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CHAPTER SEVEN SUSTAINABILITY
7.1 Introduction
This chapter explores the progress towards, and prospects for, sustainability during phase two of Choose Life (and beyond), at both national and local levels. Sustainability issues were explored both with national informants (including NIST) and at a local level (coordinator surveys and case studies). Boxed examples are intended to illustrate information provided in the main text by providing descriptive examples of activities from the case studies.
7.1 Definitions of sustainability
Although 'sustainability' is a contested term, lacking agreed conceptual or operational definitions, we follow Shediac-Rizkallah and Bone (1998) and Pluye et al (2004) in emphasising the persistence or continuation of a programme (rather than the benefits that these activities deliver). Thus, a sustained programme is defined as a set of durable activities and resources aimed at programme-related objectives (Pluye et al, 2004; Scheirer, 1994). Sustainability is important in the context of public health activities for four main reasons: maintenance of effects over a long period, allowing for the study of long-term impact; latency period between the beginning of programme-related activities and their health impacts; the absence of sustainability can result in an investment loss for the organisations and people involved; and discontinued community programmes bring disillusion to participants and therefore pose obstacles to subsequent community mobilisation (Pluye et al, 2004).
A study funded by the Department for Transport, Local Government and the Regions by Murray Stewart and colleagues (Department for Environment, Transport and the Regions, 2002) identified three levels at which mainstreaming can occur:
- Mainstreaming projects - securing funding to continue particular projects.
- Mainstreaming good practice or ways of working - ensuring that a mainstream agency adapts and reproduces examples of good practice from an initiative or activity
- Mainstreaming policy - when policy lessons from the work and experience of initiatives have a direct influence on the policy process. (Mackenzie et al, 2003)
This framework will be used (section 7.3) to explore local approaches to mainstreaming suicide prevention work .
7.1.2 Sustainability issues for Choose Life
The section provides a description of issues that were required to be addressed (nationally and locally) in developing a sustainable infrastructure for suicide prevention.
Issues to be addressed nationally included:
- Developing public awareness and ensuring that the issue of preventing suicide and reducing rates of suicide was clearly on the agenda of Scottish Executive departments and reflected in relevant policies
- National capacity for the collection of data on suicide and self-harm
- Development of national support networks and providing opportunities to exchange information and learn from developing activities
- Establishing a national training resource to oversee the development and integration of training
- Research programme on suicide prevention to guide and support development
- Publication of guidelines for the media with awareness raising and education.
Local issues to address included:
- Community Planning partners were (and continue to be) expected to work towards securing additional and long-term sustainable resources that would contribute significantly to mainstreaming suicide prevention activity
- Community Planning partners were (and continue to be) expected to ensure that Choose Life activities are cross-cutting at policy and local organisational level. For example, suicide prevention and related activities should be recognised as key elements of and embedded within Joint Health Improvement Plan and related local policies and plans.
7.2 National approaches to sustainability
The chapter considers approaches and successes achieved in developing a sustainable infrastructure for suicide prevention by NIST and other national organisations.
7.2.1 NIST activities
NIST identified a number of achievements in building a sustainable infrastructure for suicide prevention. As examples of NIST's activities have already been detailed in other sections of the report, for the purpose of this chapter, examples of activities are summarised and rationales underlying these activities in terms of building a sustainable infrastructure are outlined.
Providing opportunities to exchange information
A number of mechanisms and activities are now in place to encourage and support the exchange and dissemination of information. These include, for example, the Choose Life website, annual NIST summits and the resource database. The website is an important portal for information sharing and exchange about what is potentially effective for suicide prevention and how to become involved in suicide prevention/ Choose Life.
Raising public and professional awareness
Evidence of increased awareness was evidenced by the high number of hits (over 2000) made on the website on a monthly basis. Suicide prevention week contributed to improved awareness, as demonstrated by positive media coverage and statements from business, unions and the public sector about their commitment to suicide prevention.
'Branding' of Choose Life has additionally raised awareness of suicide prevention work and helped to provide a consistent public face. Coordinators will have media training, which should lead to the delivery of a more consistent message to Scottish public.
