« Previous | Contents | Next »
Listen
CHAPTER 11 RECOMMENDATIONS
We make a number of recommendations, relating to future investment in Choose Life, sustainability, targeting of action, the strategic integration of self-harm, the role of the Community Planning Partnership, options for delivering the national coordination function, and outcomes and targets. We do not stage these recommendations, since all are considered to be of high priority and therefore require consideration and action early in phase two.
11.1 Future investment in suicide prevention
Threshold analysis carried out for this report suggests that, if Choose Life achieves even a very modest reduction in the rate of suicide, at the current level of investment this is likely to generate costs per life year saved below £30,000. This is the case even if a narrow public sector cost perspective, rather than a societal perspective, is adopted. Investment in suicide prevention at the current level would appear, therefore, to represent value for money and the level of success required by the strategy would be modest. With greater success the programme would even be cost saving. However, cost-effectiveness analysis cannot be conducted (even less, cost-effectiveness demonstrated) if there is no evidence of effectiveness - and at present such evidence is not available.
Any future economic evaluation of the Choose Life strategy would almost certainly be one of the first (if not the first) evaluations worldwide to be undertaken of a national strategy. In addition to issues of outcome measurement, it will be critical to collect data on the cost and uptake of different components of a suicide prevention strategy. This should include measurement of all in-kind resources, including the contribution of volunteers. It is also important to link the results of any economic evaluation to the context in which interventions are delivered. In the case of Choose Life, the wealth of information emerging from phase one of the evaluation could play an important role in describing this context. ( See annex 3 for more discussion of these issues and arguments on the potential use of different economic evaluation techniques, including cost benefit analysis,)
Immediate decisions about the allocation of funding for Choose Life in the early years of phase two have to be based, therefore, on what is required in terms of the further development and maintenance of national and local infrastructures so as to maximise successful progress towards the key strategic target (20% reduction in suicide). We have not collected any evidence to suggest that radical changes should be made in the current allocation to local partnerships. Given the amount of unspent funds at local level, there might be calls for a redistribution from local to national elements, but we believe that this move would be premature and should be resisted. There were valid reasons for the underspend in the first two years of Choose Life and budgets are now moving into balance. In time, more resources may be required at local level to enhance the integration of clinical and drug/alcohol services into suicide prevention activity. Consideration might be given to an increase in funds to the national coordinating body, since NIST has been overwhelmed at times by the support needs of local partnerships.
11.2 Sustainability
Key steps to promote mainstreaming in the next stages of Choose Life implementation might encompass the following:
At national level:
- Using opportunities presented by recent developments in national health and social care policy, including Delivery for Health and the emergent Mental Health Delivery Plan, as well as the Review of 21 st Century Social Work, to demonstrate the relevance of Choose Life to overarching policy goals, such as promoting self help and self management; anticipatory/preventive care
- Involving clinical services in population-based suicide prevention activities
- Strengthening the engagement of national bodies, e.g. COSLA and Communities Scotland, that can promote involvement of key sectors at local level
- Harnessing the energies and skills of national voluntary sector organisations in awareness raising and campaigning
- Promoting the incorporation of Choose Life objectives and priorities into other national policy streams and initiatives as an ongoing priority
- Purposive innovation to test out, evaluate, learn and implement, with a view to building knowledge and enhancing capacity to work towards key objectives and priorities.
At local level:
- Using intelligence from a range of sources, including needs assessment, research evidence on risk and protective factors, local evaluations and service reviews as tools in planning for sustainability
- Building in mechanisms to track and review progress towards objectives across policy areas.
11.3 Targeting of action
There should be more focused targeting of action in order to maximise the value of the ring-fenced Choose Life investment. The following issues should be taken into consideration when addressing this recommendation.
- Unnecessary duplication of effort at local level should be avoided. This particularly applies to training initiatives and the implementation of innovative suicide prevention interventions. The possibility of pooled/collaborative initiatives across several local areas should be given serious consideration. The national coordinating body should seek to influence this process.
