As part of the Pharmacy Quality Scheme (PQS), all patient-facing staff working at the pharmacy are now required to complete training by Zero Suicide Alliance (ZSA) and contractors must have an action plan prepared or updated in case anyone reports to staff that they have suicidal feelings.
Reena Barai, a pharmacist and NPA board member, who has completed the training says it is something she wanted to do “for a long time”.
“The whole point of PQS is to improve the quality of services pharmacy offers so I think it’s absolutely right to be in there,” says Reena.
“Sometimes I have felt unequipped to have these deeper conversations with certain patients so this training has been a great help.”
Pharmacy as a lifeline
Reena runs SG Barai Pharmacy in Sutton and during the last year she believes pharmacies have become a lifeline for vulnerable people.
“We are currently the only easily accessible health care professional in the community that can be seen face to face,” says Reena.
“When it comes to something like depression, people often won’t feel comfortable talking on the phone or on a video call because it’s hard enough to admit you're struggling. Also admitting you're struggling may have connotations to other problems such as childcare so it’s really difficult.”
Reena reveals that since the pandemic began people who have been struggling with their mental health are frequently attending her pharmacy.
Data analysis by the charity Mind1 has revealed that more people have experienced a mental health crisis during the Covid-19 pandemic than ever previously recorded.
According to the Department of Health and Social Care2 in England there were already concerns about the rising rate of suicide in 2018 and 2019 and Covid-19 has actually exposed fault lines in society where risk of suicide is also found – inequalities based on deprivation, ethnicity, disability and stigma.
"Our role in social prescribing is getting much bigger"
“All sorts of problems are coming through our door,” says Reena.
“At least two or three people a day are coming in with symptoms of depression. They have social, psychological and financial issues going on and as a pharmacy we are confronting things we've never had to deal with.
“Our role in social prescribing is getting much bigger. Primary Care Networks have recognised this because they've employed social prescribers but there's a role for them in pharmacy. We are social prescribers informally and always have been, so I think that role is really growing for community pharmacy. Our teams needs to be equipped and armed to deal with that.”
Lets talk about suicide
After she and her staff, including the delivery drivers, dispensers and pre-registration pharmacists, did the training by ZSA, Reena feels confident in talking about the subject.
“All of us have always been scared to use the word suicide because you think, what if someone does this because I’ve said it?,” says Reena.
“But in the training it tells you to use the word suicide because if they're thinking about it, it’s better you say it and ask the obvious question. Doing this training course has been a massive myth buster for us.”
The issue has come close to home as Reena says she had three people in the last month coming saying “they wanted to kill themselves”.
She adds: “The training has definitely given me the confidence to tackle these conversations. I felt I asked these questions before but now I can be more assertive and ask with confidence.”
Joe Rafferty CBE, is the Chair and one of the founding members of the ZSA, alongside Steve Mallen, Chair of the MindEd Trust, Dr Geraldine Strathdee OBE, the National Clinical Director for Mental Health with NHS England, and Elaine Darbyshire, Executive Director of Estates, Governance and Communications at Mersey Care NHS Foundation Trust.
Over a million people have accessed some sort of training provided by ZSA
Joe says their mission was to make training “really easy and accessible” for people.
“The training by Zero Suicide Alliance would challenge us around the notion of zero,” says Joe.
“Some people say it's impossible to bring the number of suicides to zero but we go back and say to them ‘why do you think it's impossible? Is that because you think suicide is inevitable?’
He adds: “You stop suicide by understanding how to create safety in our communities, how to encourage people to talk and if people are in care or they're approaching their local pharmacy, pharmacists and people who work in pharmacies are then alert to these issues.
“Asking things like ‘Is everything okay?’, ‘Do you want to have a chat?’ or ‘Is there something more we need to talk about?’ These are very simple opening questions that help.”
The short course by ZSA, which is one of three modules, takes approximately 20 minutes to complete. It aims to provide the skills and confidence to help someone who may be considering suicide and focuses on breaking stigma and encouraging open conversations.
“The training requires no specialist knowledge and the beauty of it is that it’s really engaging, it’s all online and it’s all free,” says Joe.
“It’s been developed by clinical people but also by those who have a lived experience of suicide – including those who have been bereaved by suicide and those who have attempted but didn't complete it. It uses really normal situations on how to best approach someone who is struggling.”
Joe stresses that the training “won’t make you an expert in the field”.
“It’s not intended to do so. What it is intended to do is to raise your awareness and make people feel less hesitant about talking to somebody who has expressed suicidal thoughts. There is a common perception that people who talk to somebody about suicide are more likely to stimulate that suicide. Actually if you do that in a sensitive and sensible way you're much more likely to prevent that suicide.”
Joe believes community pharmacies can play a big role in tackling this issue.
“They fit the mould beautifully,” he says.
“Not only are they in every high street, they're pretty much nearby every GP practice. They're open all the time so they are truly accessible and people identify them as a trusted brand.”
In the six months prior to the pandemic, between October 2019 to March 2020, over 155,000 people accessed just the 20 minute training module. In the 11 months since the pandemic from March 2020 to February 2021 over 182,000 people did the same course.
Joe adds that since April 2020 over a million people have accessed some sort of training provided by ZSA.
“Does that mean people have been harbouring more suicidal thoughts? - I don't know,” says Joe.
“Have people been much more focused on their mental wellbeing? - for sure they have. People have really been thinking about how they keep their emotions in the right place.”
He adds: “There's clearly a demand for this. The whole purpose of generating this was to help people overcome the nervousness of reaching out for help. Sometimes people are nervous about going to the GP, or mental health services about this. They see this as a sudden big step.”