Generating ownership of suicide prevention across organisations and communities, e.g. prisons, schools and workplaces, was noted by NIST as a key issue that would help build in sustainability to suicide prevention work. At the NIST workshop, it was felt that links made with national organisations to engender ownership of suicide prevention had evolved and were increasingly more 'proactive' (rather than reactive).
NIST has worked in partnership with other elements of the National Programme, such as Breathing Space, HeadsUpScotland and see me, to promote activities. For example, awareness raising seminars for Breathing Space were held in conjunction with Choose Life in rural parts of Scotland.
Suicide Information, Research and Evidence Network ( SIREN)
SIREN represented efforts to 'sow seeds' for a self-sustaining suicidology association in Scotland. SIREN was intended to improve access to research and involved a range of stakeholders, including national and local coordinators. There has been success in attracting additional investment by charging for a forthcoming conference.
Data on suicide statistics
NIST has ensured freedom of information and equality of access for professionals and lay people. Information will be maintained and updated by the SPHO.
Training
ASIST was seen nationally as a vehicle for raising awareness, building longer term capacity, and widening ownership of suicide prevention beyond professional health specialists.
NIST has established a national resource to oversee development and integration of training. The Training Manager has sought support from an international expert in connection with the development of a training strategy. Based on evidence from elsewhere and United Nations criteria for suicide prevention strategies, this provided the foundation for a sustainable training infrastructure.
Although the pricing policy for training has been unpopular at a local level, findings from the survey of coordinators suggest that charges were often made at local level in order to help sustain training activities. NIST felt that the policy would have been less challenging to implement if the charge had been 'top sliced' prior to the allocation of funding to local areas. There was also concern locally about the amount (£400) requested for the delivery of each workshop, particularly in rural/remote areas. As it stood, it was necessary for local areas to return funding for training costs that had already been allocated to the Scottish Executive. NIST learnt from the pricing policy and has lowered costs that are returned centrally in phase two.
Issues requiring attention
National networks and alliances have developed with solid foundations and there are appropriate mechanisms on which to build in phase two. However, NIST is aware that the infrastructure is still fragile and that it will take time to mature. Continuing facilitation and maintenance are required to foster a culture that encourages and nurtures ownership of suicide prevention objectives.
The challenge of generating local investment in suicide prevention was highlighted as a key issue that required on-going national attention and support. In line with this, the issue of sustainability and mainstreaming was emphasised as a key action in the national guidance issued to local areas for phase two of Choose Life.
Box 7.1 Commentary NIST's approach is not so much to provide information to coordinators but to engage them in working with information and to develop a sustainable infrastructure to support this effort. NIST has developed a number of core activities as building blocks for a sustainable infrastructure. It is recognised, however, that infrastructures remain fragile; and continued work is required to build relationships and networks, and to ensure that sustainability is built in (locally and nationally). |
7.2.2 Other national organisations
Nationally, the model of the national coordinators (ChildLine and Samaritans) was implemented with a view to develop sustainable change.
The ChildLine coordinator is charged with recruiting volunteers, which helps with awareness raising. Attracting funding from local Choose Life partnerships is also important for sustainability and it is felt there has been more success with the former activity. Progress was hampered by organisational changes over which NIST had little or no control. ChildLine is merging with Children First and the focus of attention has been on internal restructuring. The post for the Choose Life coordinator has not been renewed. NIST intends to wait until this is concluded before refreshing partnership working arrangements. ChildLine appreciates the transparent approach to funding adopted by NIST. The organisation recognises that funding is time-limited and welcomes the additional two years to provide evidence about effective practice. The link between demonstrating value for money and enhanced sustainability is understood.
The funding allocated to the Samaritans in phase one allowed the organisation to employ a Scottish Development Manager, whose role is to support the Samaritans in Scotland in the areas of volunteer recruitment, publicity, awareness of work, and liaison with other organisations. In terms of sustaining suicide prevention activity, it was highlighted by the Samaritans that the organisation's vision (independent of Choose Life) is to reduce suicide, and that the organisation would continue to participate in suicide prevention whether funding continued or not. The Samaritan s have agreed to continue funding the post that was originally supported by Choose Life. The organisation had recognised the value of the post for developing a distinctive Scottish approach.
