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CHAPTER FIVE ALLOCATION OF RESOURCES

5.1 Introduction

One of the key issues for the commissioned evaluation was to track resources allocated by the Scottish Executive to the implementation of the strategy and action plan, and to investigate whether and how the money allocated to national and local initiatives was:

• stimulating local investment from CPPs
• targeted at relevant priority groups
• being spent on proven effective practice and interventions
• stimulating innovation.

This section considers the allocation of Choose Life funding both nationally and locally and provides a number of different breakdowns on how these resources have been used. These include: looking at the split between national and local resources, targeting across key action areas for Choose Life (training, community/voluntary & self-help initiatives, and coordination), national and local priority groups, Choose Life objectives and type of intervention.

The issue of additional investment and in-kind support is of key importance. Funding was intended to act as a stimulus for additional support for local suicide prevention work. It was expected that CPPs would take steps towards fostering partnerships and generating additional resources which could aid in potential long term mainstreaming and sustainability of suicide prevention activity. Projected levels of expenditure over the first three years of Choose Life are also compared with actual levels of expenditure on projects and activities. The section concludes by considering progress made in targeting of resources, and identification of emerging gaps/issues.

5.2 Allocation of national funding

Over the three financial years 2003-2004, 2004-2005 and 2005-2006, £12 million was set aside by the Scottish Executive to fund the initial phase of Scotland's suicide prevention strategy.

One quarter of all funding was earmarked for national activities including support for implementation of the strategy.

Funding at both national and local levels was broadly evenly spread across the three year period. This commitment was also intended to " encourage local investment from NHS Boards, NHS Trusts, local authorities and other agencies, in developing effective interventions and, in particular, in coordinating efforts between agencies." (Scottish Executive, 2002).

Earmarking funding for Choose Life was important both symbolically in terms of highlighting the important of the issue, and also practically in terms of providing a period of time during which appropriate infrastructures might be developed or enhanced to reduce suicides in Scotland. While ring-fencing of funds at the national level appears clear, it should be noted that at the local level ring-fencing of funding for Choose Life is somewhat weaker as funds are absorbed into local authority budgets. Theoretically, local funds set aside for Choose Life might be used for other purposes; local authorities might also seek to recover unspent Choose Life monies at the end of any financial year. In practice this has not proved to be a major concern thus far, with less than 1% of the overall budget being retained by local authorities in this fashion. Mechanisms (if feasible) to ensure that Choose Life funds can only be used for Choose Life activities would of course minimise this potential risk.

5.2.1 Planned allocation of resources

Table 5.1 sets out the initial planned allocation of resources at the national level and also across all 32 local authority areas. National funding was allocated to NIST and other national organisations. National support has included running many events, providing training opportunities, working to improve communication and coordination between different groups, website development and the publication of information materials. This has also included financial support of £150,000 for the Samaritans, £500,000 for the Scottish Prison Service and £50,000 to ChildLine for Choose Life related activities, as described in chapter four. Almost £424,000 from national funding has been used to support training, including £275,000 for the National Training Strategy Development Fund. Funds were also used to support the initial training of ASIST trainers across all 32 local authority areas. The category of research and evaluation in this table includes activities such as commissioned research reviews related to suicide and suicidal behaviour, and a resource database to gather information about suicide prevention activities. It also includes commissioning of this independent evaluation of phase one of the strategy. These activities are detailed in chapter eight.

Funds at the local level consisted of a universal flat sum for all, plus population-related supplementary funding. Funding at local level was intended to promote and strengthen local partnerships as well as support training and innovation.

Table 5.1 Planned allocation of resources between national and local activities in phase one

5.3 Allocation and use of funds at local level

This section looks at how all source of funding for Choose Life in each of the 32 local areas has been allocated. This includes: targeting across key action areas for Choose Life, national and local priority groups, Choose Life objectives and type of intervention. It also looks at how successful local areas have been in obtaining additional resources, both monetary and in-kind. Most of this information is based upon a detailed analysis of data collected from local areas by NIST using a standard template (as outlined in chapter three). This information has been supplemented by information from case studies in eight areas and a survey of all 32 areas.

5.3.1 Strengths and limitations of data

It is important at the outset to flag up strengths and challenges in data collection. When NIST was first established, little financial information was available in local areas. The first local action plans submitted in December 2003 were, in general, not costed. Thus, an early priority for NIST was to develop a system that would capture how resources were being put into budgets for different activities and how money was in fact being spent. A bespoke template represented the first attempt at a management information system. It was a multi-purpose tool that captured both financial information about projects and other information such as links to priority groups and objectives, any local evaluation design in place, etc.

There have been practical challenges for some local coordinators to complete the template; for instance, not all possessed the basic spreadsheet skills needed to complete the first version of the template. A further continuing difficulty is that, while NIST can request information, CPPs are under no formal obligation to comply. Providing information to NIST may be less of a priority at a local level than dealing with day to day matters; thus, there can be delays in receiving feedback from some local areas. Moreover, in many instances, even when this information when received, it can be incomplete or inconsistent.

