Mental Health & Emotional Wellbeing

Good mental health and wellbeing are fundamental for a happy and healthy life. Mental health problems can significantly affect any individual, their family, the community and the wider society. In the UK, half of life-long mental health problems start before the age of 14. Three quarters of cases start before the age of 25. Today’s children are exhibit worse mental health outcomes compared to previous generations (Source: State of Child Health). The Covid-19 pandemic is likely to have exacerbated the mental health needs of many. Before the pandemic, the prevalence of a mental condition in children aged 5 to 16 was already increasing from 1 in 9 (2017) to 1 in 6 (2020). Additional anxieties have been caused by lockdowns, school closures, isolation from peers, bereavement, and the stresses on families. Nationally, frontline mental health services report large increases in children needing help, but who are denied as they do not meet referral criteria for specialist CAMHS intervention. This potentially stores up problems in the future. Demand modelling suggests 1.5 million children may need initial or additional mental health support as a result of the pandemic (Source: NHS Confederation ‘Reaching the tipping point’).  

For adults, one in four will experience a mental health problem in any year. Together with substance misuse, mental illness accounts for 21.3% of the total morbidity burden in England (Source: Health Matters). 

To understand how we can best support people to maximise their mental health and wellbeing it is helpful to think about mental wellbeing and mental health as two separate (but related) things. 

• Mental (or emotional) wellbeing is about our thoughts and feelings, and our ability to cope with the ups and downs of everyday life. Long periods of poor mental wellbeing can lead to the development of diagnosable mental health conditions (such as anxiety or depression). 
• Mental health refers more specifically to the presence or absence of certain indications or symptoms that can develop into a mental illness. 

People living with diagnosable mental ill health, for example depression, bipolar disorder or schizophrenia, can be living in good mental wellbeing despite their mental ill health diagnosis. Mental ill health is an umbrella term for many different conditions that include, depression, anxiety, eating disorders, and post-traumatic stress disorder. The phrase severe mental illness (SMI) refers to psychological conditions that people find so debilitating, their ability to engage in functional and occupational activities is severely impaired. Schizophrenia and bipolar disorder are often categorized as SMI. 

Understanding risks and protective factors for mental health conditions help target prevention activity to support those affected. The risks and protective factors are well documented. They include: childhood abuse, trauma, or neglect; social isolation; loneliness; experiencing discrimination and stigma; social disadvantage; poverty; debt; bereavement; severe or long-term stress; having a long-term physical health condition; unemployment; losing a job; homelessness or poor housing; being a long-term carer for someone; drug and alcohol misuse; domestic violence; bullying or other abuse as an adult; significant trauma as an adult – such as military combat; being involved in a serious incident in which you feared for your life; or being the victim of a violent crime (Source: Health Matters). There are interrelationships between many of these with ethnicity, age, and gender. 

“Feeling lonely can also have a negative impact on your mental health, especially if these feelings have lasted a long time. Some research suggests that loneliness is associated with an increased risk of certain mental health problems, including depression, anxiety, low self-esteem, sleep problems and increased stress.” (Source: Mind). It is cruel that mental illness can increase the risk of loneliness with presentation of low mood, exhaustion, and anxiety – all of which can lead to people withholding themselves from participating in society. 

With these risk and protective factors in mind, groups at high risk of mental ill health include (Source: Mental Health and Wellbeing JSNA toolkit): 

• Black and minority ethnic groups 
• People living with physical disabilities 
• People living with learning disabilities 
• People with alcohol and/or drug dependence 
• Victims of crime, offenders of crime and the prison population 
• Lesbian, gay, bisexual and transgender (LGBTQ++) people 
• Carers 
• People with sensory impairment 
• Homeless people 
• Refugees, asylum seekers and stateless persons 

The burden of physical ill health is higher in people with severe mental illness (SMI). This burden affects both quality of life and mortality. As an example, amongst those with SMI, it is estimated that two-thirds of deaths are due to physical illnesses such as cardiovascular disease. Deaths that can be prevented. Compared to the general population, adults with SMI aged 15-74 years are 1.8 times more likely to be classified as obese; 1.9 times more likely to have diabetes; 2.1 times more likely to have chronic obstructive pulmonary disease; and 1.6 times more likely to suffer a stroke (Source: Health Matters). 

