More than 140 000 people present to hospital after an

episode of self harm each year in England and Wales.

Improving the general hospital management of these

people is a key area in preventing suicide. Although

professional consensus has been reached on how self

harm services should be organised and delivered,

wide variations in care delivery have been reported in

two regions in England. Using a nationally

representative sample, we investigated the variation in

services and delivery of care for self harm patients in

hospitals in England

Bennewith, O.

Gunnell, D.

Hawton, K.

House, A.O.

Peters, T.J.

English

PubMed

Bennewith, O

Gunnell, D

Peters, T

Hawton, K

House, A

ORA - Oxford University Research Archive

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

Oxford University Research Archive

Olive Bennewith

David Gunnell

Tim Peters

Keith Hawton

Allan House

Crossref

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

More than 140 000 people present to hospital after an
episode of self harm each year in England and Wales.1
Improving the general hospital management of these
people is a key area in preventing suicide.2 Although
professional consensus has been reached on how self
harm services should be organised and delivered,3
wide variations in care delivery have been reported in
two regions in England.4 5 Using a nationally
representative sample, we investigated the variation in
services and delivery of care for self harm patients in
hospitals in England

Bennewith, Olive

Gunnell, David

Peters, Tim J

Hawton, Keith

House, Alan

Oxford University Research Archive (ORA)

White Rose Research Online

This is a repository copy of Variations in the hospital management of self harm in adults in 
England: observational study.
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Bennewith, O., Gunnell, D., Peters, T.J. et al. (2 more authors) (2004) Variations in the 
hospital management of self harm in adults in England: observational study. BMJ, 328 
(7448). pp. 1108-1109. ISSN 0959-8138 
https://doi.org/10.1136/bmj.328.7448.1108
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doi:10.1136/bmj.328.7448.1108 
 2004;328;1108-1109 BMJ
  
Olive Bennewith, David Gunnell, Tim Peters, Keith Hawton and Allan House 
  
 harm in adults in England: observational study
Variations in the hospital management of self
 http://bmj.com/cgi/content/full/328/7448/1108
Updated information and services can be found at: 
 These include:
Data supplement
 http://bmj.com/cgi/content/full/328/7448/1108/DC1
 "Details of sampling process"
 References
 http://bmj.com/cgi/content/full/328/7448/1108#otherarticles
1 online articles that cite this article can be accessed at: 
  