NIST has adapted their templates to try and ensure these are more 'user friendly', allowing local areas to provide text based information using a Word format. They also provide hands-on support to coordinators to help them complete the template. A management information tool has been developed using information from the templates. For example, this enables someone looking at the Choose Life website to search across Choose Life funded implementation activities in Scotland. Nevertheless it should be stressed that, at the time of writing this report, some information gaps on how local resources are being used still remain.

5.3.2 Planned and allocated funding including complementary investment

Table 5.2 provides information on funding distributed to CPPs from central government by the Scottish Executive. Local areas differ in the extent to which they have already designated how this funding will be used for specific activities. For instance, while Aberdeen has allocated all its core budget to activities, neighbouring Aberdeenshire had not allocated £8,500 at the end of 2005/2006. This may reflect a gap in information provided on the templates; alternatively it might also be due to delays in getting activities and projects up in running in some areas, in part resulting from the short lead in time to the initiative (see Choose Life timeline in annex 2).

The table also highlights the amount of additional complementary investment (both monetary and in-kind) generated for Choose Life, where information is available. What is clear is that the majority of areas have been successful in raising some additional funds from a variety of sources, including local councils, the NHS, national charities and the national lottery. In total more than £1.6 million has been identified. According to data derived from the templates, 13 areas have not obtained any additional funding; some of this may be due to an information deficit.

CPPs may be able to learn from successful experiences on how to increase their fund raising potential. In Glasgow, for example, on application for funding, each project or initiative was asked to state additional funding or costed in-kind support which could be bought to their bids. This led to significant levels of new investment to back the Choose Life fund and investment in terms of actual funding and in-kind support.

In Inverclyde , funding was secured from Changing Children's Service Fund for a post employed through National Children's Home's ( NCH) Gap project in phase one. The bid was developed by a representative from Integrated Children's Services, Child & Adolescent Mental Health Services and the Social Work service manager. The NCH project received existing funding through youth justice monies for young offenders and had also received Scottish Executive monies for a mental health nurse to work with multiple/complex needs. The funded post through Choose Life/Integrated Children's Services was identified as an opportunity to put in a peer for this worker.

Table 5.2 Planned and allocated funding including complementary investment for phase one

Figure 5.1 demonstrates the planned versus actual allocation of Choose Life core funding in phase one across the 32 local areas.

Figure 5.1 Core Community Planning partnership ( CPP) budgets versus actual allocation of Choose Life core funding in phase one

Case study data also suggest that levels of additional funding may be much higher than those actually reported (see section 5.4). Few areas have reported and put a monetary value on any in-kind investment identified. Such in-kind funding is almost certainly being provided in most CPPs and it is important to quantify this to get a true sense of the potential of CPPs through the Choose Life partnership model to obtain additional resources.

5.3.3 Allocation of resources by Choose Life action area for phase one

This section considers how available resources have been allocated across the Choose Life action areas: community/voluntary/self-help initiatives, training initiatives and coordination of local area activities. The 'training initiatives' category includes research activities, while the 'coordination' category covers planning, management, and partnership working issues, including the funding of local coordinators.

Table 5.3 and figure 5.2 highlight the allocation of resources by Choose Life action area for phase one. Overall approximately 62% of funding from all sources has been allocated to community/voluntary and self-help initiatives, 22% to coordination activities and 16% to training. Local areas can differ markedly in how they have allocated resources between these three areas, reflecting different needs and potentially also the availability of pre-existing services or skills. Glasgow, for instance, has a very high level of investment (93%) in community/voluntary and self-help initiatives - this is to a large extent due to the fact that additional monetary support has focused on this area. Highland has concentrated quite heavily on training (59%) (see below), while Argyll & Bute (60%) and Perth (79%), for instance, have devoted much of their funding to coordination.

Table 5.3 Allocation of resources by Choose Life action area for phase one

Figure 5.2 Allocation of resources by Choose Life action area in phase one

5.3.4 Training

Highland has invested heavily in training activities; for example around one third (£42500) of the total costs of STORM training have been identified as in-kind contributions, much of which have been funded by complementary resources. This included staff time from local statutory agencies, the provision of accommodation and the time contribution of volunteers from the Highland Users Group. In Highland, skills gaps for different groups (e.g. mental health professionals, generic health professionals and community members) were identified through local consultation during the Choose Life planning process. Training was expected to meet needs quickly and to provide a sustainable approach to improving the skills of the local community and professionals. It was also thought that the chances of mainstreaming training interventions beyond the Choose Life funding period might be more likely than for mainstreaming community and voluntary initiatives.

In Perth, a significant proportion of funding was allocated to learning in phase one. This has resulted in funding of research on young people, self-harm issues and needs assessment.

It should be borne in mind that many other activities, which support the delivery of local suicide prevention plans, are not listed in the template information because they are not funded by Choose Life. In East Ayrshire, Fife, Shetland and Glasgow, coordinators undertake this role as part of their non-Choose Life activities (including, for example, training).