Suicide is a significant cause of death amongst people with mental illness. Suicide devastates families and communities. Suicide, and injury or poisoning of undetermined intent, is the second biggest killer of males aged 35 to 49 years (after accidental poisoning). Suicide is the leading cause of death for males and females aged 20 to 34 years in the UK (ONS, 2020). The causes of suicide are complicated and for the majority of people a death by suicide is the result of the ultimate loss of hope and purpose in life. The relationship between suicide and mental ill health is well established, but many suicides happen impulsively, in moments of crisis, when a breakdown in the ability to deal with any of life’s stresses; financial problems; relationship break-up; chronic pain; or illness. 

• The NHS Long Term Plan  makes a renewed commitment to improve and widen access to mental health care and sets out plans to improve how the NHS treats people with severe mental illness, including during crisis. 
• The Care Act sets out the duty for local authorities and their partners to promote wellbeing including mental health and emotional wellbeing; 
• Core20PLUS5 is the NHS England and NHS Improvement approach to reducing health inequalities. There is a clinical focus on ensuring annual health checks for 60% of those living with severe mental illness. 
• No Health Without Mental Health sets out six objectives to improve mental health, wellbeing, and outcomes for people with mental health problems. 
• The Suicide Prevention Strategy for England (2012) is enhanced at a local level by the Lincolnshire Suicide Prevention Strategy.  
• The Prevention Concordat for Better Mental Health promotes evidence-based planning and commissioning to improve mental health and wellbeing and reduce inequalities. 
• The Mental Health Crisis Care Concordat is an agreement between services involved in the care and support of people in crisis, detailing how they will “work together better to make sure that people get the help they need when they are having a mental health crisis”. 
• The Government is developing a national mental health plan, and in spring 2022 completed a call for evidence. The plan will set out a vision for mental health in 2035. Publication is expected 2023. 
• National Institute for Health and Care Excellence (NICE) has produced guidance and quality standards for Mental Health and Wellbeing, including for specific settings (e.g. workplaces) and population subgroups (e.g. adults in contact with the criminal justice system). 

The number of new referrals to specialist mental health services in Lincolnshire was higher than national average in all age groups in 2019/20 (the most recent year for which data is available). We know that rates of referrals have been impacted by the Covid-19 pandemic, and in Lincolnshire we have seen significant increases in the number of referrals in the last two years. The rate of attended contacts (non-inpatient) with secondary mental health services is also higher than England, for all ages except people aged 65 and over (where the rate is below England average).  

Children and Young People 

The ‘Mental Health of CYP in England, 2021’ used surveys completed with parents, children and young people to assess different aspects of mental health, including problems with emotions, behaviour, relationships, and hyperactivity. Responses are used to estimate the likelihood that a child might have a mental disorder, classified as either ‘unlikely’, ‘possible’ or ‘probable’. For further information on methodology please see the Survey Design and Methods Report. 

Rates of probable mental disorders have increased since 2017 from 1 in 9 (2017) to 1 in 6 (2020) children. For children aged 6-16 years in Lincolnshire, an estimated 17.4% are likely to have a probable mental disorder and a further 11.1% are likely to have a possible mental disorder. (Source: NHS Digital ‘Mental Health of CYP in England, 2021’).  

In Lincolnshire, data suggests: 

• More boys are likely to present with a probable mental health disorder than girls in younger age groups. Conversely, more young women are likely to present with a probable mental health disorder than young men in older age groups. 
• 1 in 7 children aged 11-16 years and almost 3 in 5 young people aged 17-19 years have possible eating problems. 
• Problems getting to sleep, waking in the night, or waking early on three or more nights in the previous week, are common, and increase with age. This affects more than 1 in 4 children aged 6-10 years, almost 2 in 5 aged 11-16 years, and nearly 3 in 5 aged 17-23 years. 
• 1 in 20 children aged 11-16 years, and more than 1 in 10 aged 17-23 years, are likely to ‘often’ or ‘always’ feel lonely. 
• More than half of children with a special educational need or disability (SEND) are likely to have a probable mental disorder (based on 2022 SEND returns). 

(Source: NHS Digital ‘Mental Health of CYP in England, 2021’) 

The number of contacts with community and outpatient mental health services, attended by a child, is higher in Lincolnshire than the East Midlands regional rate, but lower than the England average. The rate of new referrals to secondary mental health services for children in Lincolnshire is higher than the East Midlands rate but below the England average (Source: OHID CYP’s Mental Health and Wellbeing). 

