SOAPBOX: Suicide – the public health crisis of our times

Carrie Montgomery is deputy chief executive at Contact NI. She has led Lifeline since its 2006 pilot inception and in this article shares her vision of society free from suicide.

In 2014 the World Health Organisation declared suicide as a preventable harm, calling for a 10% global reduction in suicide deaths by 2020.

Suicide rates have fallen across UK and Ireland, especially in Scotland. Yet Northern Ireland still has the highest and rising general population suicide rate.

The latest available figures for 2015 report the highest number on record: in Northern Ireland, 318 people died by suicide, devasting families and communities. That’s a preventable death almost every day.

If suicide is preventable, who is responsible?

The strapline of recent times ‘suicide is everyone’s business’ comes to mind. It is true that all government strategies, particularly social welfare should give careful consideration to safeguarding against suicide. A good example is Finland’s recent success in declaring the eradication of homelessness. It has provided all the support needed to afford permanent housing instead of temporary accommodation, instilling hope that this will be linked to a reduced national suicide death rate.

However, for me this question has been answered in the 2014 Atlanta Zero Suicide Declaration setting the audacious ambition to render suicide as a preventable harm … a ‘never event’ for the people in the care of our health service. In other words with the right support, at the right time, suicide is preventable in every case, until the last moment of life.

In spite of that, just this week at the launch of the National Confidential Inquiry into Suicide and Homicide (NCIHS) 2017 report, lead Professor Louis Appleby commented “it’s hard to be positive after 1,538 in-year UK patient deaths by suicide but our evidence shows services are making a difference to safety”.

Critically, the NCISH report shows 90% of Northern Ireland patient deaths by suicide were assessed as no or low risk during their last contact with services. This research finding informed National Institute Health & Care Excellence (NICE) guidelines recommending that services “do not exclude on the basis of crude suicide risk scales”.

Why then has the draft NI suicide prevention stategy commended the policy implementation lead, the Public Health Agency, “provide accessible services for people at high risk of suicide”?

The draft strategy notes that “low threshold crisis intervention helplines are an evidence-based effective intervention”, yet the Public Health Agency plan to restrict Lifeline access by “targeting people most at risk”.

Surely this contradiction is unsafe?

Contact piloted what is now Northern Ireland’s 24/7 Lifeline service a decade ago and has run it ever since. With ten years service innovation and international benchmarking expertise, we have raised concerns directly with the Public Health Agency for over two years on their planned access restriction to Lifeline counselling many times to no avail.

Taking no pleasure in exposing the Public Health Agency’s imminent plans for Lifeline restructure as unsafe and unfit for purpose, last week we brought our concerns to the public’s attention. The Public Health Agency corporate response is to blame, discredit and censor Contact, chastising media attention for our safety protest.

They say “the eligibility of who can access Lifeline follow-on support will remain the same … it is misleading to print otherwise” when the evidence from the PHA’s most recently published documents (sourced by FOI) reiterate the clear intent to unsafely restrict Lifeline access.

What motivates this public authority to dismiss criticism of their contradictory published plans?

The Public Health Agency’s two recent public consultations on future plans for Lifeline are not informed by independent peer-led evaluation. A glaring omission.

Independently reviewed Lifeline evaluations found the current integrated regional service model as “exemplary for securing high quality data, exceptional service delivery and demonstrating evident clinical expertise”. Yet this finding was excluded from two public consultations. Why?

These questions remain unanswered.

I would contend the answer points towards a fundamental organisational culture clash between Contact as pioneer provider and the PHA as Lifeline commissioner.

As remarked in Sir Liam Donaldson’s 2014 review of Northern Ireland health service leadership, “a proper regard should be given to the overwhelming evidence that a climate of fear and retribution will cause deaths not prevent them”.

Or is it more a clash of confidence?

Contact’s vision is a society free from suicide, recognising suicide as a preventable harm.

In contrast the NI Department of Health noted health service “pessimism amongst staff about the preventability of suicide” in their draft Protect Life 2 suicide prevention strategy.

I suggest both factors are significant leadership culture insights, given Donaldson’s constructive criticism on limitations to health care leadership’s lamentably slow pace of change. Donaldson’s 2014 NI leadership culture review for the NHS coincided with the WHO declaration that “suicide is preventable”.

Public concern will be for the safest way forward for Lifeline, not the detailed conflict between Contact and PHA.

Protecting vulnerable people from preventable harm far outweighs protecting organisations from reputational harm.

Tackling the unacceptable suicide death rate in Northern Ireland requires courageous, transparent and determined leadership, inside and outside government.

It requires not only policies and strategies that instil hope, but a clear statement of intent to make the biggest difference in the shortest time possible.