Targeting of training

There was additionally diversity in types of training undertaken (see table 5.4). Applied Suicide Intervention Skills Training ( ASIST) was endorsed as a national training approach by the Scottish Executive. LAP data show that 23 areas have allocated some funding to ASIST related activities. This is probably an underestimate, due to the limitations of existing information. ASIST training is almost certainly included in the 'other' undefined training category as well, as all are committed to delivering ASIST as part of Choose Life. Some areas may also include activities such as Mental Health First Aid within this general 'training category'. This is the key reason why the 'other' training category appears to have the highest level of funding. Moreover, as noted in section 5.2.1, £424,000 has been allocated from the national budget to training activities, including funding for the initial training of ASIST trainers in all 32 local authority areas.

A minority of activities are focused on postvention training (to help deal with the aftermath of suicide); this is supported by information on the allocation of resources by intervention type later in this section. Few areas invested in STORM initially, although case study data suggest an increased interest in this approach. This has been particularly influenced by learning between areas of the experiences of implementing STORM in Highland.

In relation to ASIST, a key approach to training rationalisation has been to target workers who support vulnerable groups, although there has been diversity according to locally perceived need. In Glasgow, for example, the general public did not receive training. This was influenced by the need to prioritise training for those regularly in contact or working with vulnerable groups and the lack of resources to target the general public in a large urban population. In comparison, significant numbers of the general population have participated in training in rural and remote areas (Highland and Shetland Isles). In the case studies, factors thought to influence this were rural isolation and perceptions that many vulnerable people come into contact with, or are supported by, community members.

A variety of local training/awareness raising approaches has also been funded. Common approaches are:

• Schools/community based with young people (promoting emotional literacy)
• Awareness raising in schools settings with staff/in the community
• Mental health promotion training
• Training for workers supporting people with mental health problems/people who self-harm.

National training strategy

NIST has also taken an increasingly strategic approach to training, as reflected in the employment of a training manager and development of a training strategy. National interviews highlighted an increase in the popularity of training across Scotland in phase one and revealed that local areas required support in terms of delivery of training and in understanding whom to target. All trainers' time was delivered in-kind during working hours. An important need was not only to harness enthusiasm and goodwill locally but also consider the quality of training and the availability of support systems.

Although a training coordinator was in place, a key decision was to appoint a training manager in summer 2005. The purpose of this post was to support development of a training infrastructure across Scotland, including an overarching training strategy that would support sustainability of training and coordinate different training approaches (local and national) and in prevention, intervention and postvention training.

The development of the strategy was supported by local and national consultation and NIST commissioned an international suicide prevention training expert to support the strategy's development.

Table 5.4 Allocation of resources by type of training

* Some areas have indicated that training funds have been used for more than one category of training, but no split of funds has been provided. These are indicated with an asterisk - totals for each category of training will therefore be higher than the total amount of expenditure on training in the table.

Type of interventions

Table 5.5 outlines how resources have been allocated to specific interventions intended to reduce the risk or suicide, as well as to other tasks, such as coordination of activities and awareness raising events. Additional information on the number of specific projects in each category is provided in table 5.6. Universal preventive interventions are distinguished from selective preventive interventions. The former are aimed at specific groups within a population not known to be of high risk of suicide; this, for instance, would include interventions targeted at school populations. The latter refer to interventions targeted at individuals known to be at higher risk of suicide, such as people with diagnosed mental health problems. Postvention interventions deal with the issues arising in the aftermath of suicide. Population-wide activities largely consist of education and awareness raising events and campaigns.

Table 5.5 Allocation of resources to type of intervention

* Some activities may fall cover both prevention and postvention

Table 5.6 Number of projects by type of intervention

* Some activities may fall cover both prevention and postvention

It is clear from this breakdown that the overwhelming majority of resources are devoted to delivering, coordinating and providing relevant training for suicide prevention activities. Only £1.2. million (approximately 10%) of all funds identified for Choose Life have been allocated to dedicated staff posts, such as coordinators and development workers whose positions cannot be linked directly to specific activities. It is reasonable to expect that this is also an information deficit - these individuals may spend a significant amount of time coordinating and delivering specific interventions

Of universal prevention initiatives, over half target young people and children (e.g. schools/community based mental health awareness). Population-wide approaches to community awareness can be seen across areas (e.g. material for the public, training sessions, beer mats and postcards, links to football/rugby clubs), and it is evident that a range of different approaches, materials and messages is being developed locally. Activities focused upon mental health awareness are funded in a number of local areas, although the extent to which these complement or overlap with other relevant initiatives (e.g. MHFA) is unclear. Feedback from the second evaluation workshop noted that the continued shared understanding of 'messages' should be developed in partnership (to ensure ownership) and must be responsible/evidence based.

Intervention responses target a variety of priority groups and include counselling for at risk groups or crisis response in the community and voluntary setting and funding to national organisations such as the Samaritans. There are also commonalities in approaches in new partnerships that link voluntary sector services with statutory services ( see chapter six).