Lincolnshire has lower rates of children needing mental health inpatient care. Inpatient stays in secondary mental health services are lower than both the East Midlands and the England average (Source: OHID CYP’s Mental Health and Wellbeing). 

During the pandemic, local services received an increase in referrals leading to staffing capacity become an issue. Waiting times from assessment to first treatment remain a concern, particularly for interventions such as specialist eating disorder services. 

Across Lincolnshire, there are a very small number of children that die by suicide each year. In most of the past ten years, there has been none, or only a single completed suicide recorded, each year, for under-17-year-olds. Between early 2021 and 2022, six suspected/confirmed child suicides were reported. A thematic review has been completed to gain learning from these sad deaths. 

Adults (including working age and older adults) 

Mental wellbeing is difficult to capture and is poorly measured at a local level. Nationally, wellbeing is measured through estimates of life satisfaction – reporting on feelings that activities are worthwhile, on happiness and anxiety. Most recent data suggests that during the Covid-19 pandemic, males and females exhibited increased anxiety with a reduction in life satisfaction scores (ONS, 2022). Data reveal that, for all people, happiness scores have returned to pre-pandemic levels, but for women life satisfaction remains below levels recorded in 2019. In Lincolnshire; almost 1 in 4 people report a high anxiety score, similar to the national average; while 6.2% report a low happiness score, which is better than the England average (Source: Public Mental Health Dashboard). 

Lincolnshire fares better than England as a whole for some adult mental ill health risk factors. For example: figures for 16-17 years olds not in education, employment or training is lower for Lincolnshire (and trending down); as are figures for first time entrants to the youth justice service. Conversely, hospital admissions for alcohol-related conditions is trending upwards, as is the rate of statutory homelessness; both are significant risk factors for poor mental health (OHID, 2022). Social isolation and loneliness are significant risk factors for mental health and wellbeing. The proportion of citizens who are over 65 is high in Lincolnshire, and this is projected to increase. Consequently, prevalence of dementia, and other age-related conditions, are likely to present an increasing challenge.

The estimated prevalence of common mental disorders among people aged 16 years and older in Lincolnshire is 15.8%; among adults aged 65 and older the prevalence is 10.2% (OHID, 2022). Both rates are comparable to the East Midlands and England average. Mental illness in Lincolnshire shows an increasing trend, particularly for disorders such as depression. This 5 year trend was likely exacerbated by the Covid-19 pandemic from 2020-22. The trend for depression is expected to continue to increase by up to 40% amongst people aged 65 years and older (POPPI, 2022). 

The Lincolnshire adult inpatient admission rate for specialist mental health services is similar to the England rate (Source: Public Mental Health Dashboard). Emergency hospital admissions rates, for Intentional Self-Harm are, lower than the England average, but trending upward. Hospital admissions for mental and behavioural disorders due to the use of alcohol are significantly lower than national average with a horizontal trend (OHID, 2022). 

Demand for Adult Social Care for people with a Primary Support Reason (PSR) of Mental Illness is increasing. Local Residential Admissions data (part of our Section 75 Agreement) for 2021-22 shows that about 60% of residential admissions, for working age adults with mental illness, have previously been a mental health inpatient (lifetime); and over 40% have been discharged from inpatient care within the last 12 months. Lincolnshire has a higher than average proportion of adults with mental illness accommodated in Residential or Nursing Care (Source: Adult Social Care Outcomes Framework 2022). This is partly attributed to a deficit in alternatives such as community-based accommodation for people with Mental Illness, particularly for those with complex needs.

Outcomes for people with SMI in Lincolnshire are generally worse than in England overall, for example; premature mortality among people with SMI is higher in Lincolnshire. Adults in contact with secondary mental health services in Lincolnshire are also less likely to live in stable and appropriate accommodation.  

The rate of suicide deaths in Lincolnshire is significantly higher than the national average; for the most recent data reported, Lincoln showed the highest rate of suicide in the country. Four in five of suicides in Lincolnshire are men, with rates generally higher among older middle-aged men, however there are year-by-year fluctuations. In recent years, the suicide rate in the most deprived decile has been between 2.5 and 3 times higher than the least deprived decile – reflecting existence of clear inequalities across Lincolnshire. Read more in the Lincolnshire Suicide Audit. 