Department of Health declaration last week for a 10% target reduction by 2022 in NI’s suicide death rate was welcomed by the NI Assembly All Party Group on Suicide Prevention as courageous, hopeful and encouraging.

It requires learning from what worked for the thousands of Lifeline clients who reported recovery from suicidal crisis, compared to the devastating outcome when a person who has sought help dies by suicide.

Meaningful learning will require independent peer evaluated review of Lifeline governance to evidence-inform how Lifeline and its many partners, commencing with health, justice and education, can improve crisis care continuity so that not one person in our care dies alone and in despair by suicide.

Our collective task is to justly and fairly challenge corporate pessimism and blame culture to create a society wide climate of optimism, hope and achievement for suicide as a preventable harm, commencing with every person in our care.

If you or someone you know has been affected by these issues, call 24/7 crisis helpline and counselling service Lifeline 0808 808 8000. Calls are free from all landlines and mobiles.

This is a guest slot to give a platform for new writers either as a one off, or a prelude to becoming part of the regular Slugger team.

  • Gopher

    Which sector do you suggest we take money away from to fund the increase of researchers and councillers you are suggesting for Lifeline? Me, since I dont believe in the magical money tree that people seem to believe exists would scrap all cultural spending from the Ulster Orchestra to the Irish language and Orange Order to provide more money for health be it physical or mental.

  • Korhomme

    Poverty is a significant factor in suicide; poverty means that peoples’ thoughts and actions are totally directed towards a daily struggle for survival. Do I eat or do I say I’m not hungry and feed the kids? At times, this existential struggle overwhelms.

    Austerity is the neo-liberal reaction to poor economic times. And it’s very clear that austerity is associated with poor health outcomes — and not just mental health. I wrote about this a couple of years ago:

    We don’t just need more facilities for the treatment of mental illness, we need to see that economic policies can and do worsen things; we need to start to prevent rather than just react.

    The 0808 808 8000 number for Lifeline is free. To call the Samaritans, the numbers are 116 123 for both NI and the Republic. They are free.

    The helpline of the Department of Work and Pensions, where you would call to ask about why your benefits haven’t been paid out (what we used to call ‘welfare’) costs up to 55p per minute:

  • SilentMajority

    This whole suicide and despair is fathomable in many areas of NI and yet we have an Assembly that has spent almost a year (yes the anniversary is fast approaching) wrangling over what is not entirely clear, but whilst they wrangle the despair in society is ongoing. I am not by any means suggesting that they are entirely to blame or have the solution, but opportunity and facilities, which are to a degree in their control, are a significant factor.

    A significant part of this is a result of the deep anxiety caused by lack of a future, opportunity or hope. The affluence of the UK government subsidy to NI is funnelled to supporting certain sectors and parts of NI whilst ignoring others (in particular the Invest NI focus on funding jobs almost exclusively in Belfast and the concentration of public sector jobs and universities in the Belfast region, although I acknowledge many parts of Belfast do not benefit from this and also have deep issues).

    At the same time as ‘fiddling whilst Rome burns’, those supported by the subsidy sit in the trendy bars and restaurants in the leafy suburbs of Belfast and the fat cats in the Assembly take their inflated salaries and allowances and live like lords whist the poor in society suffer . On Friday as I was at home the helicopters were out at another incident of what was described in the media as a ‘vulnerable male’ on the Foyle Bridge. This made me both deeply sad but also angry at the system.

    The civil rights of citizens in this State are being badly ignored to a point which is deplorable and unacceptable. What type of action is required to address this? Some thing is needed quick and the first step is perhaps bringing back Direct Rule, close the Assembly completely, turn Parliament Buildings in to a recovery/care centre for those in despair and spend the savings from this worthless talk shop on some remediation and suicide prevention. The technocrats can govern this small place without this waste of money and anti democratic nonsense.

  • Brian O’Neill

    I always find it curious that Suicide and road deaths kill dramatically more people than the troubles ever did but as society we collectively shrug our shoulders at both issues.

    As the post states there needs to be the will out there to solve these issues.

    I also wonder if we have a lot of duplication in the services. Do people call the Samaritans, lifeline, Pips, lighthouse?? There seems to be a whole proliferation of organisations in this area.

  • Granni Trixie

    Brian, I have heard people saying that the step described above is in fact “civil servants” delivering cuts prior to MLAs going back and having to do so.

  • SeaanUiNeill

    It’s a recognised thing by most people that mental well-being is enhanced in a cultured and empathic society. The way you are responding to this Gopher is the setting of broken bones where health and safety measures would have prevented the fall that broke the bones in the first place. Don’t just think outcome, think cause.