Of the main categories (prevention, intervention and postvention), the latter has received least attention. Activities include CRUSE, support for those bereaved (including by suicide), and support for the families of those who attempt suicide. Potential explanations for this relatively low level of priority were lack of capacity in local areas, e.g. insufficient service providers, and reliance upon volunteers who then leave.

5.3.5 Allocation of resources by Choose Life objectives

Table 5.7 shows the allocation of resources by the seven Choose Life objectives across the three key action areas.

Table 5.7 Allocation of resources by Choose Life objectives*

* Many activities fall into one or more category as activities are often stated to target a number of objectives.

The majority of activities target several different Choose Life objectives. Table 5.7 indicates that there has been less funding directed at a local level to 'knowing what works'. This appears to be influenced by a lack of skills/experience to assess the evidence base locally and a similar lack of local evaluation capacity.

5.3.6 Allocation of funding to national priority groups

Table 5.8 provides a breakdown of funding allocation to nationally defined Choose Life national priority groups, while table 5.9 shows the number of projects targeting each national priority group.

Table 5.8 Allocation of funding to Choose Life nationally defined priority groups*

* Many activities fall into one or more category as activities are often stated to target a number of priority groups.

Table 5.9 Number of initiatives stated to target nationally defined priority groups*

* Many activities fall into one or more category as activities are often stated to target a number of priority groups.

The majority of activities targeted multiple priorities. This breakdown demonstrates that a substantial proportion of funding was allocated to children/young people, people with mental health problems and those who attempt suicide.

The focus on children and young people, particularly in targeting prevention activities, is illustrated by case study examples that demonstrate approaches taken to targeting risk factors, e.g. tackling stigma in schools, family issues (e.g. parents with substance misuse problems), barriers to help seeking (bullying, mental health), and in promoting protective factors, e.g. more normalised understanding of mental health, increased coping skills and improved self esteem.

People with mental health problems

Interventions targeted at people with mental health problems are generally focused upon mental health improvement activity in the community and voluntary sectors. Of 101 community and voluntary projects stated to target people with mental health problems, fewer than five allocated resource to statutory services. This is in line with the phase one guidance that specified funding should not be used as a substitute for existing services. Funding allocation underplays links established in some areas to Doing Well by People with Depression ( DWBPWD) and clinical services (as discussed in the previous chapter).

Substance misuse

Links to substance misuse services have been considered in chapter four. Typically, there were few instances where funding was targeted at services directly supporting people with substance misuse problems. Data from the case studies indicate that, in one area, the link between suicide and substance misuse was identified as a priority prior to Choose Life and the Choose Life partnership was strongly championed by campaigners. This led to funding being allocated to substance misuse services. In another area, the substance misuse service manager was involved in the Choose Life partnership and implementation activities. This was thought to be facilitated by existing partnership working and co-terminosity of the local service boundaries that resulted in significant cross-over.

There is also evidence in some cases study areas that substance misuse has been identified as a local priority but there was insufficient community/voluntary capacity or willingness to develop activities. In two cases, for example, community and voluntary organisations were encouraged to submit bids but these did not materialise. Although it is uncertain why this occurred in one area, there was some apprehension from a second organisation about the potential impact upon the service and lack of capacity to deal with any increased demand for its service.

Progress in targeting priority groups

Local coordinators reflected on the targeting of priority groups in the second survey. Most progress had been made in supporting children, young people, mental health and substance misuse. Least progress was thought to have been made in targeting those in prison, unemployed or homeless people. National level feedback on progress in targeting priority groups identified the following key points:

• Local variability in what constituted a high risk group
• Challenges in achieving the 20% reduction in suicides: uncertainty about where the focus on priority groups should lie in order to meet this target; whether this meant a 20% reduction among key priority groups, e.g. young men
• Good progress in targeting young people, although there was some uncertainty how effective this would be in reducing suicide
• Lack of understanding of prisoners as priority group for local communities
• More attention required around the needs of those who abuse alcohol and drugs, recent bereavement by suicide, and those experiencing mental illness.

5.3.7 Allocation to locally defined priority groups

In the NIST templates, local coordinators indicated that action plans were targeting a number of locally defined priority groups. Table 5.10 provides a breakdown of the most significant locally defined priorities (those that have received at least £20,000 in funding), while table 5.11 provides a breakdown of the number of projects targeting each of these locally defined priority groups.

Table 5.10 Allocation of funding to Choose Life locally defined priority groups

* Caution should be noted about the term 'self-harm' as there is clear potential for overlap with the national priority group of people who have attempted suicide. The category 'self-harm' is included where this was specifically noted as a local priority or target group.

Table 5.11 Number of initiatives stated to target locally defined priority groups

* Caution should be noted about the term 'self-harm' as there is clear potential for overlap with the national priority group of people who have attempted suicide. The category 'self-harm' is included where this was specifically noted as a local priority or target group.

