'Taking me seriously': research evaluation of a service (SCAN) that links primary care with secondary services when clients are in suicide crisis. Stephen K Bradley et al.

Prof. Kathy MurphySchool of Nursing and Midwifery, National University of Ireland, Galway. Prof. Declan DevaneSchool of Nursing and Midwifery, National University of Ireland, Galway. Mr Brendan Kennelly,J.E. Cairnes School of Business & Economics, National University of Ireland, Galway. Dr Pauline MeskellSchool of Nursing and Midwifery, National University of Ireland, Galway. Ms Mary Pat ButlerDepartment of Nursing and Midwifery, University of Limerick, Limerick. Dr. Maura DowlingSchool of Nursing and Midwifery, National University of Ireland, Galway. Ms Siobhan SmythSchool of Nursing and Midwifery, National University of Ireland, Galway. Ms Agnes TullySchool of Nursing and Midwifery, National University of Ireland, Galway. Ms Yvonne ConwaySchool of Nursing and Midwifery, National University of Ireland, Galway. Ms Fionnuala JordanSchool of Nursing and Midwifery, National University of Ireland, Galway. Co-Authors

 A fast track priority referral and assessment system for individuals experiencing a suicidal crisis, known as Suicide Crisis Assessment Nurse (SCAN) Service; operated in S. Dublin ( ) and Wexford (2008 on).  The research utilised a mixed method, exploratory sequential design. SCAN?

Mixed Method, Exploratory Sequential Design.

 Interviews:  former SCAN clients (face-to-face; n=12)  current and former SCAN staff (face-to-face; n=6),  GPs with experience of utilising the SCAN service (telephone; n=14),  Focus Groups:  SCAN CMHTs (face-to-face; n=5).  one further face-to-face focus group with a CMHT from an area with no experience of a SCAN service, so as to explore ‘usual care’; Qualitative Methods

 Without SCAN, all professionals recognised that referral and/or admission to mental health services was often a ‘default’ position; necessitated more by lack of appropriate community based facilities than by clinical need.  Clinicians were frustrated by the delays and uncertainty that regularly accompanied the process of referral/admission.  Navigating a cumbersome process and the de facto development of a possibly inappropriate psychiatric history could be the outcome for clients. Qualitative Outcomes

 SCAN - a valuable, accessible and timely gateway between primary care and mental health services; allowing for expedited admission, referral for on- going mental health intervention in the community or management in primary care.  Alongside this gateway role, SCAN was found to have a therapeutic value that was identified as pivotal by clients; apparently contributing to the perception that they were being ‘taken seriously’. Qualitative Outcomes

 GPs interviewed described the support provided by SCAN, both overt in terms of assessment/intervention and ‘hidden’ in terms of informal advice, as ‘empowering’.  Collaborative working across primary care and mental health was clearly enhanced. Qualitative Outcomes

 On-line Questionnaire – 46 Items  Skip logic  SCAN GPs were required to complete approximately items  Non-SCAN GPs were required to complete items 1-20 and items (total 26 items)  Of the 257 GPs invited, 127 completed the questionnaire yielding a response rate of 49.4% Quantitative Methods

 The majority of GPs surveyed rated themselves as confident in assessing and managing patients in suicidal crisis. There was no significant difference between SCAN and non-SCAN GPs in confidence levels.  Greater than 37% of GPs surveyed had undertaken training in suicide/deliberate self-harm and more than 70% had undertaken training in depression. Training significantly positively impacted on confidence in assessing and managing suicidal behaviour. Quantitative Outcomes

 Almost all GPs with experience of SCAN agreed that the SCAN service leads to better treatment adherence than ‘usual care’ and patients are more readily agreeable to being referred to SCAN.  Overall, GPs with access to SCAN services rated the service significantly higher on its impact on identified patient outcomes than those who had access to traditional mental health services. Quantitative Outcomes

 SCAN GPs rated the impact of the service on their knowledge and skills in assessing and managing suicidal behaviour significantly greater than colleagues that use traditional mental health services.  GPs who had access to a SCAN service rated their overall satisfaction with the service as significantly higher than those GPs in the non-SCAN group. Quantitative Outcomes

 Plausible evidence that the decline in inpatient admissions is related, at least in part, to the introduction of the SCAN service. Under reasonable assumptions about the size of effect, the SCAN service resulted in a reduction of healthcare costs.  However, it is possible that the SCAN service led to an increase in healthcare costs (taking account of the direct costs of the SCAN service itself). In those scenarios it is still likely that the SCAN service makes sense from an economic point of view, as the SCAN service is likely to have been responsible for an improvement in the health of those referred to it at a relatively low cost. Economic Analysis

 GP training sessions in suicide/self-harm should be embedded into continuous professional development programmes  Clear guidelines/protocols need to be in place to identify what are, and are not, appropriate referrals to SCAN and how the referral process should be managed  Clear guidelines/protocols need to be in place to identify who is responsible for follow up following SCAN assessment Main Recommendations

 The full range of demands on SCAN staff need to be acknowledged and top level management commitment to appropriate governance, support and supervision needs to be maintained and regularly reviewed.  The maintenance of adequate staffing levels for SCAN needs to be prioritised, including appropriate administrative support.  The position that SCAN occupies, what it offers and how it integrates with other services, within a changing and challenging healthcare environment, needs to be clearly articulated, periodically reviewed and constantly promoted. Main Recommendations

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