National informants highlighted that allocation of funding to existing organisations such as Samaritans at a local level was a good example that demonstrated value for money when seeking to maximise work. There was evidence that such existing organisations could provide substantial activity (e.g. the provision of training courses) on a cost-effective basis. Similarly, ChildLine believes that, as a result of voluntary organisations' access to seed corn funding, they manage to get a lot out of very little.
For the SPS, Choose Life had legitimised the efforts that colleagues were already making and brought national policy guidance and funding to suicide prevention. An SPS pilot has been used in order to secure an additional £1 million for work to support vulnerable prisoners. Following on from the successful experience of the Life Coaching project in Barlinie prison, Glasgow, SPS submitted a proposal entitled 'Routes out of prison' in response to the call for bids issued by the Scottish Executive Social Inclusion Unit for projects tackling multiple disadvantage. The primary aim of the project is to recruit ex-offenders as peer support workers to help other ex-offenders with multiple disadvantages in acquiring life, relationship and employability skills that will help to resume their place within the family and society, reducing harm and re-offending, and improving work prospects and health.
Choose Life supported Penumbra to implement research that predated Choose Life and to take their message to other parts of the country. Penumbra is a Scottish voluntary organisation working in the field of mental health and provides a range of person-centred support services for adults and young people. No national Choose Life funding has been provided to Penumbra, but six projects have received funding at local level from Choose Life. While Penumbra does not have the resources to provide on-going funding support to projects funded by Choose Life, strategies have been developed to sustain new activity. The organisation has conducted rigorous monitoring and evaluation of activities. Penumbra engaged with local partnerships to consider how projects funded by Choose Life fit into local work and to provide regular feedback on its projects to key local planning groups.
Several national organisations have been actively involved in the delivery of ASIST. SAMH has achieved targets set in training their organisation's staff and are now in a position to increase connections locally. There are three trainers in the ambulance service and a team of nine military defence trainers has been working across different parts of Scotland. The military have also been looking to work with local areas to make connections to remote areas (e.g. supporting capacity for training if there is a gap in local trainers).
SAMH is contributing to sustainability through its inputs to developments around crisis responses with NIST. The organisation will continue to produce and disseminate the booklet ' After a suicide'.
Work undertaken by NIST and NUJ ( detailed in chapter four) has helped to ensure that practising journalists and editors have been made aware of the media guidelines. The target over next year for the NUJ is to ensure an ethical approach to reporting suicide in guidelines for students in colleges and universities.
Box 7.2 Commentary The model of the national coordinators has contributed to the development of sustainable change, e.g. the Samaritans have provided funding for the coordinator post and the SPS has achieved substantial investment for vulnerable prisoners as a result of piloting activity using Choose Life funds. Organisations such as Penumbra and the SPS provide good examples of how existing infrastructures can be used to good effect to inform learning from initiatives funded in phase one. There is little evidence that other national organisations have been successful to date in attracting additional funds for suicide prevention work, although significant in-kind work has been forthcoming, for example, provision of training and roll out of bereavement support booklet. |
7.3 Local approaches to sustainability
7.3.1 Successes in mainstreaming Choose Life funded activities
Local coordinators were asked to identify current activities that they would anticipate being mainstreamed beyond Choose Life and how this would be achieved. In the survey of local coordinators, most local areas were able to provide examples of activities that would be mainstreamed. A further three respondents did not answer this question and six areas felt that it was currently too early to anticipate what activities would be mainstreamed
Mainstreaming training
Most success has been achieved in mainstreaming training activities (particularly ASIST). This is highlighted by 18 areas.
In some case study areas, considerable potential was seen for training as a sustainable resource that would benefit the broader community by building capacity and strengthening existing skills and knowledge, thus reducing reliance on specialised professionals. Training also met locally identified needs quickly and provided short term gain.