The case studies indicate that various factors contributed to the direction of emphasis on locally defined priority groups. In some cases, the priority was identified through a local consultation process (e.g. the role of the church in rural areas). Another area highlighted the impact of national media attention on older people. In others, the priority was identified through implementation, e.g. from discussions in the partnership, local needs assessment or looking at the experiences of other areas. The coordinator's background was sometimes a factor, e.g. in working with hard to reach groups (e.g. people who are hearing impaired).

5.4 Identifying the level of resources invested in Choose Life

It is important to identify the 'true' level of investment of resources in Choose Life activities, not only as a prerequisite to any future analysis of their cost-effectiveness, but also to identify the level of resources that may have to be found in future to sustain these activities. Activities that are currently provided by community groups might, for instance, rely heavily on in-kind resources, such as rent-free premises or volunteer time. Should these activities be mainstreamed and provided by the statutory sector in future, then additional funding may be needed to substitute for many of these in-kind inputs.

Tables 5.2 and 5.3 provided a breakdown of all resources invested in Choose Life and how they have been allocated across different Choose Life action areas. As we have noted, most of these figures do not fully reflect the level of investment in Choose Life projects: 20 areas indicated in the second survey that they had received additional funding and/or in-kind investment, but few provided information on these sources of funding in their returns to NIST. This is especially true for in-kind investment.

A better sense of the full investment in Choose Life can be obtained from the evaluation case studies. As part of the analysis of eight case study areas, information was requested on resources invested in sixteen activities, two per area. This included not only information on the allocation of official Choose Life Funds but also on how any additional funds raised were used. Respondents had to indicate the proportion of staff and volunteer times spent on the activity, and indicate sources of in-kind funding. Substantive and sufficient information was provided on nine of these projects to provide the breakdown between different sources of funding, as shown in table 5.12 below. In seven of the nine projects at least 45% of funds invested in Choose Life projects came from non core-funded sources. In-kind support was particularly high in those projects which relied on volunteer input or time provided free of charge by trainers; in the case of the ASIST/ STORM training, for example, this was particularly significant, as both the time of trainers and venues for training were in-kind investments in the project.

While in some areas no monetary value could be put on in-kind investments, two of the four projects in table 5.12 listed as having no in-kind investment indicated that some additional in-kind assistance was in fact received. On average, across these nine projects almost one third of the investment in activities came from additional financial support raised by the project and just under one quarter from in-kind contributions.

While we have no information to judge whether the experience of these projects is representative of Choose Life as a whole, it is noteworthy that in our survey 20 areas reported receiving some additional monetary or in-kind funding. Little information is kept across areas on the time inputs of volunteers and unpaid time of professional staff to projects. Nor is much information provided on equipment and premises received in kind.

In our analysis of resources invested in case study projects, the time of volunteers has been valued very conservatively using the 2004 level for the national minimum wage. The opportunity cost, that is the next best use of the time of volunteers, is likely to be considerably higher. In addition to these costs there are economic benefits generated by increasing the skills of volunteers and/or staff from attending training courses and from managing community-led health projects. However, due to a lack of detailed information, it is difficult to place a monetary value on these benefits. Experience from other similar community orientated initiatives, such as Healthy Living Centres, suggests that some individuals use skills acquired in such projects to enhance their career prospects.

Table 5.12 Source of funding for nine projects in case study areas

Two examples of how resources are being used in case study projects are provided below.

Example 1: Befriending Scheme for Younger People

This case study provides an example of the substantial additional amount of funding and in-kind contributions that also help to support and deliver Choose Life services. This is a befriending project for young people. A core Choose Life grant of £10,000 per annum is used to cover most of the costs of one part-time project worker. Several grants from local organisations have also been generated, helping to cover the costs of the project. There are additional substantial in-kind resources. The project relies heavily on 17 volunteers befriending young people for between two and three hours at a time, typically on a fortnightly basis. The time of trainers to run courses for these volunteers, together with the venue for these training courses, have been provided free of charge. The project worker uses her home as her office, again incurring maintenance costs.

An estimate of annual costs for the scheme suggests that these are in excess of £29,000. The estimate is conservative as the time of volunteers, the key driver of in-kind costs (who are all of working age) has been valued at the level of the minimum wage. The opportunity cost of the time of these volunteers may in fact be much higher. It also does not seek to put a value on the costs of coordination and steering of the project by a management committee. As Figure 5.3 indicates, the input of volunteers, together with their training, accounts for one third of all investment.

