Mental health service changes, organisational factors, and patient suicide in England in 1997–2012 : a before-and-after study

Background

Research into which aspects of service provision in mental health are most eff ective in preventing suicide is sparse. We examined the association between service changes, organisational factors, and suicide rates in a national sample.

Methods

We did a before-and-after analysis of service delivery data and an ecological analysis of organisational characteristics, in relation to suicide rates, in providers of mental health care in England. We also investigated whether the eff ect of service changes varied according to markers of organisational functioning.

Findings

Overall, 19 248 individuals who died by suicide within 12 months of contact with mental health services were included (1997–2012). Various service changes related to ward safety, improved community services, staff training, and implementation of policy and guidance were associated with a lower suicide rate after the introduction of these changes (incidence rate ratios ranged from 0·71 to 0·79, p<0·0001). Some wider organisational factors, such as nonmedical staff turnover (Spearman’s r=0·34, p=0·01) and incident reporting (0·46, 0·0004), were also related to suicide rates but others, such as staff sickness (–0·12, 0·37) and patient satisfaction (–0·06, 0·64), were not. Service changes had more eff ect in organisations that had low rates of staff turnover but high rates of overall event reporting.

Interpretation

Aspects of mental health service provision might have an eff ect on suicide rates in clinical populations but the wider organisational context in which service changes are made are likely to be important too. System-wide change implemented across the patient care pathway could be a key strategy for improving patient safety in mental health care.

Funding

The Healthcare Quality Improvement Partnership commissions the Mental Health Clinical Outcome Review Programme, National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, on behalf of NHS England, NHS Wales, the Scottish Government Health and Social Care Directorate, the Northern Ireland Department of Health, Social Services and Public Safety, and the States of Jersey and Guernsey.