NHS Greater Manchester Integrated Care Partnership and the Greater Manchester Older People’s Network: Reducing self-harm in older people

"We sometimes think of self-harm as a problem in younger people and of course it is. But it affects older adults too and the concerning issue is the link with increased risk of suicide. Older people might be particularly vulnerable as they are uniquely exposed to issues such as bereavement, isolation and physical as well as mental illness."

Self-harm among older people is not well recognised and often overlooked. Yet older people who self-harm are at 67 times greater risk of suicide than the general older population and three times greater than the relative risk of suicide among younger people who self-harm.

Self-harm in a primary care cohort of older people: incidence, clinical management, and risk of suicide and other causes of death published in The Lancet in 2018 (Morgan et al) found that there is an elevated risk of suicide in older people who self-harm, yet older people do not always get access to specialist care.

• Only 12 per cent of over 65s who self-harm are referred to mental health services within 12 months of their initial self-harm episode. 
• Referrals are a third less likely for older people in the most deprived areas even though the incidence of self-harm is higher in these areas. 
• One in seven older people self-harmed again within a year of the initial episode.
• We chose self-harm in older people as one of our suicide prevention priorities with a view to co-producing an awareness campaign reaching older people across Greater Manchester

The aim of the campaign was education and awareness. While self-harm is often talked about with young people, it is an issue for older people too. However, this group was not always front of mind for professionals when thinking about self-harm.

The campaign aimed to start a conversation locally with older people, their friends and families, and professionals, sharing what we were learning more widely.

We were determined that the campaign would be co-produced with the target audience, ensuring we were in the places they were, talking to them in a way that was not patronising or alarming.

We partnered with the Greater Manchester Older People’s Network to develop and run the campaign. The Network invited a group of people (aged 55 to 82) from across Greater Manchester, including representatives from our ethic minority and LGBTQ+ communities, to take part in an initial focus group. That first meeting lasted around 90 minutes and was held online. Clearly, it was a very sensitive issue to discuss, so, alongside our mental health partners, we made sure that safeguarding and wellbeing were a priority. We did not specifically request participants with lived experience, but some did share stories or anecdotes about neighbours or friends.

We had an experienced cartoonist/ graphic minute taker (Tom Bailey) join us at that meeting to capture the conversations in an accessible way. Once our discussion was over, he shared the cartoons with all of us. This form of communication was very well received and helped us to shape campaign messaging in our second group session.

Also in that second session, we shared some mocked up posters and social media posts. Some were based on the cartoons from the original session, others came from suggestions from a creative agency. The group were unanimous that the cartoon-style posters and images were the most effective for their cohort. Cartoons also enabled us to ensure the images of older people were diverse and age positive.

We had a limited budget for the campaign, £10,000 in total, which had to include printing, staff resources, etc. It was important to make that budget go a long way, so we were guided by our older people’s group to target our activity most effectively. Posters and social media posts were circulated in communities by local groups like Age UK. We included a QR code on the posters so that families and friends could easily access information too. All audiences were directed to our website for more information and signposting.

We had always planned that this small campaign would be ‘phase one’. It was essential that we also tried to reach professionals to raise awareness and challenge assumptions often made. There are, unknowingly, age blind assumptions and myths around self-harm and older people. There is an ongoing need to educate and have conversations about this.

From the outset, we were in touch with the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) at the University of Manchester. The research by Professor Nav Kapur was instrumental in alerting us to the issue. NCISH developed two infographics around self-harm and older people that could aid us in our reach to professionals.

We monitored our campaign outputs; 10,000 posters printed and distributed, website visits, media coverage. But the main outcomes are still to come. We are interested in whether we see an increase in older people accessing talking therapies, for example. We know that older people who access talking therapies are likely to complete the course and have a positive outcome and improvement in mental wellbeing.

The campaign proved to be a catalyst to obtaining funding to establish an Older Peoples’ Mental Health Group in Greater Manchester to support ongoing programmes in mental health transformation work

We accepted early in the process that our group meetings would be organic – the agenda always went out the window! But there was always so much to talk about and people were fully immersed in the conversations. In that sense, it was a different type of campaign for us. We went with the ideas that felt important by the group rather than any preconceived ideas.

We have had huge interest in our campaign from around the country. We have presented to national and regional groups about what we did and how. We are more than happy for others to use our imagery and insert their own links and information. We always felt that what we were doing was just the seed, spreading the word about the issue is so important too.

It Is especially important to keep this on our, and others’, radars post-Covid. A shocking number of people lost their partners, and have been left bereaved, isolated, often with long term conditions. We need to ensure that the needs of older people are recognised and not neglected and to talk about them more.

The statistics about older people and self-harm are shocking, but don’t be afraid to talk about it. People have a lot to share and want to share. Older people will have lived through times when mental health, self-harm and suicide were never talked about and when stigma and shame were very apparent. They may not also recognise that some of their behaviours are maybe a form of self-harm. But given the right supportive environment to speak up they will talk.

To ensure a campaign of this sort is successful it is essential that it is co-produced involving the very audience it is intended for.  It is easy to make assumptions, but our focus groups uncovered some valuable audience insights that helped us to target our messages appropriately and from the beginning.

Co-production is also a way of raising awareness of the campaign itself. People who were involved felt a sense of ownership and took it upon themselves to talk about and distribute campaign materials with their peers.

We continue to share the campaign with other organisations across the country, while we produce more posters to circulate across our city region. With the development of the Greater Manchester Older People’s Mental Health Clinical Reference Group, further avenues to raise awareness and share good practice and training will be explored. We will continue to discuss the issue with our newly emerging older peoples’ mental health network. We would also like to influence training programs to ensure this issue is included.

The infographics below were created with National Confidential Inquiry into Suicide and Safety in Mental Health.

• Self-harm in older adults: self-harm and suicide
• Self-harm in older adults data samples

 New campaign launched to shine a light on the issue of self-harm in older people

Adele Owen QPM, Greater Manchester Suicide Prevention & Bereavement Support Programme Manager