Figure 5.3 Resources required per annum to run befriending scheme

Example 2: Crisis support intervention

This project experienced initial difficulties in recruiting the primary project worker; as a result, the project is now running on a two year rather than three year basis. Surplus funding available because of the shorter time frame was used to fund additional support workers to provide out of hours and weekend support. In addition to Choose Life funding, the project also benefits from the provision of shared services that are funded through a grant from the Big Lottery Fund. Up to 10 volunteers contribute around 5 hours of time per week, largely providing cover during out of service hours (see figure 5.4). These volunteers are all fully qualified holistic therapists with stress management qualifications. A tentative estimate of the potential value of this volunteer input is included here, although a detailed analysis of time contributed to the project would be required to estimate this input more accurately. Conservatively, it would appear that around half of the total investment in this project is complementary to Choose Life funding. Volunteers and staff have opportunities to further develop their skills through training courses which are funded through Big Lottery Fund monies. This is one additional benefit of such a project in addition to the potential long-term impact on suicide that might be realised.

Figure 5.4 Breakdown of allocation of resources for crisis support

5.5 The economic case for investing in Choose Life

A key pre-requisite to understanding whether investing in Choose Life is a cost-effective approach to suicide prevention is to capture fully all the costs associated with delivering the Choose Life initiative. These go well beyond the resources invested by the Scottish Executive and must also take account of the additional resources invested by all other partners, both statutory, non-statutory and individual volunteers. Our analysis of case studies suggests that these resources are significant - indicating a partnership approach between government, local authorities and other stakeholders can create a synergy by which additional resources are committed to community based initiatives. These resources may not be forthcoming if an intervention is funded and delivered by the statutory sector alone.

This information, however, is insufficient to make an economic assessment of the case for Choose Life. Information is required not only on the costs of interventions and any potential tangential benefits in terms of additional skills required, but also on the effectiveness of Choose Life interventions in reducing the rate of suicide. Measurement of the effectiveness of Choose Life is a critical component in economic evaluation. As yet no such analysis of effectiveness has been conducted, although this is planned for phase two.

As very little evaluation of the effectiveness of population wide strategies for suicide prevention has ever been conducted (see annex 4), there is hardly any comparable economic evaluation of population-wide suicide prevention strategies from other countries. Discussion on how economic evaluation can be conducted alongside any effectiveness analysis in phase two of Choose Life is briefly discussed in chapter one and in more detail in Annex 3.

Nevertheless, it should be noted that the lifetime costs of suicide in Scotland are profound; the lifetime costs of all completed suicides in 2004 are estimated to be more than £1 billion. A 1% reduction in the annual suicide rate as a result of the strategy could therefore reduce economic costs to society by approximately £10.8 million in lifetime costs. This strongly suggests that, if approaches adopted by local areas can be demonstrated to be effective, given the relatively modest level of funding in Choose Life any economic evaluation may well indicate that the strategy is cost saving - i.e. it leads to better outcomes and also reduces costs (this potential cost-effectiveness is briefly illustrated in section 5.5.1 below )

5.5.1 An estimate of the potential cost-effectiveness of Choose Life

In the absence of information on the long term outcomes of Choose Life compared with appropriate alternative interventions, what can be done to help policy makers assess whether investing in Choose Life represents value for money?

One possibility is to undertake what economists call a threshold analysis. This simply refers to the threshold at which different societies consider interventions and programmes still to be cost-effective. It is a subjective judgement depending on many factors, including the level of resources in a country. In this context a reasonable benchmark might be that implicitly used by the National Institute for Health and Clinical Excellence ( NICE) in England and Wales, a body which looks at the cost-effectiveness of public health and health care interventions within the NHS. If the cost per additional year of full quality life gained is no more than £30,000, then a decision to recommend the use of the intervention by NICE is usually forthcoming.

If costs are higher the decision becomes more complex, but in any case decisions never are (nor should they be) made on the basis of cost-effectiveness alone; other factors, such as fairness, as well as ethical and political considerations, will also be important. We may, for instance, be willing to sacrifice some efficiency in how we allocate resources in order to reach a sub-group of the population who might have very poor levels of health, or in this case a greater risk of suicide.

Nevertheless, by undertaking such a threshold analysis (see box 5.8) we can look at what the maximum level of investment in Choose Life might be under different circumstances if we wish to invest no more than £30,000 per life year saved. (Further details on the methods used are provided in annex 3.) This can then be contrasted with the current level of investment in the programme. The technique can also be used to crudely estimate how many lives would need to be saved in order for the strategy to represent value for money or even become cost saving, that is where the net benefits from investing in Choose Life outweigh the costs of the strategy.

5.5.2 Potential years of life that could be saved

In 2004, using data on average life expectancy, approximately 28,400 lifetime years could potentially have been saved if all suicides in Scotland had been avoided. However, in economic analysis, the concept of time preference is often applied. This assumes that both costs and benefits incurred/gained in the future, are considered to be of less value than those costs/benefits gained immediately. In our analysis, if future lifetime years are discounted to reflect time preference (using the same rate we have for costs - 3.5% per annum), the number of lifetime years saved would be reduced to just over 16,000.

5.5.3 Estimated current annual investment in Choose Life

The total costs of investment in Choose Life includes £4m in core funding per annum plus an identified £0.52m per annum in additional monetary funding and £0.09m in in-kind investment. We have noted evidence from case studies suggesting that these additional investments are underestimated. Extrapolating this level of investment across all 32 CPPs, the total annual cost of investment in Choose Life would rise to £6.01 million, with in-kind investments accounting for £0.9 million and monetary funding for £1.11 million.

