Understanding how to support GPs to deliver NICE recommended care for those who have harmed themselves

Behavioural science has been used to investigate why GPs follow or don’t follow existing guidelines from the National Institute for Health and Care Excellence (NICE) on self-harm. As a result, researchers were able to identify ways of helping GPs to follow the guidelines. NICE guidelines help health and social care professionals to prevent people becoming ill by setting out the recommended care that should be delivered.   

The first update to NICE guidelines on self-harm in 11 years is published in July 2022 and so it is important that researchers are able to identify ways of helping GPs to follow them. The research also highlights how supporting GPs to follow the guidelines could improve outcomes for people who have harmed themselves.

The research ‘Examining drivers of self-harm guideline implementation by general practitioners: A qualitative analysis using the theoretical domains framework‘ was published in The British Journal of Health Psychology, and is funded by the National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC). The Centre is a partnership between The University of Manchester and Northern Care Alliance NHS Foundation Trust.

Jessica Leather, researcher at the GM PSTRC and lead author of the study, said: “GPs play an important role in assessing and managing self-harm, and as a result, they need a range of ways to support people who have harmed themselves. Previous research has shown that some GPs weren’t aware of the guidelines. For those who were aware of the guidelines we wanted to understand what stopped them or helped them, so our interviews concentrated on this group of GPs.

“This is hugely important given the volume of people seeking help from their GPs and the recent increases in the number of people who harm themselves.

”The study involved interviewing GPs and using a theory based framework to identify the reasons that either allowed GPs to follow (enablers) or not follow (barriers) the NICE guidelines. These can be categorised into five areas (known as theoretical domains).  In total there were 5 enablers and 7 barriers (summarised under each domain below).

1. Environmental context and resources (reported by 100% of GPs) Barriers – GPs worry that following guidance is difficult due to time pressures and a lack of access to mental health referrals. The format of the guidelines makes them difficult to access.  
2. Cognitive and interpersonal skills (reported by 86% of GPs) Barriers – GPs need strategies to communicate efficiently in high-pressure consultations.Enablers – GPs are trained to be highly skilled at communicating with patients sensitively.
3. Memory, attention and decision processes (reported by 67 % of GPs)Barriers – following the guidelines can be a distraction from watching for risk cues during consultations. GPs make decisions about self-harm based on their professional experience and the patient’s underlying mental health needs.  Enablers – Online alerts can prompt GPs to engage with NICE guidelines.
4. Beliefs about capabilities (reported by 67% of GPs) Barriers – GPs have clinical uncertainty surrounding longer term care for people that self-harm, particularly patients that are waiting for or cannot access a referral. Enablers – Guidelines provide confidence and reassurance.
5. Knowledge (reported by 62% of the GPs) Enablers – GPs are trained as junior doctors to have a good understanding of mental health risk assessment, but who had further mental health education felt better equipped to respond to self-harm.

Ms Leather, continued: “Our research identifies five domains and we believe there is an opportunity to tackle these individually or together through interventions. By doing this, GPs will be better equipped to follow the new guidance when it’s published.”

After identifying the domains researchers used the Behaviour Change Wheel to identify intervention strategies that could help GPs to follow the guidelines for self-harm. For example, poor access to resources and time pressures was a common reason for not following guidelines. The Behaviour Change Wheel suggests that a useful strategy to address this would be to change the environment that GPs work in to enable them to follow the guidance.

Professor Chris Armitage, lead for Behavioural Science at the GM PSTRC, said: “This study makes important recommendations for future interventions to change GPs’ behaviour to follow national guidelines for self-harm. These could include optimising the delivery of national guidance for quick reference, further guidance about long-term management in primary care, and enhanced training to address knowledge and skill gaps.”