Rapid responses
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 (645 articles) Other Psychiatry •
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 Notes   
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To order reprints of this article go to: 
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 go to: BMJTo subscribe to 
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9 MacMahon S, Peto R, Curtler J, Collins R, Sorlie P, Neaton J, et al. Blood
pressure, stroke and coronary heart disease, part 1: prolonged differences
in blood pressure: prospective observational studies corrected for the
regression dilution bias. Lancet 1990;335:765-74.
10 Hostetter TH, Rennke HG, Brenner BM. The case for intrarenal
hypertension in the initiation and progression of diabetic and other
glomerulopathies. Am J Med 1982;72:375-80.
11 Williamson JR, Rowold E, Chang K, Marvel J, Tomlinson M, Sherman
WR, et al. Sex steroid dependency of diabetes-induced changes in polyol
metabolism, vascular permeability, and collagen cross-linking. Diabetes
1986;35:20-7.
12 Mathiesen ER, Rønn B, Jensen T, Storm B, Deckert T. Relationship
between blood pressure and urinary albumin excretion in development
of microalbuminuria. Diabetes 1990;39:245-9.
13 Coonrod BA, Ellis D, Becker DJ, Bunker CH, Kelsey SF, Lloyd CE, et al.
Predictors of microalbuminuria in individuals with IDDM. Pittsburgh
epidemiology of diabetes complications study. Diabetes Care
1993;16:1376-83.
14 The Microalbuminuria Collaborative Study Group. Predictors of the
development of microalbuminuria in patients with type 1 diabetes melli-
tus: a seven-year prospective study. Diabetic Med 1999;16:918-25.
15 Rossing P, Hougaard P, Parving H-H. Risk factors for development of
incipient and overt diabetic nephropathy in type 1 diabetic patients. Dia-
betes Care 2002;25:859-64.
16 The Diabetes Control and Complications Trial Research Group. The
effect of intensive treatment of diabetes on the development and
progression of long-term complications in insulin-dependent diabetes
mellitus. N Engl J Med 1993;329:977-86.
17 Wang PH, Lau J, Chalmers TC. Meta-analysis of effects of intensive
blood-glucose control on late complications of type I diabetes. Lancet
1993;341:1306-9.
18 Rossing P, Tarnow L, Nielsen FS, Boelskifte S, Brenner BM, Parving H-H.
Short stature and diabetic nephropathy. BMJ 1995;310:296-7.
19 Brenner BM, Chertow GM. Congenital oligonephropathy and the etiol-
ogy of adult hypertension and progressive renal injury. Am J Kidney Dis-
eases 1994;23:171-5.
20 Fioretto P, Steffes MW, Sutherland DER, Goetz FC, Mauer M. Reversal of
lesions of diabetic nephropathy after pancreas transplantation. N Engl J
Med 1998;339:69-75.
21 Cordonnier DJ, Pinel N, Barro C, Maynard C, Zaoui P, Halimi S, et al.
Expansion of cortical interstitium is limited by converting enzyme inhibi-
tion in type 2 diabetic patients with glomerulosclerosis. J Am Soc Nephrol
1999;10:1253-63.
22 Perkins BA, Ficociello LH, Silva KH, Finkelstein DM, Warram JH,
Krolewski AS. Regression of microalbuminuria in type 1 diabetes. N Engl
J Med 2003;348:2285-93.
(Accepted 5 March 2004)
doi 10.1136/bmj.38070.450891.FE
Variations in the hospital management of self harm in
adults in England: observational study
Olive Bennewith, David Gunnell, Tim J Peters, Keith Hawton, Allan House
More than 140 000 people present to hospital after an