Attending to issues of Mental Health in Lincolnshire is a priority of the Joint Health and Wellbeing Strategy (JHWS) – approved by the Health and Wellbeing Board in June 2018. 

The Mental Health, Learning Disability and Autism (MHLDA) Alliance in Lincolnshire lead a multi-agency collaboration to improve mental health and wellbeing across Lincolnshire. The broad membership of the MHLDA includes Lincolnshire Partnership Foundation Trust (LPFT), Lincolnshire County Council (LCC), Lincolnshire Integrated Care Board (ICB), the Voluntary and Community Sector, District Councils, and the Office of the Police and Crime Commissioner. Adopting an overarching, all-age, prevention and early intervention approach, priorities are achieved by: 

• Mental health promotion and developing an MHLDA inclusive society 
• Improving access to community-based services (reducing the need for specialist services) 
• Minimising in-patient, and residential care placements, especially to ‘out of county’ 
• Suicide Prevention 
• Delivering an MHLDA-informed workforce 

Children and Young People  

LPFT is the lead provider for outstanding (CQC 2020) children’s mental health and emotional wellbeing services in Lincolnshire. 

• Healthy Minds Lincolnshire (HML) provides emotional wellbeing support to children and their families who are experiencing emotional distress with early interventions; by promoting resilience; and by preventing deterioration of emotional wellbeing leading to mental health issues.   
• Mental Health Support Team (MHST) provision is expanding and expected to cover half of the county by 2025. MHSTs deliver three core functions set by NHS England (NHSE) and the Department for Education. These are: 
• Delivering evidence-based interventions for school-aged children experiencing mild to moderate mental health issues 
• Supporting the Senior Mental Health Lead in each education setting working in partnership with individual MHSTs to introduce or develop their whole-setting approach to positive mental health and emotional wellbeing 
• Giving timely advice to education setting staff, liaising with specialist services to help children get support at the right time and stay in education.  
• Child and Adolescent Mental Health Service (CAMHS) provides community-based specialist support when children develop moderate to severe mental health concerns, or present in a mental health crisis; deliver evidence-based treatments and interventions that are appropriate to the child’s age, development and presentation/diagnosis and that are culturally competent and delivered within a family context. 
• The Complex Needs Service (CNS) works with partners to support mental health, wellbeing and wider outcomes for children with complex needs and trauma, including those within the youth justice system, children in care, adopted children, or with other complex needs. 
• Keyworking is currently being implemented for under 25s who have a Learning Disability (LD) and/or are Autistic and are at high-risk of being admitted to specialist inpatient services, or already inpatient in a specialist LD or mental health setting. 

Adults (including working age and older adults) 

Individuals, communities and organisations across Lincolnshire can all play a part in prevention of poor mental health and wellbeing. From awareness raising campaigns supporting people to look after their own mental health and wellbeing and knowing where to find help; through to community and societal measures such as developing whole-setting approaches to mental health and wellbeing. Shine Lincolnshire supports a range of community and voluntary sector organisations supporting mental health and wellbeing, increasing the range and reach of local organisations. Across the country there are many organisations connecting people to opportunities to improve their mental wellbeing and build resilience, for example, Active Lincolnshire and Connect2Support. Additionally, there are a range of commissioned services and voluntary and community sector organisations, like Acts Trust, providing Night Light Cafes offering out-of-hours, non-clinical support (e.g. debt advice or food parcels). 

To support the physical health of those with SMI, NHS England requires SMI Health Checks are completed annually. In the most recent 12 months, just under half of SMI adults had completed a physical check. This only includes people with diagnosed SMI on General Practice Mental Health Registers, so it is inevitable that some people will remain unassisted. This only exacerbates health inequalities. Work is ongoing to increase capacity and to promote delivery of SMI health checks in general practice and to optimise delivery in secondary care. A work programme is underway to ensure needs identified through health checks are met, with support such as access to behaviour change services of One You Lincolnshire. 

LPFT is the lead provider for mental health treatment services in Lincolnshire. Their community and specialist services include inpatient care for Lincoln and for Boston. In addition to NHS commissioned services, LPFT deliver functions on behalf of Adult Social Care via a Section 75 agreement. This includes, the assessment and care management function, for adults aged 18 to 64 with mental illness, enabling LPFT to better integrate mental health related support. 

