Communication between secondary and primary care following self-harm: are National Institute of Clinical Excellence (NICE) guidelines being met?

General Practitioners (GPs) are pivotal in the management of patients who self-harm. A recent review [1] suggested that one strategy that helps GPs manage these patients is efficiency of communication between secondary and primary care. Most patients who present to the Emergency Department (ED) with self-harm consult their GP soon afterwards [2, 3]. Many of these patients present with physical complaints, which may disguise an underlying risk of psychological problems [4]. At first point of contact after an episode of self-harm, the patient may be unknown to the GP. Prior knowledge of this history should assist in their assessment, yet less than half (41%) of GPs receive a discharge summary [5].

Clinical practice guidelines are systematically-developed statements that aim to assist physicians in supplying the appropriate health care for specific clinical circumstances [6]. Government guidelines in the UK provide recommendations for practice based on the best available evidence. One such guideline on the short-term management of self-harm patients in secondary care recommends that all patients presenting with self-harm should receive a psychosocial needs assessment including social, psychological and motivational factors, and mood and risk [7]. This information should be passed on to GP 'as soon as possible'. Mental capacity and evidence of mental illness should be communicated to GPs if patients leave before a specialist assessment. The guidelines endorse the Royal College of Psychiatrists' (RCP) recommendations [8] on the content of these communications. However, implementation of National Institute of Clinical Excellence (NICE) guidelines has been variable [9].

In light of developments in national policies and further research, the Royal College of Psychiatrists produced a revision of their earlier document [10] on a consensus of standards for assessment following self-harm. Several standard competencies (for non-specialist staff and specialist staff) were recommended [8]: psychosocial assessments should ideally be carried out by specialist staff; medical staff may undertake assessments if trained for the task; where a patient is not admitted or assessed by a specialist, ED staff should record information according to the recommended list below, which should be passed onto the GP; there should be a policy for referral to specialists for patients admitted to general medical wards; and information from assessments should be passed on to the GP (by fax) within 24 hrs and written communication within 3 working days. The recommended patient information to be obtained before discharge following self-harm included specific arrangements for any follow-up if not referred on for specialist opinion.

The aims of the present study were to assess the standard of documentation and communication after presentation to an ED in the northwest of England with self-harm of patients aged 16 years and over, based on national guidelines. Our objectives were to assess: the proportion of self-harm cases that were discharged from EDs that were notified to primary care services; the content and nature of communications from EDs to primary care services about such patients; the proportion of self-harm cases that were assessed by psychiatric services that were notified to primary care services; the content and nature of communications from psychiatric services to primary care services about such patients; and the timing of communication between EDs/psychiatric services to primary care services.

This was a prospective case note study using ED/medical/mental health records in a general teaching hospital in the northwest of England, UK. All episodes of self-harm of patients 16 years and over between 18 January and 14 February 2006 were identified using information from a monitoring database of self-harm known as the Manchester Self-Harm (MaSH) project [12]. We completed a proforma on all episodes. The proforma was based on criterion derived from NICE guidelines and RCP recommendations.

Nearly all self-harm episodes at the study hospital were either seen by specialist psychiatric staff, or a member of the SAFE team would write to the patients' GP, if registered, using information available from ED records. However, for those individuals not seen and assessed by specialist staff this information was limited. Communication with the patient's GP was not made in half of those cases seen by a mental health specialist. We suggest that psychiatric services (particularly doctors as they appear to assess proportionately more patients) need to improve the rate of communication to the patient's GP following assessment.

Although the SAFE team provide a liaison or "add-on communication service" for those not seen by a specialist, they cannot compensate for the lack of information recorded by ED staff. Reliance on communication by ED staff would leave a substantial proportion of patients discharged from the ED with no or minimal communication to primary care. A national sample of NHS trusts would establish if this is a problem elsewhere. EDs must have procedures in place to aid communication between the psychiatric service and primary care if discharge directly from the ED. We suggest that ED staff protocol might include completion of an initial psychosocial assessment using a proforma designed for the task, which could be forwarded directly to primary care.

Due to increased specialization of service provision and subsequent criteria for meeting inclusion, patients remain liable to fall between service boundaries. This leaves an important role for GPs. External validity of the study is limited to EDs in urban areas with similar service provision and variability in organisations and provision of service for this group has been reported in the UK [13]. The study demonstrates that even with a bespoke self-harm service these patients can fall between service provisions. This emphasises the role of ED staff in the subsequent psychosocial management of self-harm patients.