episode of self harm each year in England and Wales.1
Improving the general hospital management of these
people is a key area in preventing suicide.2 Although
professional consensus has been reached on how self
harm services should be organised and delivered,3
wide variations in care delivery have been reported in
two regions in England.4 5 Using 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 (table and see
bmj.com). 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 bmj.com).3 In 2001-2 each
hospital did a prospective eight week audit of their
management of self harm (see bmj.com). Trust staff
used emergency department, medical, and mental
health records if audit data were incomplete.
A designated self harm or liaison service was avail-
able 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 bmj.com).
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 con-
tact 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% v 58%; odds ratio 0.88; 95%
confidence interval 0.56 to 1.38; P = 0.57), admissions
(42% v 52%; 0.65; 0.37 to 1.13; P = 0.13), psychiatric
admissions (10.5% v 11.4%; 0.89; 0.59 to 1.37;
P = 0.61), or arrangements for follow up (53% v 56%;
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 consider-
ably less likely to be undertaken by junior (training
grade) psychiatrists alone (22% v 75%; 0.04; 0.01 to
0.14; P < 0.01).
Comment
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
Details of the sampling process, a table, and the audit form
are on bmj.com
Papers
Department of
Social Medicine,
University of
Bristol, Bristol
BS8 2PR
Olive Bennewith
research associate
David Gunnell
professor of
epidemiology
Division of Primary
Health Care,
University of
Bristol, Bristol
BS6 6JL
Tim Peters
professor of primary
care health services
research
Centre for Suicide
Research, University
of Oxford
Department of
Psychiatry,
Warneford
Hospital, Oxford
OX3 7JX
Keith Hawton
professor of psychiatry
Academic Unit of
Psychiatry and
Behavioural
Sciences, University
of Leeds, Leeds
LS2 9LT
Allan House
professor of liaison
psychiatry
Correspondence to:
D Gunnell
D.J.Gunnell@
Bristol.ac.uk
BMJ 2004;328:1108–9
1108 BMJ VOLUME 328 8 MAY 2004 bmj.com
 on 21 October 2004 bmj.comDownloaded from 
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.3 Although
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.
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 moni-
tored 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.
Competing interests: None declared.
Multi Centre Research Ethics.
1 Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberate
self-harm in Oxford, 1985-1995: implications for clinical services and the
prevention of suicide. Br J Psychiatry 1997;171:556-60.
2 Department of Health. National suicide prevention strategy for England.
London: DoH, 2002.
3 Royal College of Psychiatrists. The general hospital management of adult self-
harm:a consensus statement on standards for service provision. London: RCoP,
1994.
4 Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E. Manage-
ment of deliberate self poisoning in adults in four teaching hospitals:
descriptive study. BMJ 1998;316:831-2.
5 Gunnell DJ, Brooks J, Peters TJ. Epidemiology and patterns of hospital
use following parasuicide in the South West. J Epidemiol Comm Health
1996;50:24-29.
(Accepted 18 November 2003)
Variation in management of self harm patients across 32 English hospitals