LPFT Adult Services are structured around four key divisions: 

• The adult community mental health division provides mental health services and care for people in the community, providing the right support in the right way in the right place and ultimately avoiding hospital admissions. Teams work with many different groups of people, including the homeless, those involved in the criminal justice system and those accessing maternity services.  
• The adult inpatient and urgent care division provides hospital care and support across the county. Care ranges from acute support through to reablement.  
• The specialist service division works alongside mental health teams helping support people in the community. This includes support for veterans, autistic people and those accessing the sexual advice referral centre, amongst others.  
• LPFT also offers mental health support for older people from assessment through to diagnosis and beyond. This incorporates support for dementia, as well as ME and neuropsychology. 

A full list of LPFT services can be found here.  

Significant transformation is currently underway in adult community mental health services. Developments include; a county-wide expansion of Community Rehabilitation Teams; development of an eating disorder service; and progression of the Mental Health Co-Production Network; and expansion of Night Light Cafes.  

The Lincolnshire Community Mental Health Transformation programme has established community connectors, mental health social prescribing link workers and peer support workers – all supporting access to mental health and wellbeing in the community and voluntary sector. The Transformation programme aspires to reduce demand for specialist services like mental health crisis, adult social care and mental health inpatient care. This will be done by utilising integrated place-based teams, aligning to primary care network areas, and striving to deliver locally-focussed, connected-communities; developing strong partnerships; fluid pathways for access to mental health services; an integrated digital offer to support face to face engagement; continuous and active mental health dialogue; training and upskilling communities; reducing mental health prescribing; and delivery of comprehensive psychological therapies. 

The Suicide Prevention Steering Group (SPSG) is responsible for delivering the Lincolnshire Suicide Prevention Strategy. The SP action plan responds to specific local intelligence (Lincolnshire Suicide Audit). Priorities for suicide prevention include: improving access to timely data (e.g. coroner’s data and real time suicide surveillance); using data to guide action (e.g. identifying and responding to suicide clusters); developing support for bereavement by suicide; encouraging uptake of suicide prevention training; and improving our understanding, and response to, attempted suicide. Amparo will deliver a Suicide Bereavement Service for Lincolnshire from November 2022.  

This factsheet was developed in collaboration with stakeholders of the Mental Health, Learning Disabilities and Autism Alliance

Children and Young People (CYP) 

The CYP Mental Health Transformation Programme will identify any further unknown gaps and unmet needs, in addition to: 

• Improve access to services with a single point of contact for all emotional, behavioural and mental health concerns.  
• Improve joint working between organisations and professionals to pinpoint the right support and the right professional(s) without referral to multiple services 
• Enhance universal support for parents and carers, to identify risk factors early, enhancing their ability to meet their own child’s needs 
• Earlier support for children with signs of an eating disorder 
• Increase non-interventionist support for everyone: Prevention, advice, signposting, consultation, digital information, etc. 
• Support education settings to embed whole-setting, trauma-informed and solution-focused approaches so children receive consistent support.  
• Build teams around local communities to respond by understanding local population needs. 
• Invest more in the workforce by developing skills, therapies, and approaches to support, increase provision of family, play and art therapy where appropriate. 

Adults 

• The impact of the cost-of-living crisis on mental health and wellbeing is uncertain, but we know from the 2008 recession that the impact could be significantly negative. In the short term, the number of people needing support is likely to increase. Help will be needed to afford food (food banks) and to pay heating and electricity bills. Training and awareness raising for staff, about where support is available, is vital for rapid and knowledgeable signposting. 
• A considerable number of referrals to Mental Health Crisis, and Home treatment teams, do not meet the criteria for support. This results in additional challenges for teams to manage these people’s support. It will increase the risk of needs escalating and generating greater need for specialist care services. Greater use of wider community mental health services may help to reduce pressure on the Crisis and Home Treatment teams. 
• Adult Care is experiencing an increase in referrals for mental health support and an increasing complexity in those referrals. Pressures demand new ways of commissioning care and an inclusion of hybrid social care/health care solutions. There is an urgent need to develop community-based accommodation and care as an alternative to residential and nursing care. 
• Many risk factors for poor mental health are events in which the police are involved (e.g. victim of domestic abuse, trauma, or serious violence). An opportunity to explore prevention and early intervention work, with the police, for example – during initial victim contact, to make sure proactive prevention is maximised to reduce poor outcomes. 