5.5.4 Potential level of acceptable investment in Choose Life

Table 5.13 provides information on the maximum level of investment that would be consistent with our threshold under different circumstances. Even when future years of potential life saved are discounted at a rate of 3.5% per annum and the success rate of Choose Life in reducing the annual rate of suicide is just 1%, the value for money of investing in Choose Life appears highly promising. Our analysis would indicate that, if we were willing to pay £30,000 for each additional year of life gained as a result of Choose Life, we could invest up to £15.6 million per annum as cost offsets of some £10.79 million would be generated. This is well in excess of the current level of investment in Choose Life. If the annual rate of suicides were to fall by 20%, then the programme would be highly cost saving. We would save more than 5600 life years (undiscounted) or 3200 (discounted) and generate cost offsets to society of almost £216 million. We would have to be spending more than £386 million per annum before the cost per (undiscounted) life year gained was above our threshold.

Table 5.13 Maximum levels of investment in Choose Life permissible to maintain a cost per life year saved of £30000 or less (2005 prices)

Another way of looking at this is to explore the impact of varying the number of potential lives saved on the potential cost per life year saved (see table 5.14). Again, we use our baseline assumptions on total investment per annum in the programme and potential costs avoided. We also assume that on average an additional 34 (undiscounted) years of life would be saved in any one year from each suicide averted. In the base case scenario only 3.2 lives would need to be saved for the strategy to cost less than £30,000 per life year saved (the threshold below which interventions are generally considered to be cost-effective). This analysis also suggests that five lives would need to be saved in any one year for the strategy to be cost saving (dominant) compared with no action, that is for the value placed on suicides averted to be in excess of the annual investment in the strategy.

Table 5.14 Potential cost per life year saved varied by number of suicides averted (2005 prices)

* CL strategy is dominant compared with no action with both lower costs and additional lives saved

5.5.4 Varying perspective

Much economic analysis is conducted not from a societal perspective but from a very narrow public sector perspective. In this case we would only be interested in the direct public sector costs of investing in Choose Life (£4 million per annum), while the only cost offsets of interest would be any costs to the public sector, such as emergency and health care services, that can be avoided as a result of not having to respond to a suicide.

In this case, where only a 1% reduction in suicide was achieved, with life years saved discounted at the base rate of 3.5 %, the threshold for investment would be £4.88 million. This is still in excess of the current £4 million level of investment. If our analysis also included indirect costs avoided, i.e. productivity losses from lost opportunities for paid and non-paid work, then this threshold for investment would rise to more than £7.87 million.

Considering the impact on the cost per life year saved, 11 lives would have to saved for the strategy to be considered cost-effective. It would, however, take more than 700 lives to be saved for the strategy to become cost saving because of the very low level of direct costs avoided per life saved. If the analysis also included indirect costs avoided, i.e. productivity losses from lost opportunities for paid and non-paid work, then the number of lives per annum that would need to be saved for the strategy to be cost saving would be just over 17.

5.5.5 Limitations

There are important limitations of this analysis to note. First, we have not adjusted future years of life to take account of their quality - this would reduce the value of life years saved. (It might be argued, however, that value placed on the intangible benefits of life foregone reflect this on the cost side of the equation). Second, we have here compared investing in Choose Life with taking no other action (over and above what is already in place) to tackle suicide. There may be other alternative models or programmes of suicide prevention, i.e. those that are more closely controlled and delivered centrally, that might be better options against which to compare Choose Life. Again, the challenge here is to identify the effectiveness of alternative models and consider whether these could work in a Scottish context. We have, however, been highly conservative in not including the potential added benefits of avoiding non-fatal deliberate self-harm events in this analysis. A third limitation is that the value of the intangible benefits of lives saved has had to make use of data related to road traffic accidents rather than death by suicide. One final limitation noted here is that our analysis looks at what would happen if we can reduce the current rate of suicide in Scotland; it may be the case that this rate might naturally fall (or rise) substantially in future years. This might have implications for the value for money of investing in Choose Life.

5.6 Expenditure 2003 - 2006

Table 5.15 provides information on expenditure on Choose Life activities for the first three years of the initiative. It should be stressed that information relating to last financial year is still provisional and not complete and the final level of expenditure will be higher still. As the table indicates, approximately £0.7m and £2.5m were spent during the first two years respectively. The relatively low level of expenditure in the first year is not unexpected; coordination, staff recruitment and needs assessment are some of the factors that need to be in place before funds can be expended.

The strength of pre-existing partnership working arrangements in some areas was also a factor; some areas needed to focus upon building new partnerships as an early priority before final decisions could be taken on what activities to fund. There have also been specific structural issues relating to how funds could be distributed within the Choose Life initiative. For example, at a local level, local suicide prevention plans were required to be signed off by the CPP and this process was not always without delay. In one case study area, for example, the LA required each Choose Life funded project to submit a portfolio; and a requirement for funding was that these were signed off by a senior committee. This committee did not meet regularly, however.