Hospital size (No of
acute beds 2000-1 to
nearest 100)*
Service scale
score (maximum
21)
No (%) receiving
psychosocial
assessment†‡
No (%) assessed
by senior house
officer in
psychiatry alone§
No (%) admitted to
hospital bed‡¶
No (%) admitted to a
psychiatric bed‡**
No (%) referred for
specialist mental health
follow up‡††
No of self
harm episodes
during eight
week audit
Hospitals with a designated self harm or liaison service
600 11 174 (70.7) 1 (0.6) 149 (60.6) 13 (5.3) 128 (53.1) 246
400 11 91 (57.6) 0 77 (48.7) 11 (7.0) 81 (51.3) 158
400 11 66 (62.9) 21 (33.9) 58 (55.2) 4 (3.8) 55 (52.9) 105
1000 16 130 (48.5) 36 (34.6) 116 (43.5) 25 (9.6) 132 (51.0) 268
300 14.5 37 (44.1) 3 (10.0) 35 (41.7) 7 (8.3) 54 (64.3) 84
700 13.5 80 (55.2) 13 (24.5) 62 (42.5) 26 (17.9) 88 (61.1) 146
500 14 83 (60.6) 28 (38.9) 53 (38.7) 11 (8.2) 67 (49.6) 137
1000 8.5 118 (68.6) 3 (2.8) 120 (69.8) 9 (5.3) 83 (50.0) 172
300 14 40 (48.8) 0 42 (51.2) 2 (2.5) 32 (39.5) 82
600 7.5 43 (36.4) 0 30 (25.9) 10 (8.6) 76 (66.1) 118
1000 15.5 103 (50.2) 22 (23.7) 49 (24.4) 10 (5.0) 70 (34.7) 205
700 12 124 (70.5) 34 (34.3) 153 (83.2) 16 (9.6) 77 (46.1) 184
400 11.5 39 (38.2) 8 (36.4) 35 (34.0) 16 (16.0) 51 (51.5) 103
400 8.5 46 (35.7) 12 (35.3) 52 (40.0) 12 (9.2) 58 (45.3) 130
700 17.5 104 (55.0)§§ NA 59 (31.2)§§ 29 (15.3) 95 (51.9)§§ 189
800 13.5 97 (71.9) 11 (14.5) 40 (29.9) 19 (14.5) 63 (48.8) 135
400 8 32 (41.0) 0 17 (21.8) 12 (15.4) 31 (39.7) 78
700 7 69 (51.9) ¶¶ 77 (57.5) 29 (22.7) 79 (63.2) 134
300 10.5 115 (71.9) 0 56 (35.0) 12 (7.5) 97 (61.0) 160
200 11 58 (55.8) 13 (31.0) 26 (25.0) 16 (15.4) 48 (46.2) 104
500 15.5 112 (44.8) 9 (11.1) 107 (42.5) 30 (12.1) 163 (66.5) 252
400 20 88 (65.2) 23 (32.4) 56 (41.5) 17 (12.6) 93 (68.9) 135
700 16 81 (54.7) 2 (3.0) 39 (26.4) 14 (9.5) 81 (55.4) 150
Summary: mean (range) 12.5 (7-20) 54.8% (35.7%-71.9%) 17.5% (0-38.9%) 42.2% (21.8%-83.2%) 10.5% (2.5%-22.7%) 52.9% (34.7%-68.9%) 151 (78-268)
Hospitals with no designated self harm or liaison service
200 11.5 49 (76.6) 42 (95.5) 39 (60.9) 4 (6.3) 32 (50.0) 64
300 15 34 (53.1) 26 (100) 45 (70.3) 5 (7.9) 34 (54.0) 64
400 10 32 (42.1) 18 (90.0) 35 (44.3) 12 (15.2) 38 (48.7) 79
200 10 52 (76.5) 44 (100) 22 (32.9) 8 (11.4) 44 (63.8) 70
300 7.5 36 (49.3)‡‡ 9 (33.3)‡‡ 23 (31.5)‡‡ 8 (11.3)‡‡ 41 (56.9)‡‡ 73‡‡
400 8 56 (67.5) 40 (90.9) 58 (69.1) 11 (13.3) 37 (44.6) 84
700 9.5 32 (38.1) 0 27 (32.1) 5 (6.0) 39 (47.6) 84
300 10 67 (81.7) 44 (91.7) 68 (82.9) 19 (23.8) 65 (82.3) 82
500 14 52 (36.4) ¶¶ 70 (47.6) 11 (7.7) 72 (51.8) 147
Summary: mean (range) 10.6 (7.5-15) 57.9% (36.4%-81.7%) 75.2% (0-100%) 52.4% (31.5%-82.9%) 11.4% (6.0%-23.8%) 55.5% (44.6%-82.3%) 86 (64-147)
NA=not available.
*From Department of Health Hospital Activity Statistics.
†Data missing for 26/4033 (0.6%).
‡Information on missing data not available for 189 episodes where management data were provided by the hospital from a recent in-house audit.
§Data missing for 8/1736 (0.5%); because of missing data, the data shown are for episodes where the patient was not admitted to a psychiatric bed.
¶Data missing for 10/4033 (0.3%). **Data missing for 70/4033 (1.7%). ††Data missing for 100/4033 (2.5%). ‡‡Data for this hospital are for a six week period.
§§Data provided by the hospital from a recent in-house audit. ¶¶Data not included as missing for >10% episodes.
Papers
1109BMJ VOLUME 328 8 MAY 2004 bmj.com
 on 21 October 2004 bmj.comDownloaded from 


