Back in October 2014, an audacious NHS initiative was launched at a meeting in Exeter, aiming:
“to reduce suicide to zero across the south west by October 2018”
Although I wasn’t at the meeting, it’s aim appears to be covered by the old saying, “If it seems too good to be true, it probably is.” I’ve been wondering why anyone would support such a too-good-to-be-true cause, let alone allocate scarce NHS funding to it. The reasons turn out to be complicated.
The project is formally called the Zero Suicide Collaborative, which I’ll abbreviate to ZSC, and it’s being run by the South West Strategic Clinical Network (SWSCN), which is a kind of strategic planning consortium of healthcare commissioners and providers in the south west of England.
According to the SWSCN website, the idea of zero suicides originated in Detroit:
“…the suicide rate in Detroit (population 200,000) was reduced from 89 per 100,000 (baseline) to 22 per 100,000 (average over years 2-5). In years 9 and 10 there were no suicides at all.”
Whether this rings warning bells already depends on how much you know about the city of Detroit. It’s been in the news in recent years mainly because of its many problems, which have included a declining population. But declining to only 200,000?
In fact the figure is piffle. According to the US Census Bureau inner city Detroit had a population of around 900,000 at the start of the suicide prevention project there in 2001. (Now, it’s fallen dramatically to only around 700,000.)
But the suicide prevention project in Detroit wasn’t just an inner city project. It was run by the Henry Ford Health System (HFHS), a private healthcare provider that operates five hospitals and around 40 medical centres across the whole of south east Michigan. Although HFHS is by no means the only big healthcare provider in the area, the population it potentially serves is vast. The Detroit Metropolitan Area (essentially the commuter belt around the city) has a population of 4.3 million people, comparable to the 4.7 million population that the SWSCN covers in England.
The figure of 200,000 isn’t just a misprint, however. It’s the number of patients included in HFHS’s original Perfect Depression Care project. A report from 2007 about the project suggests that all 200,000 had a diagnosis of depression, and that further separate projects covering anxiety disorders, psychosis and other causes of suicide have been pursued.
So Perfect Depression Care in south east Michigan can’t simply be mapped to the south west of England, even though the populations are comparable. The project based in Detroit targeted only the patients with diagnosed depression being treated by one healthcare provider. The project in England apparently plans to target all causes of suicide and involve all healthcare providers.
A Zero Suicide Collaborative Charter from August 2014 describes in more detail what the SWSCN hopes to achieve and how it plans to go about it.
This isn’t the only document around describing how to go about achieving zero suicides, however. In the US, the National Action Alliance for Suicide Prevention (NAASP), based in Washington DC, has its own Zero Suicide initiative complete with a toolkit, dating from 2011, called the Suicide Care in Systems Framework that explains what to do.
The funny thing is, the SWSCN’s ZSC Charter doesn’t appear to mention the NAACP or its zero suicide toolkit anywhere. Nor does it mention Detroit, Michigan, Perfect Depression Care, or even depression.
The NAACP toolkit does refer to the work of HFHS in Michigan. For example, it reports that:
“…the HFHS lesson is that culture change focused on a goal of zero errors (deaths) was the essential foundation for improving interventions.”
But the SWSCN’s ZSC Charter doesn’t mention culture change at all.
Another curiosity in the SWSCN’s ZSC Charter is its definition of suicide right at the start:
“1.2. For the purposes of this collaborative, suicide will be defined as ‘an act that intentionally ends one’s life’.”
This definition will be all but impossible to operationalize, because it relies on knowing the intention of someone who has just died, and in many cases that’s essentially unknowable.
Also, the definition invites an unhelpful distinction between people who suffer from a mental illness and who die as the direct result of a single act, and people who suffer equally from mental illness but who die as the indirect result of other behaviours caused by the illness.
An operational definition of suicide, it seems to me, should include all those people who lose their lives as a result of mental illness, regardless of their apparent intention. It should specifically exclude those people who make a rational decision to end their lives while having mental capacity to make that decision, although there probably aren’t many of those.
Although the SWSCN’s ZSC Charter doesn’t appear to rely on the existing zero suicide methodology in the US, it does rely on another US methodology, the “Breakthrough Series” from the Institute of Healthcare Improvement (IHI) in Cambridge, Massachusetts.
The Breakthrough Series appears to be a model of brief collaborative learning that can, allegedly, close the “gap between what we know and what we do” through a focus on systems change. Its core is a series of three learning sessions, each lasting two days and bringing together representatives from many organisations.
Whether it’s really a model of collaborative learning, or just a way to overcome resistance to the opinions of experts by making them seem to have been arrived at collaboratively, is probably not important. If it works, it works.
The key difficulty the SWSCN’s ZSC faces, however, may be that it has adopted a model based on systems change for a problem that has been shown in Michigan to depend more on culture change.
The three learning sessions are scheduled for January, April and June 2015. At the time of writing, a week before the first session, the web page still says: “Watch this space for more details and a link to the on-line booking form.”
So whether this will come to anything is anybody’s guess. On the surface, it doesn’t look like the SWSCN has the capability to interpret what was achieved in Michigan in a way that can be implemented here. Spin-off benefits arising simply from getting lots of people together for six days of conferencing on the theme of suicide are always possible. Even so, it looks like they might simply get bogged down in processes and systems, and then run out of money with no real outcomes in terms of lives saved.
But I could be completely wrong.
I hope I’m completely wrong.