Summary of the impact

In 2011 there were 6,045 suicides in people aged 15 and over in the UK. Training health and social care professionals is an essential component of suicide prevention strategies across the world. The University of Manchester (UoM) has developed and evaluated a method of training health and other frontline professionals in suicide risk assessment and management skills (STORM). The STORM project, now incorporated as a social enterprise with 2 permanent members of staff, has provided training to 670 training facilitators who have subsequently trained around 230,000 workers in the UK and overseas. In the first year of trading as a social enterprise, the majority of customers of Storm CIC were NHS Trusts with an annual turnover of £250k in 2012-13.

Underpinning research

See section 3 for references 1-6. UoM researchers are given in bold.

The impact is based on research that took place at UoM from 1995, with the first major publication in 2000.

Key researchers:

• Linda Gask (Senior Lecturer, 1995-1999; Reader, 1999-2004; Professor, 2004-date)
• Louis Appleby (Professor, 1996-date)
• Richard Morriss (Senior Lecturer, 1995-2003)
• Gillian Green (Research Fellow, 2003-date; STORM Project Manager, 2004-date)

The STORM research programme incorporated a number of linked projects. The key steps were:

• We demonstrated that it is possible to significantly improve the attitudes, confidence and skills of a range of health and social care professionals (including doctors, nurses, psychological and social workers, occupational therapists, health care assistants and other allied workers) in assessing and managing people at risk of self-harm and suicide. These improvements are achieved through interactive educational methods, consisting of: brief, focussed presentation of the key knowledge required by the frontline workers; demonstration of specific tasks to be carried out; and skills to assess and manage suicide risk. This is followed by discussion, role- play and video-feedback of recorded therapist-patient interactions in small groups.
• The training has been delivered successfully in a range of health and social care settings, including mental health services, accident and emergency, primary care and the prison system (1, 2, 4, 5).
• STORM was disseminated successfully across South Lancashire by training and supervising a team of trainers (two mental health nurses and a psychologist) to deliver it locally in general practices, hospitals and community settings (2).
• Research into dissemination across the North West of England and Highland Region in Scotland identified a number of organisational barriers to the dissemination and implementation of training (4, 6). These barriers included the level and type of support provided within health and social care organisations for the delivery of skills training to employees.
• We concluded that training alone is insufficient to change the suicide rate (3). However it is a necessary component of any suicide prevention strategy, providing the essential skills for professionals both to communicate effectively with people who are in crisis and engage in redesigning services.

Extensive national and international dissemination has now taken place (see below).

References to the research

The research has received funding from the NHS in the North West and the MRC. The research has resulted in several academic outputs in highly rated journals in the field of health services research.

Details of the impact

See section 5 for corroborating sources S1-S10.

Context
Suicide is amongst the top 20 leading causes of death globally for all ages. Every year, nearly one million people die from suicide. Innovative approaches have been sought to reduce suicide rates and the provision of training for health and social care professionals and frontline workers has been a key component of national suicide prevention strategies. In designing STORM, our group at UoM built on extensive experience in the development and delivery of skills training in mental health and primary care settings.

Pathways to impact
Following publication in peer-reviewed journals and recommendation of STORM training in national guidance in 2004 (`The training has been shown to improve risk management skills in a range of staff from health care and other agencies', p. 33) (S1), requests were received from health and social care organisations for dissemination of the training reported in research publications. Initially training was supported by pump-priming funding from NHS North-West to employ one of the original trainers. With further public endorsement (`Training in the assessment and management of suicide risk can be delivered to 90% of targeted mental health professionals. The training package can improve confidence and attitudes and is well accepted', p.37) (S2), dissemination became self- funding through a network of `consultant facilitators'. The STORM team also worked with UMIP to create the relevant IP, (background IP, copyright, Registered Trade Mark). As a result of these steps to impact, STORM training is now recommended by UK Government agencies and the Royal College of Psychiatrists (S3-S5).

Reach and significance of the impact

Scope of the STORM project

• STORM uses a cascade model in which training is provided within a licensed organisation by staff trained as STORM facilitators who are supported and supervised by 15 specially-trained and experienced `consultant' trainers.
• STORM became an independent social enterprise in 2012 and currently employs two full-time staff.
• The STORM team has continued to research the impact and dissemination of STORM training, through re-investment of profit (now in excess of £1 million).
• STORM has also developed and evaluated training models and materials for different settings, including criminal justice and younger persons' services.