This is a repository copy of Variations in the hospital management of self harm in adults in England: observational study.White Rose Research Online URL for this paper:http://eprints.whiterose.ac.uk/152/Article:Bennewith, O., Gunnell, D., Peters, T.J. et al. (2 more authors) (2004) Variations in the hospital management of self harm in adults in England: observational study. BMJ, 328 (7448). pp. 1108-1109. ISSN 0959-8138 https://doi.org/10.1136/bmj.328.7448.1108eprints@whiterose.ac.ukhttps://eprints.whiterose.ac.uk/Reuse See Attached Takedown If you consider content in White Rose Research Online to be in breach of UK law, please notify us by emailing eprints@whiterose.ac.uk including the URL of the record and the reason for the withdrawal request. doi:10.1136/bmj.328.7448.1108  2004;328;1108-1109 BMJ  Olive Bennewith, David Gunnell, Tim Peters, Keith Hawton and Allan House    harm in adults in England: observational studyVariations in the hospital management of self http://bmj.com/cgi/content/full/328/7448/1108Updated information and services can be found at:  These include:Data supplement http://bmj.com/cgi/content/full/328/7448/1108/DC1 "Details of sampling process" References http://bmj.com/cgi/content/full/328/7448/1108#otherarticles1 online articles that cite this article can be accessed at:   Rapid responses http://bmj.com/cgi/eletter-submit/328/7448/1108You can respond to this article at:    http://bmj.com/cgi/content/full/328/7448/1108#responsesfree at: 2 rapid responses have been posted to this article, which you can access for serviceEmail alertingbox at the top right corner of the article Receive free email alerts when new articles cite this article - sign up in theTopic collections (645 articles) Other Psychiatry • (1146 articles) Other emergency medicine •  Articles on similar topics can be found in the following collections  Notes    http://bmj.bmjjournals.com/cgi/reprintformTo order reprints of this article go to:  http://www.bmjjournals.com/subscriptions go to: BMJTo subscribe to  on 21 October 2004 bmj.comDownloaded from 9 MacMahon S, Peto R, Curtler J, Collins R, Sorlie P, Neaton J, et al. Bloodpressure, stroke and coronary heart disease, part 1: prolonged differencesin blood pressure: prospective observational studies corrected for theregression dilution bias. Lancet 1990;335:765-74.10 Hostetter TH, Rennke HG, Brenner BM. The case for intrarenalhypertension in the initiation and progression of diabetic and otherglomerulopathies. Am J Med 1982;72:375-80.11 Williamson JR, Rowold E, Chang K, Marvel J, Tomlinson M, ShermanWR, et al. Sex steroid dependency of diabetes-induced changes in polyolmetabolism, vascular permeability, and collagen cross-linking. Diabetes1986;35:20-7.12 Mathiesen ER, Rønn B, Jensen T, Storm B, Deckert T. Relationshipbetween blood pressure and urinary albumin excretion in developmentof microalbuminuria. Diabetes 1990;39:245-9.13 Coonrod BA, Ellis D, Becker DJ, Bunker CH, Kelsey SF, Lloyd CE, et al.Predictors of microalbuminuria in individuals with IDDM. Pittsburghepidemiology of diabetes complications study. Diabetes Care1993;16:1376-83.14 The Microalbuminuria Collaborative Study Group. Predictors of thedevelopment of microalbuminuria in patients with type 1 diabetes melli-tus: a seven-year prospective study. Diabetic Med 1999;16:918-25.15 Rossing P, Hougaard P, Parving H-H. Risk factors for development ofincipient and overt diabetic nephropathy in type 1 diabetic patients. Dia-betes Care 2002;25:859-64.16 The Diabetes Control and Complications Trial Research Group. Theeffect of intensive treatment of diabetes on the development andprogression of