’ guidance subsequently led to local authorities drawing up site-specific action plans [5.2] and by 2019, 78% of local authorities had specific actions to reduce suicides in public places included in their suicide prevention plan, and 64% (97/150) reported that these actions were already being delivered [5.2], [3.4]. Consequently, public health leads in 16 English local authorities contacted Owens for advice on the management of particular high-risk locations. Furthermore, Stoke-on-Trent City Council has worked with Owens to develop specific guidance for developers and the construction industry [5.2].

Private and voluntary sector: Many suicide attempts are made on impulse, so considering suicide risk when designing buildings is critical. Owens advised Sir Robert McAlpine Ltd on the design of high-rise buildings in the City of London and ROSPA on the design of student residences at the University of Exeter. In addition, Owens advised the National Trust on measures to reduce suicide risk at cliff-top locations such as closing a section of footpath or fencing off a stretch of cliff. This research-based advice to these various organisations was subsequently used as a model for new national guidance in both Scotland and Ireland. Highways England also subsequently used it as the basis for its strategy and guidance for preventing suicides on the strategic road network [5.3].

The University of Exeter Stranger on the Bridge study was used to develop a training module, and since March 2019 it has been delivered to every traffic officer in England (n=2,000) [5.4]. In September 2018, it also directly informed three of the recommendations within NICE Guideline 105: Preventing suicide in community and custodial settings [5.5]. The recommendations were: increased use of CCTV or other surveillance to allow staff to monitor when someone may need help; increasing the number and visibility of staff, or times when staff are available, and; ensuring training is available for relevant people.

**4.1b Utility of suicide audit. Owens’ guidance contributed to a significant upturn in the development of suicide prevention plans in local authorities. The Exeter research was identified as a seminal study and heavily cited in a report by the 2015 All Party Parliamentary Group (APPG) on Suicide and Self-Harm Prevention on the future of local suicide prevention plans [5.6]. The APPG report led PHE to commission the 2016 Local suicide prevention planning: a practice resource, and Owens was invited to play a key role in its development [5.6]. This guidance was distributed to every local public health team in England (n=152) [5.7]. A 2016 survey by PHE indicated that the number of local authorities with a plan in place or in development had increased from 70% in Jan 2015 to 95% in Jan 2017 [5.7].

**4.1c Review of local suicide prevention plans.

Exeter research (study 2.1) raised the quality of local suicide prevention work in Local Authorities. The findings and recommendations from Owens’ report [3.4] “feed directly into this sector-led improvement programme” for suicide prevention (Background section of **[5.8]**). This is a £600,000 Sector-Led Improvement programme, launched in 2018 and coordinated by the Local Government Association. During 2020, the programme delivered national masterclasses/webinars on key issues, a Must-Know Guide, and provided bespoke expert support for local authorities identified as facing particular challenges [5.8] .

4.2: Helping everyone play a part in preventing suicides.

The leaflet’s message ‘It’s safe to talk about suicide’ has empowered friends and family members to overcome their fears and initiate conversations about suicide.

4.2a Public education leaflet: ‘It’s safe to talk about suicide’. Exeter research revealed a deep-seated fear of talking about suicide. Significant others can play a key role in suicide prevention, but little attention was given to the resources they may need to do so effectively. The evaluation of our leaflet distribution evidenced that it was a vital information resource. This resulted in Devon County Council producing a further 30,000 hard copies which were distributed across the county through frontline agencies and community groups, including housing and benefits departments, GPs, student wellbeing services, Citizens Advice and family solicitors. Since 2016, it has been made available online through the National Suicide Prevention Alliance (NSPA)’s repository of approved resources. Also in 2016, in response to widespread demand, the leaflet was made free to share and adapt under a Creative Commons Licence. Organisations have endorsed it with their own logo and are actively distributing it, including eight local authorities besides Devon, five UK universities, the Fire Officers Association, and the RNLI [5.9]. It is promoted in Universities UK’s guidance on the creation of Suicide-Safer Universities (UUK, 2018) and Business in the Community’s guidance for employers (BITC, 2017). In 2019 it was also translated for use by local health teams in Malaysia [5.9].

**4.2b Informing national campaigns: In 2015, the leaflet’s key messages and content formed the basis for a # BiggerIssues campaign by the Campaign Against Living Miserably (CALM), estimated to have reached over 23 million people via social media, and in 2016 for the #TalkThroughTheTaboo campaign by PAPYRUS (Prevention of Young Suicide) [5.10].

5. Sources to corroborate the impact

  1. Letter of thanks from Public Health England, for underpinning research and production of national guidance on Preventing Suicides in Public Places (research output Ref. [2]) distributed to every local public health team in England and well-received.

  2. PDF document entitled ‘Testimonies from local authority contacts’ contains extensive evidence of emails received from public health leads in local authorities in England requesting and thanking Prof Owens for her advice on the management of specific high-risk locations, as a result of Prof Owens’ authorship of PHE guidance, Preventing suicides in public places (2015), and developing further guidance with them for specific organisations (e.g. property designers and developers, with Stoke-on-Trent City Council)

  3. Guidance used by Highways England for developing a strategy and action plan for preventing suicides on the strategic road network. Evidence: HE strategy/toolkit and letter of thanks, and ‘Suicide Prevention Interventions’ guidance document, 2020.

  4. Owen’s research directly informed: NICE guideline 105: Preventing suicide in community and custodial settings. Specifically, recommendations: 1.6.3; 1.6.4; 1.7.1

Study 2.1b)

  1. Utility of suicide audit was identified as a seminal study and heavily cited in a report by the All Party Parliamentary Group (APPG) on Suicide and Self-Harm Prevention on the future of local suicide prevention plans. Evidence: APPG report, Jan 2015

  2. Guidance on Local suicide prevention planning, A Practice Resource (Public Health England), Oct 2016. Commissioned by PHE and Owens advised on development.

  3. Department of Health, Preventing suicide in England: Third progress report of the cross-party outcomes strategy to save lives’ (Jan 2017), see p.7.

Study 2.1c)

  1. Review of local suicide prevention plans resulted in £600,000 Sector-Led Improvement programme coordinated by the LGA https://www.local.gov.uk/suicide-prevention-sector-led-improvement-programme. Key sentence about Exeter’s contribution is in ‘Background’.

Study 2.2a)

  1. ‘It’s safe to talk about suicide' leaflet. Evidence of leaflet being widely used, under a Creative Commons licence, and badged by: eight local authorities (emails); five UK universities (emails); The Fire Officers Association ( https://www.fireofficers.org.uk/new/images/Wellbeing/Safe%20to%20talk%20leaflet-FOA_June%202016.pdf); the RNLI (emails). Universities UK, Suicide-Safer Universities ( https://www.universitiesuk.ac.uk/policy-and-analysis/reports/Pages/guidance-for-universities-on-preventing-student-suicides.aspx); Business in the Community toolkit ( https://www.bitc.org.uk/toolkit/suicide-prevention-toolkit). Evidence of translation and use in Malaysia (emails). Content used as the basis for nationwide awareness-raising campaigns: Campaign Against Living Miserably (CALM) ‘#BiggerIssues’ in 2015 (email from CEO of CALM, 22/12/2015); PAPYRUS (Prevention of Young Suicide) #TalkThroughTheTaboo campaign in 2016 (email from CEO of PAPYRUS).

  2. Emails from Highways England (latest 24/07/2020), including the training module PowerPoint slides with Prof.Owen’s added and curated content.

Additional contextual information

Grant funding

Grant number Value of grant
MR/P01707X/1 £122,959