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Health and Community Care Research Findings No. 22

National Framework for the Prevention of Suicide and Deliberate Self-harm in Scotland: Analysis of Written Submissions to Consultation

Julie Ridley, Scottish Health Feedback

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Main findings

• The overall emphasis and approach advocated in the Framework was generally welcomed as a 'timely' and constructive way forward.
• There was enthusiasm for the notion of a shared responsibility and a multi-layered approach to prevention within the context of the promotion of health and well being.
• A number of organisations offered their support to implement the framework.
• Respondents predicted problems with achieving the level of joint working required locally to implement the Framework.
• Tensions were highlighted concerning the degree of central direction versus local control and how commitment might be achieved across all agencies.
• It was felt that further consideration should be given to the role of voluntary and community providers, with additional consultation involving these bodies.
• There was a perceived neglect of the complex issue of deliberate self-harm (DSH) within the framework and respondents identified the need to distinguish more clearly between suicide and DSH.
• To overcome the challenges of collecting and sharing data on suicides and DSH and with measuring outcomes, the need for large scale and long-term studies was stressed.
• Respondents acknowledged the resource implications arising from the proposed approach, given competing priorities and finite resources, as well as "over-stretched" mental health services.
• The limitations of tackling the structural and organisational issues, rather than "deeper alienation" and disaffection within society, were highlighted.
• To implement the Framework, respondents identified the need for "dedicated resources" for: training and awareness-raising among staff; systems for dissemination of information and good practice; central co-ordination; and investment in developing joint information systems.

Introduction

Over the past 30 years, the rates of suicide and deliberate self-harm have risen alarmingly in Scotland, especially among young adult men. Since 2000, the Public Health Division of the Scottish Executive has sponsored a process of policy development resulting in the production of a draft National Framework, written by the Scottish Development Centre for Mental Health (SDC) and overseen by a National Planning Group, convened by Public Health Division. The Framework was developed following 2 national seminars held in 2000 and 2001, and was one element among an array of measures to promote mental health and well being.

The National Framework issued for consultation was in 6 main parts:

• Part I provided background and context, an explanation of suicide and deliberate self-harm and defined 'prevention'
• Part II outlined the scope of the framework, including guiding principles
• Part III offered an action plan with proposed steps for implementation
• Part IV presented priorities for action and identified success factors
• Part V proposed a timetable to 2004
• Part VI presented specific consultation questions to find out whether the draft National Framework provided adequate support for local and national agencies

Response

Consultation documents were sent out to over 1400 individuals and organisations in October 2001. Responses were received by the deadline from 140 respondents from a variety of bodies. The vast majority (94%) were organisational responses, while 8 came from individuals. The greatest proportion of responses came from Health bodies (22%) and Voluntary organisations (21%), then Local Authorities (18%). While in the minority, the views of user and carer organisations and other bodies were also represented. Six responses were received as multi-agency submissions. These were from health, local authority social work departments and voluntary organisations.

Comments about Parts of the Framework Document

The content of responses was analysed and presented in the main Report according to whether it referred to Parts or Sections of the Framework document, or a response to one of the consultation questions asked in Part VI.

Commenting on the document itself, the approach advocated in the National Framework was overwhelmingly welcomed by a variety of organisations and individuals as a 'timely' and constructive way forward.

The most serious criticism levelled at the National Framework was that it failed to properly distinguish between the issues of suicide and DSH and, as a result, DSH was felt to be neglected. Gaps were highlighted in terms of clear definitions of suicide, DSH and prevention.

Respondents anticipated difficulties achieving the level of joint working on implementing the Framework in some cases. They also identified resource implications arising from implementing action plans. Respondents raised a number of practical concerns both about the collection and the sharing of information between agencies, and the challenges of measuring outcomes, particularly from prevention strategies.

An inherent tension concerned the balance between central direction and local control. Priorities and action plans had to be decided locally to achieve broad ownership and flexibility, while central accountability was felt to be essential. However, in spite of such tensions and potential challenges, there was enthusiasm for the notion of a shared responsibility and a multi-layered approach to prevention within the context of the promotion of health and well being. A number of organisations offered their support to implement the framework.

Responses to Specific Consultation Questions

The consultation questions in Part VI covered a range of topics relating to implementation - from general issues to roles and responsibilities, priorities for action and research. Answers to these questions indicated that, overall, respondents felt the National Framework provided a useful starting point. However, opinion was divided as to whether it provided sufficient detail on the action planning and implementation process. Some felt there was insufficient detail about key roles and responsibilities and the 'lead agency' role.

Respondents stressed that the natural link with other planning mechanisms would have to be decided locally, taking account of boundary and local concerns. Given the existence of a variety of planning structures, some respondents felt that joint community care planning, community planning or Health Improvement Plans were the most obvious link.

If Health was to become the 'lead agency' there was a concern that this would over-medicalise issues. However, some local authorities stated they would be hard pressed to take on a lead role. It was suggested there might need to be different 'lead agencies' for parts of the action plan.

How local responsibilities should be carried out, how best to engage key local players, and the relationship between national and local bodies were identified as requiring further detailed consideration in the Framework, particularly how to involve voluntary and community groups.

Although the Framework endorsed a community and neighbourhood focus and community development approach, the document was felt to be unclear about the role they would play in implementation. This was perceived as a "fundamental flaw" that should be addressed at both national and local levels. A key issue for many voluntary sector organisations was the short-term nature of funding, which militated against their involvement in long-term planning.

While there was broad enthusiasm for the proposed approach, there was also a request that it be founded upon sound evidence-based practice, especially in terms of advocating community approaches and interventions. In response to whether the treatment of primary prevention and the societal level in the Framework were adequate, respondents' views were polarised. For some the inclusion of primary prevention and tackling issues at a societal issue was a strength of the document, while others felt this was "underplayed".

Respondents highlighted a number of areas for future research. These included:

• evaluating the effectiveness of different types of intervention, particularly of preventive strategies;
• more research into the needs of specific groups, such as older people and young people 'looked after' by the local authority.

Conclusion

The National Framework appeared to offer a positive way forward in tackling the complex issues surrounding suicide and DSH. Respondents suggested, however, that more work was required specifically on the issues around DSH. They also suggested that many of the practicalities, especially the relationship between national and local bodies, and identifying which organisations should take the lead, still needed to be fleshed out. The National Framework would be implemented in an already crowded policy arena and with existing mental health services feeling "over-stretched." The consultation exercise therefore, was successful in highlighting the many constraints on implementing the proposed strategy, but has also identified ways to take this work forward.