The timescales for expenditure were also affected by delays in the local action planning processes (see Choose Life timeline, table 1.2). Many local action plans submitted in December 2003 were broadly defined and did not always detail specific planned activities. This resulted from the short lead-in time between appointment of coordinators/ Choose Life partnerships and the submission of the first plans. In one case study area, a steering group wished to commission research in order to establish a baseline and inform an approach. There was a delay of some months, however, due to a lack of suitable responses to the tender and personnel turnover both in the steering group and in the coordinator's role.As a result the steering group experienced some challenges in operationalising the local action plan. Guidance was sought from NIST who advised the area to proceed in allocating funding to implementation activities.

It is also important to note that the costs of delivering some services may have been over-estimated, while some areas have been relatively successful in raising additional funds from other sources, leading to a substantial increase in funds available to be spent on Choose Life activities. In these cases less core funding than originally anticipated may have been required to deliver activities. (Case study examples discussed later also highlight the important contribution of these other sources of funding and suggest that these funding sources may be underreported.) This occurred particularly in the delivery of training where all trainers' time was provided in-kind from their parent organisation (including both statutory and voluntary organisation providers).

Preliminary data from the third year of the strategy (2005/2006) indicate that expenditure on Choose Life activities has continued to increase sharply as more and more projects are fully implemented; total expenditure is already well in excess of the notional £3 million allocated to that financial year and will rise still further.

Table 5.15 Reported expenditure in Choose Life areas 2003 - 2006

* Data for 2005/2006 are provisional and incomplete

5.7 Funding decisions : phase two 2006 - 2008

A further £8.4m has been allocated to help support the continuing implementation of Choose Life and suicide prevention action across Scotland for 2006-2008. National activities will receive up to £2m while local Choose Life support funds will receive a total of £6.4m over 2006-08 (£3.2m per annum).

In addition, a further £200,000 has been allocated to Highland in 2006-8 (£100,000 per annum) to help support suicide prevention action and to help increase knowledge about effective suicide prevention in other remote and rural areas of Scotland. Key factors in taking this decision were the rate of suicide in the area and national level aspirations to further work on rural/remote issues. A proportion of funding was used to support coordination of Choose Life activities and the remit of the post included a focus on rural issues.

5.8 Supporting people who self-harm and rationales behind investment in related activities

Choose Life addresses "only those aspects of [non-fatal] self-harming behaviour which might be considered as an indication of risk of suicide. It is recognised that there are other dimensions and manifestations of deliberate self-harm [ DSH] that are not covered within the strategy's scope" (Scottish Executive 2002).

At both local and national levels, it was evident from observation of national NIST events and from other evaluation data that there has been considerable uncertainty about how to operationalise the commitment to tackle high risk self-harm.

In the case studies, the extent to which the group of people who self-harm was identified as a local priority was explored alongside approaches to implementation activities and rationales behind investments. Identified approaches to implementation activity included:

• Projects are not providing a direct service for people who self-harm but are targeting associated risk and protective factors
• Intervening with young people/adults: funding national organisation to establish new project, e.g. one to one, group work with young people, awareness raising with professionals, carers and family/friends; immediate (non-clinical) support for adults after the episode, referred from A&E, and other agencies
• Building capacity: training workers and those supporting children and young people.

5.8.1 Rationales

Case studies demonstrate that there has been varied understanding across partner organisations of what constitutes high risk self-harm and its relationship to suicide, and variability in the interpretation of the definition of self-harm. It was also thought that the spectrum of self-harm was diverse and approaches to targeting self-harm and suicide could not be homogeneous. In one area, self-harm was not identified as a priority for the Choose Life action plan because existing local services were already in place. This had, however, created some frustration with other partners working with young people who felt that there was a gap in provision. In other areas, self-harm had been a local priority prior to Choose Life (for example, local research had already identified need among young people and existing local relationships established with a national organisation working in this arena influenced funding decisions) or was raised by those working with children and young people through local consultation processes for Choose Life.

There is evidence that some areas have developed links with A&E through phase one and are considering how work is to be taken forward in this area. Examples of work underway are links to the Samaritans; and working to improve information and support to those who attend A&E after self-harming.

Choose Life is thought to have raised awareness of the issue of self-harm in Choose Life partnerships and at training events. Increased focus on self-harm has led some areas to develop new activity throughout implementation, where self-harm had not been identified as an original priority in the action plan. In a number of areas, self-harm training has evolved following local requests from workers.

NIST has additionally facilitated debate about self-harm at a national level and a national organisation working in this field has reported increasing interest in their work by local areas.

5.9 Progress in the allocation of resources

Table 5.16 provides a summary of overall progress and identifies emerging issues/ gaps in relation to targeting across priority groups, objectives and type of interventions in addition to economic investment and performance management structures.

Table 5.16 Progress in the allocation of resources

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