Means of mainstreaming training include: charging for places in five areas, use of existing local trainers (five areas), incorporation within local policies on training (three areas), coordination by other initiatives (two areas) and in-kind support (one area). Two areas do not yet know how training will be mainstreamed.
Mainstreaming project activities
There is evidence from the second survey of coordinators that 27 projects have been earmarked for mainstreaming. It is very likely that this is a gross underestimate of the number of projects that will in fact be mainstreamed. Findings from the case studies highlighted that Choose Life partnerships often felt that it too early to make judgements about mainstreaming of projects. This was because some newly established projects were at a relatively early stage of implementation and, in some areas, project workers for key local projects had only recently been employed at the time of the second case study site visit. (The impact of these delays in phase one have been documented in chapter five.) Choose Life partnerships were awaiting the outcome of projects before making decisions about which would be mainstreamed. It should also be noted that some of these projects earmarked for sustainability were activities existing prior to Choose Life. This is addressed in the following section.
The survey provided some examples of activities where decisions about mainstreaming had been made. Examples of projects are included where information about the project activity is available from local action plans:
Projects targeting children and young people
- School nurse project (structured approach to the delivery of mental and social health amongst school children in East Lothian and Agony Aunt service)
- School project (raising awareness of children around the information and supports available at times of crisis or emotional difficulty. The sessions are supported by the utilisation of the Samaritans Young Persons pack and the Young Minds 'Stay Cool in School' booklet)
- National Children's Home project (a nurse therapist post has developed in partnership with National Children's Homes and aims to offer direct support to young 'looked after' people on issues of emotional well-being, suicide and self-harm, while also facilitating the effective integrated working of professionals in the local area in a development role)
- 'Seasons for growth' training is a loss and grief education programme catering for young people aged 6 - 18 years. The core element of this programme is the promotion of social and emotional well-being for young people who have experienced significant loss due to death or family breakdown.
- RUOK? (see case study example in next section).
Projects targeting people who have been bereaved, including those bereaved by suicide
- including support to CRUSE.
Projects targeting mental health
- Local Association for Mental Health: funding for equipment and publicity and the appointment of a drop in centre manager have allowed this resource to grow and provide ongoing support to the community
- A stress management initiative has built on existing structures, e.g. established voluntary organisation and Health & Safety departments in statutory organisations.
Means for mainstreaming Choose Life funded activities
The most common stated means for mainstreaming is where the role/activity is taken over by statutory organisations or the activity has been built on to existing structures (six areas). In three areas, it is stated that the budget has already been agreed. In two areas mainstreaming has been achieved through an evaluation and prioritisation process. For a counselling service, following commissioning and evaluation, proposals will submitted for the mainstreaming of the service. In a further two areas the use of volunteers in order to support activity was a means to sustainability, particularly for existing organisations working with volunteers. For a Samaritans project, Choose Life had added value to the organisation by providing support for fund raising activities and in recruiting more volunteers. It can be suggested in relation to this point that a reliance on pool of volunteers might create challenges for sustainability (e.g. if an insufficient number of volunteers were recruited). CRUSE, however, highlighted that the actual existence of this organisation for 20 years was testimony to its sustainability.
Sustainability for existing activities in receipt of Choose Life funding
North Lanarkshire case study example Project: RUOK? In North Lanarkshire, sustainability was a key consideration from the start of phase one and an objective of the development coordinator's post was to develop sustainability of new initiatives. RUOK? is an existing resource and Choose Life is funding implementation of the activity across local schools in North Lanarkshire. The resource pack will be widely available on the internet. |
In many Choose Life partnerships, funding was allocated to existing local projects or service activities that were not 'new' (e.g. local existing project or national organisations such as CRUSE and Samaritans (see case study example opposite).
In Highland, for example, activity was structured to take into account the short term nature of funding and the area did not initially fund revenue intensive posts. It was agreed that projects funded through statutory organisations would be mainstreamed if proven successful. Similarly, Choose Life funded one-off or existing activities in voluntary organisations and it was anticipated that that projects taken forward through community/voluntary organisations would be able to compete for voluntary funding.