long-term complications in insulin-dependent diabetesmellitus. N Engl J Med 1993;329:977-86.17 Wang PH, Lau J, Chalmers TC. Meta-analysis of effects of intensiveblood-glucose control on late complications of type I diabetes. Lancet1993;341:1306-9.18 Rossing P, Tarnow L, Nielsen FS, Boelskifte S, Brenner BM, Parving H-H.Short stature and diabetic nephropathy. BMJ 1995;310:296-7.19 Brenner BM, Chertow GM. Congenital oligonephropathy and the etiol-ogy of adult hypertension and progressive renal injury. Am J Kidney Dis-eases 1994;23:171-5.20 Fioretto P, Steffes MW, Sutherland DER, Goetz FC, Mauer M. Reversal oflesions of diabetic nephropathy after pancreas transplantation. N Engl JMed 1998;339:69-75.21 Cordonnier DJ, Pinel N, Barro C, Maynard C, Zaoui P, Halimi S, et al.Expansion of cortical interstitium is limited by converting enzyme inhibi-tion in type 2 diabetic patients with glomerulosclerosis. J Am Soc Nephrol1999;10:1253-63.22 Perkins BA, Ficociello LH, Silva KH, Finkelstein DM, Warram JH,Krolewski AS. Regression of microalbuminuria in type 1 diabetes. N EnglJ Med 2003;348:2285-93.(Accepted 5 March 2004)doi 10.1136/bmj.38070.450891.FEVariations in the hospital management of self harm inadults in England: observational studyOlive Bennewith, David Gunnell, Tim J Peters, Keith Hawton, Allan HouseMore than 140 000 people present to hospital after anepisode of self harm each year in England and Wales.1Improving the general hospital management of thesepeople is a key area in preventing suicide.2 Althoughprofessional consensus has been reached on how selfharm services should be organised and delivered,3wide variations in care delivery have been reported intwo regions in England.4 5 Using a nationallyrepresentative sample, we investigated the variation inservices and delivery of care for self harm patients inhospitals in England.Participants, methods, and resultsWe selected a stratified random sample of 32 hospitals,four from each former health region (table and seebmj.com). At each hospital we interviewed two to fivekey emergency and psychiatric staff about hospitalservice structures and made arrangements with themto start audits of the processes of care. We assessedeach hospital on 21 recommended self harm servicestandards (see table A on bmj.com).3 In 2001-2 eachhospital did a prospective eight week audit of theirmanagement of self harm (see bmj.com). Trust staffused emergency department, medical, and mentalhealth records if audit data were incomplete.A designated self harm or liaison service was avail-able at 23 of the 32 hospitals. At 11 hospitals, morethan half of the 21 recommended service structureswere not in place (median score 12; range 7 to 20). Themost commonly available aspects of service wereguidelines for medical management (at 31 hospitals)and 24 hour access to specialist psychosocialassessments (at 30 hospitals) (see table A on bmj.com).Guidelines for assessing the risk of suicide for useby staff in emergency departments were available at 17hospitals. Only 14 hospitals had self harm serviceplanning meetings with mental health services,emergency department, or medical staff. Routine con-tact with patients’ general practitioners within 24 hoursof discharge from emergency departments happenedat only half of the hospitals. Service scale scores wereweakly associated with hospital size (rank correlation0.20, P = 0.28).During the eight week audit, staff identified 4222episodes of self harm. Hospitals varied widely in theproportion of attendances leading to a psychosocialassessment (median 55%; range 36% to 82%), hospitaladmission (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 