Introduction

Introduction

Suicide and self-harm lead to significant emotional distress, morbidity, and mortality for the individual. Beyond the individual, suicide and self-harm also have broader negative impacts on families, friends, colleagues, the community, and society at large.

Self-harm is a behaviour, not a psychiatric diagnosis, and is complex and frequently misunderstood (2). The term “self-harm” encompasses a broad spectrum of behaviours, some involving suicidal intent and others not. For individuals without suicidal intent, self-harm may serve as a means to relieve internal tension, communicate distress, or cope with overwhelming situations that might otherwise feel unmanageable (3). Those who self-harm often face societal stigma and hostility, which can isolate them from support networks.

Suicide is devastating. In the UK, it is the leading cause of death in men under the age of 50 and leading cause of death for both males and females aged 20 to 34 years (4,5). Each suicide creates a ripple effect, deeply affecting immediate family, close friends, colleagues, and entire communities. Suicide can bring intense grief and confusion to those bereaved, often compounded by feelings of guilt, unanswered questions, and social stigma. The economic impact of each suicide is also substantial. In 2022, each suicide in the UK was estimated to cost £1.46 million, encompassing productivity losses, healthcare expenses, coroner and legal fees, and family-related costs (6).

The relationship between suicidal ideation, self-harm, and suicide is complex and not easily predicted. The demographic profiles of individuals reporting suicidal thoughts, attempts, and self-harm often differ significantly from those who ultimately die from suicide. Notably, although these are important risk factors, the vast majority of people who experience suicidal thoughts or engage in self-harm behaviours do not proceed to suicide. This complexity highlights the need for nuanced understanding and tailored intervention approaches to effectively address and mitigate the risks associated with self-harm and suicide.

This needs assessment seeks to integrate national and local data on suicide and self-harm, insights from key stakeholders, and evidence-based prevention to inform the update of the Cambridgeshire and Peterborough ICB’s Suicide Prevention Strategy 2025-2028.

Definitions

This needs assessment uses the following working definitions:

  • Self-harm: Intentional act of self-poisoning or self-injury, irrespective of the type of motivation or degree of suicidal intent (3). From a psycho-analytical perspective self-harm is said to be ‘a way of communication, through actions, to deal with psychological pain and vulnerability’. The associated behaviours relieve the subject of the built-up tension, albeit briefly (7).
  • Suicide attempt: An intentional act of self-harm with the intent to end one’s life, which does not result in death (8). Hence, for the purposes of this report, suicide attempt is a sub-set of self-harm.
  • Suicide: intentionally causing one’s own death through self-inflicted injury (8).

However, it is important to note that definitions of self-harm vary across professions and services nationally, especially in the role of suicidal intent in the definition of self-harm. This can affect the treatment pathways offered and not all services differentiate between self-harm without suicidal intent and self-harm with suicidal intent.

Figure 2 illustrates the relationship between self-harm and suicide, demonstrating that a large proportion of those who die by suicide have self-harmed, whilst the majority of people who self-harm do not have suicidal thoughts or attempts (9). Non-suicidal self-injury (NSSI) is highlighted as a distinct subset of self-harm without suicidal thoughts as it refers to repetitive, deliberate self-injury, whereas other forms of non-suicidal self-harm may not always fit that profile. However, this is illustrative, and it is important to reiterate that there is no consensus on how we conceptualise self-harm, with some arguing that individuals’ motivations behind self-harm are complex and can change (2). Note that “injury” typically means visible, intentional tissue damage (e.g., cuts, burns) whereas “harm” is a broader concept that can includes physical and emotional damage that is not necessarily visible (63,64).

 Figure 2: Relationship between self-harm and suicide (9)

In alignment with the national suicide prevention strategy (10), we use the phrase “prevent self-harm and suicide.” We acknowledge that self-harm can sometimes serve as a coping mechanism that prevents individuals from attempting suicide (11). Therefore, when we discuss the “prevention of self-harm,” we aim to promote healthier coping strategies that do not inadvertently increase the risk of suicide attempts.