Conversely, some projects in case study areas highlighted from their experiences that short term funding can create a barrier to sustainability by increasing the difficulty of forward planning, particularly in developing a business plan. Time spent seeking funding detracted from the actual time spent with clients and the concerns surrounding sustainability put strain on workers. The case studies also provide examples of projects that were subsequently unsuccessful in applying for future funding from other sources.
Case study examples of how suicide prevention has been incorporated in policy, plans and strategies Joint Health Improvement Plan Mental health and well-being is a theme for priority action and a key aim is to focus on suicide prevention as a first step Community Plan cross references suicide prevention action plan Regeneration Outcome Agreement (Draft) Core objective regarding mental health & well-being; stated as a Development & Regeneration Services service objective Suicide attempts and self-harm are considered to be psychiatric emergencies in Psychiatric Emergency Plan Embedded in thinking around particular service developments, e.g., early intervention strategies in Mental Health Strategy (Draft) Included in NHS Children's Health Strategy in relation to health promotion and development of preventive services Links established between suicide and community safety in Community Safety Strategy |
Mainstreaming functions of coordination
Some areas considered how coordination of suicide prevention could be sustained locally. This was a particular consideration where areas had employed local coordinators. In Inverclyde, in the latter part of phase one, the coordinator was appointed as the health improvement officer. The new post is positioned in Social Work and Housing and is employed through the community planning partnership. The coordinator has been successful in ensuring that strategic elements of Choose Life coordination are carried into this new role. In North Lanarkshire, suicide prevention has been built in to the job description of a senior social work post. In another area, the NHS plan to take over funding of mental health improvement posts on a permanent basis.
7.3.2 Successes in incorporating suicide prevention in policy, plans and strategies
Suicide prevention has most commonly been incorporated in JHIPs and Community Plans. To a lesser extent, suicide prevention is also included in Regeneration Plans/Regeneration Outcome Agreements; Domestic Abuse Strategy; Alcohol Action Plan; Children's Services Plan; NHS Director of Public Health Annual Report; and mental well-being and improvement strategies.
Respondents in the first survey felt that the inclusion of Choose Life in local policies such as the JHIP helped to mainstream suicide prevention and links up efforts to generate or lever additional funding from other sources. For example, it was indicated that the incorporation of Choose Life into the JHIP would generate strategic responsibility to ensure that the aims and objectives of Choose Life were mainstreamed. This was thought to provide potential for support and development beyond core funding. Additionally, incorporation brought joint ownership of suicide prevention that was maintained upon other agendas as plans are monitored and reported upon.
Some coordinators report mainstreaming awareness raising and raising the profile of Choose Life (and suicide prevention) at a strategic level as a mechanism to achieve sustainability. For example, one area intends to raise the profile of Choose Life through the linkage of suicide prevention issues to other planning frameworks, such as children's services planning. In Highland, high-level representation on the Choose Life steering group was thought to put Choose Life in a position of influence in future discussions of investment priorities.
Box 7.3 Commentary Training Most success has been achieved in mainstreaming training activities and in achieving in-kind support to deliver this activity. The national endorsement of ASIST and its availability as a ready available training package has helped roll out this approach. Local enthusiasm and willingness to deliver training in-kind has also been key in success. The pricing policy, albeit unpopular, has helped build an approach for longer term sustainability. Project activities When this national evaluation reported, many partnerships were not at a stage of making decisions in relation to future priorities and this led to only a small number of possible projects being earmarked for sustainability. Feedback from funded projects highlighted learning from their experiences of other time-limited initiatives and implications for sustainability such as loss of expertise, knowledge, skills and morale. These are issues experienced by projects over a number of years and across different initiatives and are not only associated with Choose Life. Mainstreaming 'learning' Sustainability of 'activities' relates not only to the continuation of the project itself but also refers to the process whereby learning from piloted activities is integrated into mainstream ways of working (both voluntary and statutory organisations). This approach can be controversial for individual projects, however, when the actual project is not sustained, leading, for example, to loss of morale. Policies and plans Local areas have achieved the milestone of incorporating suicide prevention in local JHIPs. This has been facilitated by the inclusion of JHIP as a milestone in the Choose Life strategy and action plan, access to strategic partnerships and a willingness of partners to champion suicide prevention work. However, mainstreaming in other policies and plans has been opportunistic and has often been dependent upon the composition of the Choose Life partnership itself (e.g. whether members possess access to other relevant partnerships) |
7.3.3 Intentions around mainstreaming in the future
Respondents were asked about their future plans in relation to mainstreaming Choose Life activities.