ofassessments (55% v 58%; odds ratio 0.88; 95%confidence interval 0.56 to 1.38; P = 0.57), admissions(42% v 52%; 0.65; 0.37 to 1.13; P = 0.13), psychiatricadmissions (10.5% v 11.4%; 0.89; 0.59 to 1.37;P = 0.61), or arrangements for follow up (53% v 56%;0.91; 0.66 to 1.25, P = 0.54) between hospitals with andwithout a designated service. However, at hospitalswith a designated service, assessments were consider-ably less likely to be undertaken by junior (traininggrade) psychiatrists alone (22% v 75%; 0.04; 0.01 to0.14; P < 0.01).CommentVariability in organisation and provision of services forpatients with self harm was striking. There was twofoldvariation across hospitals in levels of psychosocialassessment, fourfold variation in the proportion ofDetails of the sampling process, a table, and the audit formare on bmj.comPapersDepartment ofSocial Medicine,University ofBristol, BristolBS8 2PROlive Bennewithresearch associateDavid Gunnellprofessor ofepidemiologyDivision of PrimaryHealth Care,University ofBristol, BristolBS6 6JLTim Petersprofessor of primarycare health servicesresearchCentre for SuicideResearch, Universityof OxfordDepartment ofPsychiatry,WarnefordHospital, OxfordOX3 7JXKeith Hawtonprofessor of psychiatryAcademic Unit ofPsychiatry andBehaviouralSciences, Universityof Leeds, LeedsLS2 9LTAllan Houseprofessor of liaisonpsychiatryCorrespondence to:D GunnellD.J.Gunnell@Bristol.ac.ukBMJ 2004;328:1108–91108 BMJ VOLUME 328 8 MAY 2004 bmj.com on 21 October 2004 bmj.comDownloaded from attendances leading to admission to a hospital bed, and10-fold variation in the proportion admitted to apsychiatric bed, although for the latter we were unableto determine how many were readmissions of patientswho had self harmed while already psychiatricinpatients.There were wide variations in the implementationof the recommended service structures.3 Althoughmost hospitals had a designated self harm or liaisonservice, interdisciplinary working and service planningwere less common. Future research should examinethe relationships between the patient managementand service structures described here and indicators ofoutcome such as repetition and suicide.We thank Nav Kapur for his advice on the setting up andrunning of the audits and Andrew Newton, Jeremy Hyde, andAnthony Harrison for their help in piloting the interview andaudit form. Emily Bennewith helped enter audit data. We alsothank hospital and mental health service staff in the 32 hospitalsfor their participation in the interviews and help in running theaudits.Contributors: DG, TJP, AH, and KH initiated the study. All theauthors contributed to the design of the study. OB recruitedand visited the hospitals, interviewed staff, facilitated and moni-tored the audits. OB, DG, and TJP analysed the data. All theauthors contributed to and edited the paper. DG and OB areguarantors.Funding: South West NHS R&D.Competing interests: None declared.Multi Centre Research Ethics.1 Hawton K, Fagg J, Simkin S, Bale E, Bond A. Trends in deliberateself-harm in Oxford, 1985-1995: implications for clinical services and theprevention of suicide. Br J Psychiatry 1997;171:556-60.2 Department of Health. National suicide prevention strategy for England.London: DoH, 2002.3 Royal College of Psychiatrists. The general hospital management of adult self-harm:a consensus statement on standards for service provision. London: RCoP,1994.4 Kapur N, House A, Creed F, Feldman E, Friedman T, Guthrie E. Manage-ment of deliberate self poisoning in adults in four teaching hospitals:descriptive study. BMJ 1998;316:831-2.5 Gunnell DJ, Brooks J, Peters TJ. Epidemiology and patterns of hospitaluse following parasuicide in the South West. J Epidemiol Comm Health1996;50:24-29.