  • SeaanUiNeill

    Poverty is increasingly the product of a debt society which ensures slavery to the repayment round. The poor must borrow to keep going and the neo- liberal response in the weak can go to the wall.

  • Korhomme

    I find the sectarian triumphalism of the bands that accompany the Orange Order very disturbing, to the extent that I could be upset by a governmental subsidy. But…

    I was taught a very severe lesson many years ago by a man who was the leader of a local gym. I told him, in very explicit terms, that I was totally against professional boxing, where people went to see a ‘kill in the ring’ — I am a Freudian. I told him to his face that I thought that boxing was a totally disgusting sport; in this I was encouraged by the voice of the British Medical Association. And he said to me, that he took the young lads off the street, taught them, and showed them discipline and restraint, the benefits of training and expertise, instructed them in a particular art, and expected them to follow his example — which they did. He gave them, he explained, an activity which directed their natural, testosterone fuelled inclinations into an activity which permitted yet directed and deflected these entirely natural impulses. (He also told me that amateur boxing was subject to the most stringent rules.) Would I prefer, he asked, that they remained on the street? It’s not often that I’m silenced in argument; but this man got the better of me.

    So, while the bands hardly compare to this, I see that the provision of instruments is a healthy alternative to a life without any purpose. And you know, before meeting the gym master from Coalisland, I could never have entertained such an idea.

  • Korhomme

    Yes, Seaan, sadly this is so. Growth in the economy is not a measure of the outputs, but rather is measured by what we an buy.

    I’ve been reading John Bew’s biography of ‘Citizen Clem’; alas, I still don’t really understand the man. Yet I see how he changed — perhaps only temporarily — the nature of society into one where all the members, not just the few, were involved. But today we seem to have reverted to the Victorian idea of the ‘undeserving’ poor where those undesirables are cast out and the smug members of society, the chattering classes, the champagne socialists, the Chipping Norton set, look on with disdain.

    Meanwhile, here, up on the hill, our political leaders quibble about the trivia of an ancient language, one which perhaps all our forbears once understood, while all around them…

  • Gopher

    If someone is bent on suicide they will kill themselves no matter how many 30K plus councillors we employ, how many Irish Language signs there are, whatever concerto the Ulster orchestra play and how many garish band uniforms there are paid at the publics expense. Its just the same as Tommys Drug addiction thread, free will exists and it is ludicrous to turn various theories to try and negate it into an industry. You want to expand suicide prevention and contain drug use I have provided you for a way to increase funding for both. Whats your idea?

  • wild turkey


    i wish you well in your writings.

    an observation? do your homework; your background research and digging, before you afford open platforms like this. in essence, this is not your post, but a post from a secondary source. if you think the source is trustworthy, say so. appeal to the evidence rather than…….

    if you had wrote this particular post , it may, or may not, have been a revelation.

    But second hand, one removed posts?
    Revelation becomes, and by definition is, heresy.

    there is an old american saying “Hey cowboy, watch yer ,,)

    good luck. i mean that

  • SeaanUiNeill

    You are looking at this very, very simplistically. You don’t drop a suicidal person into a concert, and expect them to recover in an hour, but if you develop a utilitarian society simply built around making and spending money and mechanically repairing the human machines that service this, then, for goodness sake, man, what is worth living for?

    “ Man does not live by bread alone” and the one dimensional version of life your prioritising implies is so reductivist it is not worth living in.

  • SeaanUiNeill

    My uncle boxed for his regiment and told me that one of the most bonding things the activity offered was the opportunity he offered to let rankers hit an officer with impunity! It produced a bond which could make all the difference in “real” action. His skills helped me when I learnt epee fencing (the footwork and the “lunge” are very similar). Both engage the intellect in interesting ways and demand speed and flexibility of response. But I’ve also encountered just how much harm boxing can do to an individual. But anything which can discipline, structure and formalise compedive aggressiveness will serve to order the natural chaos of these things. In the Pisian Cantos Ezra Pound tells the reader to “master yourself, that others may you bear”, and to my mind the gift of self discipline which any skill offers is the most precious gift anyone can have.

  • SeaanUiNeill

    My family had strong links to the old NI Labour Party, and I had the luck to grow up here in the world Clement created. As you say, the riches this offered a generation where genuine abilities were nurtured and enabled to return the gift of their education to society at large has sadly been superceded by a culture of every person for themselves. We are living of the slow decay of the community created by the post war social revolution which has now been almost fully coined for personal profit. I remember my first frisson of shock when an old friend, a Labour stalwart of the 1970s told me in the 1990s, “we used to think we had to expropriate the rich, but with Tony we now see we can become the rich.” Him perhaps, but not the vulnerable and broken. I still believe I am part of a society and a culture which has made me what I am and to which I owe service in my life, but I feel I am one of a shrinking band.

