Intended for healthcare professionals


Variations in the hospital management of self harm in adults in England: observational study

BMJ 2004; 328 doi: (Published 06 May 2004) Cite this as: BMJ 2004;328:1108
  1. Olive Bennewith, research associate1,
  2. David Gunnell, professor of epidemiology (D.J.Gunnell{at},
  3. Tim Peters, professor of primary care health services research2,
  4. Keith Hawton, professor of psychiatry3,
  5. Allan House, professor of liaison psychiatry4
  1. 1Department of Social Medicine, University of Bristol, Bristol BS8 2PR
  2. 2Division of Primary Health Care, University of Bristol, Bristol BS6 6JL
  3. 3Centre for Suicide Research, University of Oxford Department of Psychiatry, Warneford Hospital, Oxford OX3 7JX
  4. 4Academic Unit of Psychiatry and Behavioural Sciences, University of Leeds, Leeds LS2 9LT
  1. Correspondence to: D Gunnell
  • Accepted 18 November 2003


More than 140 000 people present to hospital after an episode of self harm each year in England and Wales.1Improving the general hospital management of these people is a key area in preventing suicide.2Although professional consensus has been reached on how self harm services should be organised and delivered,3wide variations in care delivery have been reported in two regions in England.45Using a nationally representative sample, we investigated the variation in services and delivery of care for self harm patients in hospitals in England.

Participants, methods, and results

We selected a stratified random sample of 32 hospitals, four from each former health region (see At each hospital we interviewed two to five key emergency and psychiatric staff about hospital service structures and made arrangements with them to start audits of the processes of care. We assessed each hospital on 21 recommended self harm service standards (see table A on 2001-2 each hospital did a prospective eight week audit of their management of self harm (see Trust staff used emergency department, medical, and mental health records if audit data were incomplete.

Variation in management of self harm patients across 32 English hospitals

View this table:

A designated self harm or liaison service was available at 23 of the 32 hospitals. At 11 hospitals, more than half of the 21 recommended service structures were not in place (median score 12; range 7 to 20). The most commonly available aspects of service were guidelines for medical management (at 31 hospitals) and 24 hour access to specialist psychosocial assessments (at 30 hospitals) (see table A on

Guidelines for assessing the risk of suicide for use by staff in emergency departments were available at 17 hospitals. Only 14 hospitals had self harm service planning meetings with mental health services, emergency department, or medical staff. Routine contact with patients' general practitioners within 24 hours of discharge from emergency departments happened at only half of the hospitals. Service scale scores were weakly associated with hospital size (rank correlation 0.20, P = 0.28).

During the eight week audit, staff identified 4222 episodes of self harm. Hospitals varied widely in the proportion of attendances leading to a psychosocial assessment (median 55%; range 36% to 82%), hospital admission (42%; 22% to 83%), psychiatric admission (9.5%; 2.5% to 23.8%), and mental health follow up (51%; 35% to 82%). Using metaregression techniques, we found no significant difference in the proportion of assessments (55% v58%; odds ratio 0.88; 95% confidence interval 0.56 to 1.38; P = 0.57), admissions (42% v52%; 0.65; 0.37 to 1.13; P = 0.13), psychiatric admissions (10.5% v11.4%; 0.89; 0.59 to 1.37; P = 0.61), or arrangements for follow up (53% v56%; 0.91; 0.66 to 1.25, P = 0.54) between hospitals with and without a designated service. However, at hospitals with a designated service, assessments were considerably less likely to be undertaken by junior (training grade) psychiatrists alone (22% v75%; 0.04; 0.01 to 0.14; P < 0.01).


Variability in organisation and provision of services for patients with self harm was striking. There was twofold variation across hospitals in levels of psychosocial assessment, fourfold variation in the proportion of attendances leading to admission to a hospital bed, and 10-fold variation in the proportion admitted to a psychiatric bed, although for the latter we were unable to determine how many were readmissions of patients who had self harmed while already psychiatric inpatients.

There were wide variations in the implementation of the recommended service structures.3Although most hospitals had a designated self harm or liaison service, interdisciplinary working and service planning were less common. Future research should examine the relationships between the patient management and service structures described here and indicators of outcome such as repetition and suicide.

Embedded ImageDetails of the sampling process, a table, and the audit form are on


We thank Nav Kapur for his advice on the setting up and running of the audits and Andrew Newton, Jeremy Hyde, and Anthony Harrison for their help in piloting the interview and audit form. Emily Bennewith helped enter audit data. We also thank hospital and mental health service staff in the 32 hospitals for their participation in the interviews and help in running the audits.


  • Contributors DG, TJP, AH, and KH initiated the study. All the authors contributed to the design of the study. OB recruited and visited the hospitals, interviewed staff, facilitated and monitored the audits. OB, DG, and TJP analysed the data. All the authors contributed to and edited the paper. DG and OB are guarantors

  • Funding South West NHS R&D.

  • Conflict of interest None.

  • Ethical approval Multi Centre Research Ethics.