Several coordinators highlighted as a key task for the next phase the need to raise the profile of Choose Life with strategic (particularly Community Planning) partners. It was felt that work was needed to generate a broader multi-disciplinary approach to achieve longer term sustainability (rather than mainstreaming of individual projects and activities). Examples from local areas include:
- Link to strategic planning for health improvement, e.g. as part of JHIP planning; embedding the health improvement outcomes within corporate priorities and mainstreaming within the body of work of all partner agencies
- More engagement with the Community Planning Partnership and other associated agendas (e.g. regeneration): encouraging ownership of the strategy and integration of activity within the Community Planning process, in order to encourage a broad approach to suicide prevention
- Focus on integrating activity in partnerships targeting key risk areas, e.g. Children's Service Planning, Mental Health Action Group, Mental Health Strategy
- Proactive feedback of successes during phase one to other organisations at senior management level.
Box 7.4 Commentary Moving beyond individuals and champions Continuity and consistency have proved invaluable in developing the depth and range of relationships required to work towards sustainability. Over-reliance on individual champions to carry the work forward in a key sector can mean significant disruption if/when the champions leave. In the longer term, it is important to identify strategies to off-set the likely decline in capacity available for coordination and for delivery, when the momentum generated by initial good will and enthusiasm slows down. Competing priorities National policy sets the scene for local work towards sustainability and can help or hinder progress. Local areas set store by predictability and report that they are better able to make good use of short-term funding where there is clarity from the outset about funding conditionality. The existence of many simultaneous initiatives, each working within a limited time frame and targeted at specific priorities, can have a potentially negative effect on overall local capacity and capability to achieve the desired impacts. The prevailing financial climate in local authorities and in the NHS further exacerbate the ability to put principles of plans in practice. Managing expectations Local areas face a difficult and complex task in raising awareness of and engagement with Choose Life objectives and managing expectations about what can be funded in the short and longer term. |
7.4 Progress in sustainability
The table 7.1 below summarises key elements of progress and highlights key challenges and issues to be addressed.
Table 7.1 Progress in developing a local infrastructure to support implementation
Sustainability development | Progress | Challenges/issues/gaps |
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NIST | NIST has encouraged an open, two-way communication link with coordinators Core activities have been successfully developed to support sustainability of information sharing, learning, research and data, public awareness and training | Fragility of infrastructure Continued work is required to nurture and build relationships/ encourage sustainability at a local level |
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National coordinators | National coordinators have contributed to the development of sustainable change; some successes in additional investment; | More success in developmental model than fund raising approach |
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Other national organisations | Valued added in developing the work of existing organisations. In-kind support has been provided, for example, training; bereavement support booklet; media guidelines | Implications for longer term sustainability of newly funded activities |
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Local areas: mainstreaming activities | Most success achieved so far in mainstreaming training | Short-term funding can lead to a loss of morale, expertise, knowledge. Prioritisation of 'innovative work' can have negative consequences without plans for sustainability |
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Local areas: mainstreaming in plans, policies and strategies | Range of strategies to build sustainability, influence plans and infiltrate other structures | Impact of simultaneous initiatives, each working within a limited time frame and targeted at specific priorities |
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Local areas: future considerations | Areas are proactively seeking links with strategic partners to facilitate sustainability | Need to off-set the likely decline in capacity when the momentum generated by initial good will and enthusiasm slows down |
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