(Accepted 18 November 2003)Variation in management of self harm patients across 32 English hospitalsHospital size (No ofacute beds 2000-1 tonearest 100)*Service scalescore (maximum21)No (%) receivingpsychosocialassessment†‡No (%) assessedby senior houseofficer inpsychiatry alone§No (%) admitted tohospital bed‡¶No (%) admitted to apsychiatric bed‡**No (%) referred forspecialist mental healthfollow up‡††No of selfharm episodesduring eightweek auditHospitals with a designated self harm or liaison service600 11 174 (70.7) 1 (0.6) 149 (60.6) 13 (5.3) 128 (53.1) 246400 11 91 (57.6) 0 77 (48.7) 11 (7.0) 81 (51.3) 158400 11 66 (62.9) 21 (33.9) 58 (55.2) 4 (3.8) 55 (52.9) 1051000 16 130 (48.5) 36 (34.6) 116 (43.5) 25 (9.6) 132 (51.0) 268300 14.5 37 (44.1) 3 (10.0) 35 (41.7) 7 (8.3) 54 (64.3) 84700 13.5 80 (55.2) 13 (24.5) 62 (42.5) 26 (17.9) 88 (61.1) 146500 14 83 (60.6) 28 (38.9) 53 (38.7) 11 (8.2) 67 (49.6) 1371000 8.5 118 (68.6) 3 (2.8) 120 (69.8) 9 (5.3) 83 (50.0) 172300 14 40 (48.8) 0 42 (51.2) 2 (2.5) 32 (39.5) 82600 7.5 43 (36.4) 0 30 (25.9) 10 (8.6) 76 (66.1) 1181000 15.5 103 (50.2) 22 (23.7) 49 (24.4) 10 (5.0) 70 (34.7) 205700 12 124 (70.5) 34 (34.3) 153 (83.2) 16 (9.6) 77 (46.1) 184400 11.5 39 (38.2) 8 (36.4) 35 (34.0) 16 (16.0) 51 (51.5) 103400 8.5 46 (35.7) 12 (35.3) 52 (40.0) 12 (9.2) 58 (45.3) 130700 17.5 104 (55.0)§§ NA 59 (31.2)§§ 29 (15.3) 95 (51.9)§§ 189800 13.5 97 (71.9) 11 (14.5) 40 (29.9) 19 (14.5) 63 (48.8) 135400 8 32 (41.0) 0 17 (21.8) 12 (15.4) 31 (39.7) 78700 7 69 (51.9) ¶¶ 77 (57.5) 29 (22.7) 79 (63.2) 134300 10.5 115 (71.9) 0 56 (35.0) 12 (7.5) 97 (61.0) 160200 11 58 (55.8) 13 (31.0) 26 (25.0) 16 (15.4) 48 (46.2) 104500 15.5 112 (44.8) 9 (11.1) 107 (42.5) 30 (12.1) 163 (66.5) 252400 20 88 (65.2) 23 (32.4) 56 (41.5) 17 (12.6) 93 (68.9) 135700 16 81 (54.7) 2 (3.0) 39 (26.4) 14 (9.5) 81 (55.4) 150Summary: mean (range) 12.5 (7-20) 54.8% (35.7%-71.9%) 17.5% (0-38.9%) 42.2% (21.8%-83.2%) 10.5% (2.5%-22.7%) 52.9% (34.7%-68.9%) 151 (78-268)Hospitals with no designated self harm or liaison service200 11.5 49 (76.6) 42 (95.5) 39 (60.9) 4 (6.3) 32 (50.0) 64300 15 34 (53.1) 26 (100) 45 (70.3) 5 (7.9) 34 (54.0) 64400 10 32 (42.1) 18 (90.0) 35 (44.3) 12 (15.2) 38 (48.7) 79200 10 52 (76.5) 44 (100) 22 (32.9) 8 (11.4) 44 (63.8) 70300 7.5 36 (49.3)‡‡ 9 (33.3)‡‡ 23 (31.5)‡‡ 8 (11.3)‡‡ 41 (56.9)‡‡ 73‡‡400 8 56 (67.5) 40 (90.9) 58 (69.1) 11 (13.3) 37 (44.6) 84700 9.5 32 (38.1) 0 27 (32.1) 5 (6.0) 39 (47.6) 84300 10 67 (81.7) 44 (91.7) 68 (82.9) 19 (23.8) 65 (82.3) 82500 14 52 (36.4) ¶¶ 70 (47.6) 11 (7.7) 72 (51.8) 147Summary: mean (range) 10.6 (7.5-15) 57.9% (36.4%-81.7%) 75.2% (0-100%) 52.4% (31.5%-82.9%) 11.4% (6.0%-23.8%) 55.5% (44.6%-82.3%) 86 (64-147)NA=not available.*From Department of Health Hospital Activity Statistics.†Data missing for 26/4033 (0.6%).‡Information on missing data not available for 189 episodes where management data were provided by the hospital from a recent in-house audit.§Data missing for 8/1736 (0.5%); because of missing data, the data shown are for episodes where the patient was not admitted to a psychiatric bed.¶Data missing for 10/4033 (0.3%). **Data missing for 70/4033 (1.7%). ††Data missing for 100/4033 (2.5%). ‡‡Data for this hospital are for a six week period.§§Data provided by the hospital from a recent in-house audit. ¶¶Data not included as missing for >10% episodes.Papers1109BMJ VOLUME 328 8 MAY 2004 bmj.com on 21 October 2004 bmj.comDownloaded from 

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

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