UK and international reach

• 160 licence agreements have been now been completed with health and social care organisations. Through the cascade model, an estimated 230,000 frontline workers have been trained by the 580 STORM Facilitators across the UK, Channel Islands, Republic of Ireland, Malta and Australia. This figure represents a conservative estimate and is based on the average number of frontline staff employed by STORM's main customers (NHS Trusts) and the number of STORM licence agreements and contracts in place. If each trained person has mitigated risk of suicide in only 2 people, this will have resulted in an impact on 460,000 people at risk of suicide and over 2.5 million people within their social networks.
• STORM is included in Scotland's Choose Life initiative to train 50% of frontline staff in suicide prevention nationally.
• Training on a non-profit basis has been provided internationally, including training general practitioners in Northern Russia in collaboration with the government of Norway, and mental health workers in Pakistan (S6), where STORM training has been effective in de-stigmatising suicidal behaviour and developing confidence in exploring hopelessness and suicidal risk.
• A 2013 collaboration with the University of Melbourne has researched the impact of STORM gatekeeper training in secondary schools across Australia as part of the Headspace suicide prevention and postvention initiative. Headspace is Australia's National Youth Mental Health Foundation and Headspace School Support has a specific brief to support Australian secondary schools around suicide prevention and postvention (support for impact of suicide on the bereaved). The STORM collaboration played a central role in its rollout. This unique collaboration led to a number of outcomes, including the development, implementation and evaluation of specifically-designed and evidence-based training programme. This programme will be delivered to school staff throughout Australia to assist in their management and support of students at risk (S7).
• STORM CIC forecasts a profit of £1m over the next 5 years which will be reinvested in the community by funding further research, development and dissemination.

Significance of STORM

• STORM was a Level 2 UnLtd `Dare to be Different' winner in 2010. STORM also won a HEFCE and UnLtd HE Social Entrepreneurship Champions of Change Recognition Award for its `Outstanding Social Impact' in 2011.
• STORM training: enables frontline health and social care staff to acquire the talking skills needed to communicate with people who are at risk of harming themselves; it promotes a more positive approach to suicide prevention; and, it provides participants with the skills to assess and mitigate risk.
• Organisations report positive and specific benefits on attitudes, skills and confidence in relation to suicide prevention. The Ballyfermot Advance Project in Dublin reports that: `Fear of working with someone who may be suicidal has been replaced with a sense of security because there is now a clear process through which people can work' (S8). Plymouth Community Healthcare comments that: `STORM has had a positive impact in the organisation in relation to our practitioners' approach to suicide ideation, individuals who have survived an attempt and also post completed suicide for both families, providing better understanding of suicide and effects, confidence in managing situations that are very difficult. The skills learnt have been transferred to other areas of practice where communication is an essential skill' (S9).
• Some organizations have made training mandatory for staff.
• The impact of STORM training reaches beyond its intended goal as a training programme. The key task and skills have been incorporated formally into treatment pathways, record keeping and the development of local risk assessment tools (S8-S10).

Sources to corroborate the impact

S1. Appleby L. National Service Framework: Five Years on. London: Department of Health; 2004.

S2. Wale S, Roe C, Butler M, Finn E, Moore K. An educational intervention for front-line mental health professionals in both the assessment and management of suicide and self-harm (Phase 1: The STORM Project). National Institute of Health Sciences Research Bulletin. 2004;2(3):36- 38. Presented at the 34th Annual Psychological Society of Ireland (PSI) 23 November 2003, Bunratty, Co Clare.

S3. NIMHE. Best Practice in Managing Risk: Principles and evidence for best practice in the assessment and management of risk in mental health services. London: Department of Health; 2007.

S4. National Patient Safety Agency: Preventing Suicide: A toolkit for mental health services. NHS, National Reporting and Learning Service, Reference 1133; 2009.

S5. Royal College of Psychiatrists. Self-harm, suicide and risk: Helping people who self-harm. London: Royal College of Psychiatrists; 2010. Report No.: CR158.

S6. Corroborating statement from Psychiatrist, Dudley and Walsall Mental Health Partnership NHS Trust and Royal College of Psychiatrists.

S7. Corroborating email from Research Fellow, Centre for Youth Mental Health, The University of Melbourne.

S8. Corroborating email from STORM Coordinator, Ballyfermot Advance Project, Dublin, Ireland.

S9. Corroborating email from Training and Development Manager, Plymouth Community Healthcare.

S10. Corroborating email from Senior Charge Nurse in Psychological Therapies, NHS Lanarkshire.