  • Stephen Kelly

    The gym master in my opinion was doing an excellent job. The band master of orange bands i believe are part of a sectarian culture.

  • John

    Unfortunately I have been up close and personal with this subject and I see nothing relevant in this discussion. More meaningless claptrap from the chattering classes I am afraid.

  • Reader

    SeaanUiNeill: As you say, the riches this offered a generation where genuine abilities were nurtured and enabled to return the gift of their education to society at large …
    Grammar Schools? Good idea. Though you still need a mechanism to help the “vulnerable and broken”. Fortunately, the Welfare State seems to fit the bill.

  • Gopher

    There is no need for the state to decide what is culture and dont like Mao suits.

  • SeaanUiNeill

    The welfare state used to fit the bill, yes, but you really need to get out and meet some of the broken and vulnerable trying to engage with the system nowadays if you are misguided enough to believe it still does for the most at risk. With 50p a minute call charges on those calling for advice, regular refusals of applications over small trivial mistakes and with the demand that pretty much every application is made by email, by people who are on the fringes of society, the cheese paring clearly affects the most vulnerable punitively.

    A while back on the radio a spokesperson spoke of a little extra money perhaps permitting the very poor to “ take the family out for a pizza now and again.” It is this sort of thinking, carried out only “on paper” about such things which persuades some to believe all is well as the most vulnerable are driven to dispair and suicide in order to save the money which pays for even more inflated pensions for those running the show.

  • SeaanUiNeill

    In the nineteenth century a culture of social responsibility ensured that our culture was supported and sustained by philanthropy. Since Thatcher/Reagan we have been living in an all for me winner takes all greed is good situation where our culture can go to the wall as far as those with the money to sustain it is concerned. So, like the road system, welfare and the health system which provides a necessary infrastructure without which the culture of greed itself could not survive, the state now needs to fill the role hollowed out by the collapse of philanthropy. Libraries are being cut back to almost nothing, and museums and galleries simply do not happen without state intervention.

    Of course we can default to your patching up of those ground down for to allow them another try at tramping their fellows down to make their little packets, but an empathic and cultured community might just be rather more worthwhile a situation to be living in.

    For the record, I’m rather more of a corduroy or tweed jacket man myself than a Mao jacket person. From what I hear even the Chinese elite have sent the Mao jackets packing. To quote a Chinese businessman from Singapore whom I know “ they are reconnecting with their ancient cultural heritage.” To paraphrase the patrol man in “ 51st State”, “the eighties are dead, man…..”

  • Wild Turkey – It’s pretty well established in blogging and Slugger that people reference and highlight reports and studies and speeches, adding their perspective. This Soapbox article fits well.

  • Korhomme

    From the Wikipedia article on Andrew Carnegie:

    “…The amassing of wealth is one of the worse species of idolatry. No idol more debasing than the worship of money.”[68] In order to avoid degrading himself, he wrote in the same memo he would retire at age 35 to pursue the practice of philanthropic giving for “…the man who dies thus rich dies disgraced.” However, he did not begin his philanthropic work in all earnest until 1881, with the gift of
    a library to his hometown of Dunfermline, Scotland.[69]

    Man does not live by bread alone. I have known millionaires starving for lack of the nutriment which alone can sustain all that is human in man, and I know workmen, and many so-called poor men, who revel in luxuries beyond the power of those millionaires to reach. It is the mind that makes the body rich. There is no class so pitiably wretched as that which possesses money and nothing else. Money can only be the useful drudge of things immeasurably higher than itself. Exalted beyond this, as it sometimes is, it remains Caliban still and still plays the beast. My aspirations take a higher flight. Mine be it to have contributed to the enlightenment and the joys of the mind, to the things of the spirit, to all that tends to bring into the lives of the toilers of Pittsburgh sweetness and light. I hold this the noblest possible use of wealth.

  • Old Mortality

    Since welfare reform had hardly got under way in NI in 2015, it’s hard to blame poverty for a higher suicide rate than the rest of the UK. I tend to think that the depressing climate and the sheer ugliness of our physical environment are possible contributing factors.

  • Suspect the services post-phone call differ across those services, particularly those funded by PHA.

  • 1729torus

    In boxing: triumphalism, swaggering, rudeness, and arrogance are punished severely eventually. Marching bands seem to encourage and feed such sentiments on the other hand.

    Incidentally, for a young person from a rough background, a boxing club is probably the safest way to learn to appreciate both that there is always someone tougher than you, and the consequences of foolishness.