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 effective 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 effect of service changes varied according to markers of organisational functioning.


RESULTS
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 non-medical 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 effect in organisations that had low rates of staff turnover but high rates of overall event reporting.


CONCLUSIONS
Aspects of mental health service provision might have an effect 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.


BACKGROUND
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.
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK; Manchester Mental Health and Social Care Trust, Manchester, UK. Electronic address: nav.kapur@manchester.ac.uk.
Nav
N
Kapur
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Saied
S
Ibrahim
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
David
D
While
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Alison
A
Baird
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Cathryn
C
Rodway
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Isabelle M
IM
Hunt
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Kirsten
K
Windfuhr
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Adam
A
Moreton
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Jenny
J
Shaw
National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, Centre for Suicide Prevention, Centre for Mental Health and Safety, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK.
Louis
L
Appleby
D004739:England; D006801:Humans; D008605:Mental Health Services / Q000458:organization & administration*; D012306:Risk; D013222:State Medicine / Q000458:organization & administration*; D013405:Suicide / Q000706:statistics & numerical data* / Q000639:trends