The MHLDA Partnership priorities form the core of next steps. Those priorities are to: 

• Develop an MHLDA inclusive society including the Promotion of Mental Health 
• Deliver a sustained and MHLDA informed workforce 
• Increase Access to Community Based Provision (reducing the need for specialist services) 
• Minimise in-patient and Residential Care Placements (particularly outside Lincolnshire) 
• Prevent deaths by suicide 

Within these priorities are some key next steps for CYP, transition to adulthood, working age, and older adults. 

Next steps: Children and Young People 

Complete a review of children and young people’s mental health needs, and support, in Lincolnshire, leading to a comprehensive Transformation Programme, focused on: 

• Public mental health prevention, promotion, community and early intervention support;  working with Lincolnshire’s VCSE sector to scope their interest and capacity for co-producing community-based provision for children, with children,  parents, carers and Primary Care Networks (PCNs) 
• Empowering parents, carers, and professionals working with children, to identify and respond to their emotional wellbeing and mental health concerns 
• Increasing and improving access to community-based emotional wellbeing, and high-quality, evidence-based, timely, mental health assessment and support  
• Avoiding unnecessary specialist and acute mental health related hospital admissions, particularly for children with LD or autism. 
• Continue to work with NHSE and local partners to support the implementation of national initiatives, and meet access and waiting time targets, in line with the NHS Long Term Plan: 
• Invest in expanding access to community-based mental health services that meet the needs of all children needing support 
• Increase investment in children’s eating disorder services 
• Continue to roll out and embed MHSTs that provide support in education settings  
• Implement and embed trauma informed practice to support children with the most complex needs as part of the Framework for Integrated Care (Community) programme 
• Develop and implement Keyworking to support children with LD and Autistic children at risk of hospital admission, or becoming an inpatient,  due to their mental health 
• Pilot CYP Additional Reimbursement Roles (ARRs) to improve pathways between primary and secondary mental health care 
• Continue actioning recommendations related to children’s suicide prevention, augmenting the work of the Lincolnshire Strategic Suicide Prevention Steering Group, their SP action plan and the developing Lincolnshire Suicide Prevention Strategy (due in 2023). 

Next steps: Transition 

• NICE guidelines [NG43], Transition from children’s to adults’ services for young people using health or social care services, covers CYP, up to age 25, who are going through planned transition, including those with mental health problems, are disabled, or who are ‘looked after’. The guidelines define transition as the purposeful and planned process of supporting young people to move from children’s to adult services. The transition can be difficult, anxiety provoking, particularly in the context of broader cultural and developmental changes that surround young people growing into adulthood. 
• A wealth of policy and guidance outlines agreed principles of good transitional care, but there is also evidence that these principles are often not respected in practice. Lacking support, young people may not engage with services, resulting in a loss of continuity of care. This disruption can be damaging, particularly during adolescence, when there is a higher risk of psychosocial problems developing. 
• Improved support for transition to adulthood and adult services requires the work of CAMHS and Adult Mental Health Services, as recommended in the guidance [NG43]. 

Next steps: Adults 

• The Government intention to develop a new 10-year mental health improvement plan has begun, with a call for evidence recently being closed. When published, the plan will be used to benchmark local activity and identify local priorities. 
• To progress Lincolnshire’s application to the Prevention Concordat for Better Mental Health. Membership will guide future prevention activity, focussing on identifying inequalities in mental health outcomes, and supporting initiatives that address those inequalities. 
• To co-produce community assets for mental health and wellbeing – building resilience within and across the community and voluntary sector. 
• Deliver the Community Mental Health Transformation Programme. 
• Review Mental Health Crisis, and Home Treatment Services; consider alternatives. 
• Develop a Complex Case Section 75 agreement with lead commissioner arrangements for Adults with Complex Needs. 
• Develop Primary Care Network level baselines and associated activity data, of people with SMI, for key services. 
• Develop MHLDA Joint Delivery plans to confirm how key priorities will be met. 
• Work with stakeholders to test approaches to measuring rates of attempted suicide, and to develop effective signposting to suicide prevention support. 
• To review and refresh the Lincolnshire Suicide Prevention Strategy during 2023, using the anticipated national suicide prevention strategy update (expected early 2023).