An evaluation of a national suicide prevention programme

Dr Ann MillsHead of Human Factors, RSSB, UK

D. Hill (The Tavistock Institute)S. Stace, S Burden (Samaritans)T. Luke, A. Monk, S. Pitman, M.Dacre, A. Moor, K. Thompson (RSSB)

Historical railway fatalities

Comparing suicides to trespass fatalities

2006-7 2007-8 2008-9 2009-10

2010-11

2011-12

0

50

100

150

200

250

300

350

SuicidesTrespassAccidental fatalities: passengerAccidental fatalities: work-force

Num

ber o

f fat

aliti

es

5 times more fatalities as a result of suicide attempt than trespass80% of recorded attempted suicides result in a fatality

The national picture in relation to railway suicides

• Estimated that there were 6,045 suicides in the UK in 2011, or one every 87 minutes

• Twice as likely to die by suicide as in a road traffic accident

• More men than women take their own lives• Around 80% of railway suicides are by men• Men aged 30-55 are the highest risk group

Programme details

Partnership working• National Suicide Group• Identification of priority locations• Joint suicide prevention plans• Development of guidelines and polices • Wider third part engagement

Postvention• Suicide trauma support training (TST)• Post incident support• Guidance to rail staff/industry on responding to media enquiries

Prevention• Managing suicide contacts training (MSC)• Public awareness campaign (posters, leaflets & contact cards, signs)• Physical measures (barriers)• Outreach (ESOB)

In Stations

At Level Crossings

Posters

Programme & Evaluation challenges

• Complex, evolving programme, involving lots of parties• Programme gaining momentum & impact – delay in

results• Level of engagement influenced by views on whether it

is a societal issue or railway issue to manage, experience, number of manned stations…..

• Challenges in consistent delivery of programme• Impact being felt not just at priority locations• Other parties undertaking activities that are not formally

‘part of programme’• Changes in suicide rates – too crude a measure?

Example Theory of Change map

Actions

Anticipated rise in suicides Staff recruited

for training (in sufficient numbers)

Priority locations identified

More people aware of and using Samaritans

Staff training developed

Folders, cards and posters distributed

Proven interventions not being used

Change in staff attitudes and confidence to intervene

Staff proactive in identifying other risks

Outputs Outcomes Impacts

(More) staff identify potential suicides and intervene

Increased understanding of Samaritan’s role

Number of rail suicides reduced

Samaritan data on numbers/roles/location of attendeesData on referral patterns of network rail and TOC reps (interviews)

Post course questionnairesStaff survey (WP6) for evidence of changes in knowledge, attitudes and confidence

Data on staff interventions WP2 and WP6 Data on partnership working at a local level WP4

Data on rail suicides WP1 identifies any connections between suicides and programme interventions

Sources of data

Other interventions put in place (physical measures, links to other local initiatives)

Interviews with Samaritan team and trainers

Route and TOC reps appointed

Staff use folders and other materials

Staff proactive in ensuring posters displayed/using call out service

Network rail team site visits

Managing Director instructs Station ManagersRoute Reps send info on coursesHead of Stations nominate staff

Issues

Evaluation methods

1. Analysis of number of suicides2. Analysis of delay minutes, costs and staff absenteeism3. Survey of partners4. Station/Intervention case studies5. Front line staff survey

Programme roll-out

Y12010/11

Y22011/12

Y32012/13

Priority locations 175 237 254

Priority locations with posters 105 191 152

Priority locations with ESOB capability 63 159 251

ESOB activations 0 1 7

MSC courses 91 130 159

Staff trained - MSC 940 1315 1211

Staffed trained - TST N/A 187 631

Staff interventions 10 25 22

Post incident support - offered 172 253

Post incident support - accepted 78 42

Reduction?

75 73 77 72 85 90 94 80100 94

18 20 25 2220 23

3326

25 25

96 100

123 131 102105

107

97

113 119

189 193

225 225207

218234

203

238 238

0

50

100

150

200

250

300

2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

Fata

litie

s

Other locationsLevel crossingIn stations

Rail vs national picture

2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

50

100

150

200

250

300

350

400

0

1000

2000

3000

4000

5000

6000

7000

8000

41203680

3920 4080

4900

4120 41404380 4500

4280

5826 5731 5850 5671 5554 5377 5706 5675 56086045

10607.6%9631.8%10051.3%10791.7%

13233.7%11493.4%10883.3%11577.1%12036.4%

10620.3%

On railway propertyAll suicidesRailway suicides as % of national to-tal

Rai

lway

sui

cide

s N

ational suicides

Impact at priority locations

2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

10

20

30

40

50

60

70

80

90

4945 43

39

57 56

7481 79

68

56 53

Priority locations 2012

Cost and Disruption

TRUST delay costs and SMIS delay minutes:

TRUST Costs (£)

SMIS delay (mins)

2009 / 10 19,841,000 298,143

2010 / 11 11,033,000 227,860

2011 / 12 20,716,000 391,267

2012 / 13 296,112

2009 2 hours 44 mins 2012 1 hour 59 mins

Partnership working

Establishment of National Suicide Prevention Steering Group & Working Group

87% felt programme improved partnership working

77% felt programme reduced staff distress

77% felt programme had reduced service disruption

37% felt good practice effectively implemented nationally

Perceived effectiveness of programme activities

Physical barriers

Samaritans Metal signs

MSC training

Posters

Local suicide prevention plans

External engagement

Samaritans info for staff

ESOB

Risk assessments

Memorials policy

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Perception of how effective each programme activity is at reducing suicides

Would increase the number of suicides Don’t knowWould decrease the number of suicides

Perceived effectiveness of programme activities at reducing staff distress

Trauma support training

ESOB

Samaritans information for staff

MSC training

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Perceived effectiveness of programme activities at reducing staff distress

Increases distress No effect Decreases distress

Effect of the programme on relationship between your organisation and other organisations

Samaritans

Own organisation

Train Operating Companies

BTP

Network Rail

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Perceived effect of programme on relationships with different organisa-tions

Worse No effect Better

Willingness to participate in programme activities

TST

Local suicide prevention plans

MSC

Samaritans info for staff

External engagement

Station risk assessment

ESOB

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Staff willingness to take part in programme activities

Would/might refuse to take part Don’t knowWilling/keen to take part

Introduction to the ATTS

• 24 item survey• Respondents rate agreement with attitude statements

e.g. ‘It is a human duty to stop someone taking his/her life’

• Factors:– Obligation to prevent– Acceptance of suicide– Unpredictability of suicide– Suicide as a long lasting issue– Suicide as a taboo subject– Reasons why people take their own life– Preventability of suicide

Effect of MSC training on attitudes

Obligation to prevent

Preventability

Openness/acceptance of suicide

Reasons why people take their own life

Unpredictability of suicide

Suicide as a long-lasting issue*

Suicide as a taboo subject to talk about

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Participation in MSC training and attitudes

Overall No Yes

Average attitude score (max 5)

Atti

tude

fact

or

Frontline staff attitudes compared to ‘management’ attitudes

Obligation to prevent*

Preventability*

Openness/acceptance of suicide*

Suicide as a long-lasting issue*

Suicide as a taboo subject to talk about*

Unpredictability of suicide*

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Oganisational level and attitudes

Local level respondents (N ~ 670) National level respondents (N ~ 52)

Average attitude score (Max = 5)

Atti

tude

fact

or

Recognition of people who might be suicidal

Never seen anyone

Seen someone once or more than once

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%100%

Participation in MSC training and whether staff have seen someone they suspected of being suicidal

Participation in MSC No Participation in MSC Yes

MSC training and interventions

Not attended MSC

Attended MSC

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Whether an intervention has been made if someone was suspected of suicide

No Yes once or more than once

Effect of MSC training on intervention actions

Offer safe place to go to talk*

Contact BTP

Try to show empathy and understanding*

Introduce yourself and ask their name*

Encourage the person to talk and listen*

Provide Samaritans contact details*

Approach and ask how they are*

Ask for permission to pass contact details to Samaritans*

Request Samaritans ESOB service

Physically restrain them

Give advice about how to solve problems

Tell them you know how they feel*

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Average likelihood to take an action (Max = 5)

Attendance at MSC training Yes (N ~ 83) Attendance at MSC training No (N ~ 212)

Summary of findings

• Evaluation of a programme of this nature is challenging• Partnership working had improved as a result of the programme• Wide variations in level of implementation• No evidence to date to suggest programme has led to reduction in

number of suicides, reduction in delays or cancelations • BUT Improvement in response times.• Staff willingness to be involved is high• Programme activities are perceived as being effective at reducing

suicides and staff distress.• MSC training has had a positive effect on the ability of staff to

recognise when someone is suicidal and on the quality of the interventions.

• The rate of interventions when someone is recognised as potentially suicidal is high regardless of MSC training.

Thank you

Dr Ann Millsann.mills@rssb.co.uk