Joe says the local nature of community pharmacies makes it easier for vulnerable people to reach out.
“We think community pharmacy is often the first place people trust, one that isn't over medicalised, where there is a slightly more casual relationship.
“I'm a regular pharmacy attender and hardly ever go to my GP. One of the things we know is the sooner we can intervene with people and structure that conversation, the more likely we are to get them to a ‘recovery position’.
The critical thing in the alliance training is that it signposts people to where to go next. The longer these things run for the more chronic they are and eventually they become really difficult to deal with overtime.”
Good starting point
Dr Hayley Gorton, Senior Lecturer in Pharmacy Practice at the University of Huddersfield3 believes pharmacy staff can play an important role in suicide prevention and, with specialist training, they could achieve more.
Hayley is one of the founding members and co-chair of a new international research group known as Suicide Prevention in Primary Care. It aims to expand knowledge of suicide prevention among pharmacists and other healthcare providers.
"In our research4, everybody said they would like some training on this,” says Hayley.
“A lot of people have their stories to tell where they've had to help somebody and they've had to think on their feet while not have that backing of some training.”
She says the training from ZSA is “a really good start” to understanding the issue.
"We've known for a very long time that pharmacy is more than just medicine supply. We are not trained counsellors but we are trained in consultation skills. The Zero Suicide Alliance training allows people to have those conversations about suicide and then think about the next steps that might be a referral to another organisation or to another healthcare professional. It might be that conversation is sufficient.”
Local referral pathways
Hayley believes pharmacies should signpost vulnerable people to local groups who can help. She helped develop a pilot programme (AMPLIPHY) with Lloyds Pharmacy, which started in January 2020, for a new service that offered extra help and support to mental health patients. The scheme5 was carried out in ten community pharmacies in Greater Manchester.
“As part of the project we encouraged pharmacy staff to put together local signposting pathways. You can imagine, if there’s someone feeling really down and possibly suicidal in a pharmacy, the last thing you want for them to do is trek ten miles to a support centre. They need something in the vicinity.”
She also explains that signposting doesn’t always mean referring to a mental health support group.
“It’s not always necessarily the mental health charity you want to signpost to, but it could be the job centre or bereavement support for example,” explains Hayley.
“There might be very specific signposting to something in the local area they could use.
"We have a duty of care to everybody that comes in the pharmacy"
“I was really pleased to see the Ask for ANI codeword scheme by the Home Office making its way to pharmacies. Parallels can be drawn here and that note about referral pathways is something that we need work on.”
Supporting customers and patients who are feeling suicidal can take a toll on pharmacy staff too, says Hayley.
“We do need to make sure we have support in place in for our staff and each other. I was speaking to one of the leaders from charity Papyrus UK, which helps prevent suicides among young people. They offer a debrief service so if you've had a conversation with a patient about suicide, they can speak to you about it.
“I think we would do well to remember that. Sometimes in pharmacy we don't have debriefs about lots of things - it would be really useful and help to lessen the individual emotional load.”
Hayley, who is also the local lead for the Royal Pharmaceutical Society in Greater Manchester, is very much aware of the pressure that pharmacies are under while working throughout the pandemic, but believes her colleagues would still want to help those who are vulnerable.
“We have a duty of care to everybody that comes in the pharmacy. In my heart I believe that any member of staff in the pharmacy would have that conversation with a patient they were concerned about, regardless how busy they were.”
Going forward Hayley is working with pharmacies to understand what further training community pharmacies can take part in to better help the communities they serve.
“Do we need to go down the route of supporting the people who are bereaved by suicide? People who are bereaved are themselves at an increased risk of suicide. Its' an often missed population.
“Mental health first aid training is another route. That is a programme in itself and is quite extensive.”
She adds that for further training, pharmacists and pharmacy technicians can access the CPPE, Suicide Awareness package: www.cppe.ac.uk/programmes/l/suicide-e-01/
When it comes to referral pathways, Joe believes a discreet card referral system from the pharmacy to the GP or A&E would be ideal.
“If you were to take this discreet card into the GP for example, the receptionist there would understand what to do and will sort you out very quickly. The last thing you want to say to somebody who is potentially suicidal, 'by the way, pop up to the GP practice wait in the queue’ and have your business talked about all over the waiting room.”
Pharmacy has done “a great job over the past 10-15 years, not just being relevant to traditional dispensing, but being venues for more extended wellbeing” says Joe.
He adds: “I'm incredibly heartened and excited to understand that as part of the pharmacy quality scheme this is going to be something that they're going to be engaging with. Our whole drive in the alliance has been to create a set of tools that people find helpful and easy to use.
“We shouldn't take suicide as a thing that is inevitable; we should see it as a thing that is highly preventable and that if start to stimulate those discussions, through pharmacies, they can take actually the initiative themselves. Locally people will know the right things to do.”
For further information and to access the training click here.
2. Department of Health and Social Care: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/973935/fifth-suicide-prevention-strategy-progress-report.pdf
3. Dr Hayley Gorton research papers: https://pure.hud.ac.uk/en/persons/hayley-gorton
4. Current and potential contributions of community pharmacy teams to self-harm and suicide prevention: A qualitative interview study: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222132
5. H C Gorton, L Riste, C J Armitage, D M Ashcroft, Advancing Mental Health Provision in Pharmacy (AMPLIPHY), International Journal of Pharmacy Practice, Volume 29, Issue Supplement_1, April 2021, Pages i43–i44: https://doi.org/10.1093/ijpp/riab015.053