National context

National Suicide Prevention Strategy

In September 2023, The UK Government released Suicide prevention in England: 5-year cross-sector strategy (10), updated from the Suicide Prevention Strategy that had been in place since 2012. The strategy aims to prevent self-harm and suicide and to:

  • reduce suicide rates over the next 5 years
  • improve support for people who have self-harmed
  • improve support for people bereaved by suicide

Data, evidence and engagement with experts (including those with personal experience) has identified eight priority areas for action to achieve these aims, summarised in Table 2. These are accompanied by a detailed action plan (12) of over 100 actions for the government, the NHS, wider local public services, businesses and community groups to take.

Table 2: National Suicide Prevention priorities for actions

Apart from the identified target groups, the strategy also mentions several key groups for whom a more comprehensive understanding of trends in mental health and suicide rates will be important in the coming 5-year window:

  • occupational groups;
  • autistic people;
  • people affected by domestic abuse;
  • people experiencing harmful gambling;
  • ethnic minority groups including people who are Gypsy, Roma, or Travellers (GRT);
  • refugees and asylum seekers;
  • and people who are LGBTQ+.

The strategy emphases that prevention and early intervention is key, starting with society’s values of breaking down the shame that can deter men from seeking help and offering young people opportunity and hope.

In addition to the national strategy, there are several other important national guidelines, including: developing a local action plan (1); identifying and responding to suicide clusters (13); suicides in public places (14); preventing suicide in lesbian, gay, bisexual, and trans young people (15); and support after a suicide (16).

National Guidance

There are a number of National Institute for Clinical Excellence (NICE) guidelines for self-harm and suicide, which include important, evidence-based recommendations (Table 3). However, there is significant lack of guidance on self-harm prevention as NICE guidelines focus on interventions once someone presents with self-harm.

  • [NG225] Self-harm: assessment, management and preventing recurrence(Sept 2022): Outlines the importance of undertaking a psychosocial assessment at the earliest opportunity following an episode of self-harm. Emphasises not using risk-assessment tools to predict future suicide or repetition of self-harm, but instead using highly personalised assessment (safety planning).
  • [QS34] Self-harm Quality Standard (Sept 2022): There are 8 quality standards covering: 1) Compassion, respect, dignity; 2) Comprehensive initial assessments; 3) Psychosocial assessment; 4) Observation in the healthcare setting; 5) Safe physical environment in the healthcare setting; 6) Care plans; 7) Psychological interventions for self-harm; 8) Moving between services.
  • [QS189] Suicide prevention (Sept 2019): Covers 5 priority areas for suicide prevention: 1) Multi-agency suicide prevention partnerships; 2) Reducing access to methods of suicide; 3) Media reporting; 4) Involving family, carers or friends; 5) Supporting people bereaved or affected by a suspected suicide.
  • [NG105] Preventing suicide in community and custodial settings (Sept 2018): Recommendations cover: local suicide prevention strategies and action plans; collection and analysis of suicide and self-harm data; awareness raising; reducing access to methods of suicide; training for key staff; bereavement support; suicide clusters; media reporting.

In addition to these guidelines, NICE provides several scenarios of how to manage self-harm at different stages:

The Royal College of Psychiatrists also provides two key guidance documents on self-harm and suicide:

 Self-harm and suicide in adults (CR229) – Royal College of Psychiatrists: This report covers the management and secondary prevention of self-harm, including the role of crisis resolution teams in mental health settings.

Local context

Cambridgeshire and Peterborough Suicide Prevention Strategy

There is a Joint Cambridgeshire and Peterborough Suicide Prevention Strategy 2022-2025 (17) and an established multi-agency Suicide Prevention Strategy Implementation Group, which is overseeing the local suicide prevention action plan across the following 6 priority areas:

  1. Identify local risk factors for suicide and ensure approaches are considerate of different needs
  2. Provide high quality general and specialist support to people presenting with suicidal intent
  3. Protect people at a time of crisis and provide continued support following de-escalation
  4. Ensure the community is well-equipped to prevent suicide in non-clinical environments
  5. Improve understanding of self-harm and support the promotion of healthy coping strategies
  6. Ensure that appropriate steps are taken following a suicide to support the community

In 2024, an evaluation of the three years of suicide prevention activity was undertaken. Key findings have been summarised in Table 4 below. The Cambridgeshire and Peterborough suicide prevention plan was reviewed against the Suicide Prevention at Regional/Local Level: Self-Evaluation Instrument (SUPRESE) Evaluation tool, which allows local Integrated Care Systems to assess their suicide prevention plans against 21 metrics for effectiveness, measuring full and partial implementation. The Cambridgeshire and Peterborough suicide prevention plan scored 43 out of 57, with identified areas for improvement being:

  • greater resources,
  • Improved treatment and aftercare for people who have self-harmed, and
  • community engagement to address stigma around self-harm and suicide.

The Self-evaluation instrument for assessing suicide prevention at regional/local level (‘SUPRESE’) was developed by Professor Stephen Platt, with contributions from Public Health Scotland (Ms Shirley Windsor) and Samaritans, and is jointly owned by Professor Stephen Platt, Public Health Scotland and Samaritans. The findings of this evaluation and the Mental Health Needs Assessment will inform the update of the strategy for 2025-2028.

CPFT Patient Safety Incident Reporting Framework

The local mental health trust – Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) – have strengthened their processes by adopting the new national Patient Safety Incident Reporting Framework (PSIRF), as well as enhancing their Learning from Deaths programme. This has enabled better identification and embedding of learning from deaths by suicide in a meaningful way.

CPFT are also currently undertaking an audit to benchmark their services against the ‘Safer Services toolkit’ from the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) to improve patient safety and reduce deaths from suicide. This is ongoing quality improvement work and updates will be shared with the suicide prevention network.

Domestic Homicide Review Panels

The Local Domestic Homicide Review Panel offers the following key recommendations for suicide prevention, based on insights from 2019 to 2024. These focus on multi-agency collaboration, proactive training, and inclusive strategies to improve suicide prevention outcomes:

  1. Family and Parental Support: Ensure social care addresses the support needs of families impacted by a parent’s suicide.
  2. Training for Professionals: Equip frontline responders and police with training to recognise ongoing suicide risks and early intervention strategies in those who have previously self-harmed or had suicidal behaviours or thoughts.
  3. Support Coordination: Strengthen collaboration between suicide prevention and domestic violence and abuse services, emphasising shared training and awareness of the links between abuse and suicide.
  4. Inclusive and Targeted Approaches: Tailor suicide prevention activities to support people with autism, learning disabilities, and LGBTQ+ individuals through training to key organisations.
  5. Workplace Engagement: Promote suicide prevention awareness and resources to businesses so that workplaces are informed on how to support at-risk individuals.
  6. Policy and Strategy Integration: Embed domestic abuse considerations in the suicide prevention strategy and improve analysis to identify potential abuse-related suicides.

Local Services

Within Cambridgeshire and Peterborough, mental health services are provided separately for children and young people, and adults. The delivery of these services is complicated (Appendix 2), with support and treatment provided by a range of organisations within and outside of the NHS. The Cambridgeshire & Peterborough ICB is leading ongoing work to review the mental health crisis pathway. More details about these services are included in other chapters of the needs assessment, which are linked below.

First point of contact for people affected by self-harm and suicide include:

Local services requiring a referral (usually via primary/secondary care):

The majority of these services provide support for mental health more generally, which encompasses self-harm and suicide. Navigating this system can be challenging both for professionals and public due to the variety of service types and providers involved, and public awareness varies widely. Well-known services like Samaritans are familiar to many, but local resources like Lifeline are often less well known (as shown in the local stakeholder survey undertaken for this needs assessment).

For more information on crisis services, see the Crisis Services section of the Mental Health Needs Assessment.