- The national coordinating body should intervene where important aspects of suicide prevention are being ignored at the local level. A prime example would be the failure to integrate substance misuse treatment services into Choose Life delivery plans. However, the first challenge to the national coordinating body is to ensure better integration of clinical services and Choose Life activities at national level. Local areas cannot be expected to follow if the national body is not leading by example.
- A more 'experimental' approach to assessing the merit and worth of local suicide prevention interventions should be adopted, especially at early stage of phase 2. Developmental work still remains to be done in order to test the transferability to the Scottish context of interventions which have shown promise elsewhere and also to evaluate promising innovative practice. Rather than take a laissez faire attitude towards this vitally important work, the national coordinating body should seek to ensure that the whole of Scotland becomes a laboratory for a rigorous assessment and evaluation of potential suicide prevention interventions. The achievement of successful outcomes in one (or several) local areas should then be followed by roll-out across the rest of the country.
- In considering candidate activities/interventions for suicide prevention, it is important to distinguish between what is best done at local level (e.g. identify and respond to local need) and what is best done at national level (e.g. awareness raising). The national coordinating body should engage in a dialogue with national partners and local areas in order to reach consensus on the appropriate division of responsibility.
- In taking forward action in phase two, a balance should be struck between the application of 'established' suicide prevention interventions (recognising that these may still be to some degree unproven in the Scottish context - evidence of positive impact may not be transferable from another country/health system/policy context) and innovative practice. At this stage in the evolution of Choose Life, both approaches are required. The expectation of appropriate and adequate evaluation of innovative practice should be built into performance review
- The limitations of the priority group approach should be recognised. Priorities tend to be rather general and to depend heavily on the international research literature or the epidemiological picture at national level. The epidemiology of suicide at the local level, however, may be crucially different in many respects. The assessment of local priorities should be encouraged and taken into account in local action plans, even if the priorities differ from those identified at national level. Additionally, the number of priority groups should be as small as possible. When there are too many, it is inevitable that there will be further differentiation or rank ordering among them. Lower order priorities will tend to be overlooked.
- The national coordinating body should reinforce the equity focus of current priorities. In particular, it is surprising that socio-economic deprivation and low socio-economic status, which are known to be highly associated with the incidence of suicidal behaviour, are not highlighted in the strategy.
- The national coordinating body should ensure that all participating organisations and players, both national and local, adopt an evidence-based approach, drawing on findings from research (especially primary evaluated intervention studies and systematic reviews of effectiveness), local needs assessment and intelligence, and practitioner expertise, when drawing up plans for suicide prevention interventions. This expectation should be built into performance review processes.
- The national coordinating body should ensure that evidence about effective interventions accruing at local level is collated and disseminated to relevant Choose Life organisations and beyond, and that this evidence has an impact on practice.
11.4 Strategic integration of self-harm
In phase two, more consideration should be given to the integration of self-harm into Choose Life. We recommend that the strategy continues to encompass the high risk end of self-harm, but note several issues that need to be addressed.
- The national coordinating body needs to provide guidance about how to identify and reach the subgroup of people whose self-harming behaviour puts them at high risk of future suicide. An operational 'case' definition of the subgroup might be all those who are admitted to hospital following an episode of self-harm. However, there is no perfect correlation between hospital treatment and the (medical or psychosocial) 'seriousness' of the behaviour: many (perhaps even the majority) of those treated in hospital will not represent a high suicide risk and a small, but significant, minority of those who do not attend hospital (not referred or refusing to attend) will be high risk (and will go on to commit suicide). Whether an alternative approach to 'case' finding can be devised, which offers better sensitivity and specificity and is practical and feasible, remains to be seen.
- The less 'serious' component of self-harm cannot be ignored, even if it is not included in the scope of Choose Life. The majority of people who self-harm are probably not at high risk of suicide but nonetheless constitute a group with a high level of unmet psychosocial need and extensive experience of stigmatised and hostile responses from both the public and professionals. The Scottish Executive/NHSScotland should ensure that health and social care professionals in Scotland adopt the NICE guidelines on the treatment of self-harm ( NICE, 2004), pay attention to recommendations of the National Inquiry into Self-harm among Young People (2006) and continue to focus anti-stigma campaigns on this behaviour.
- If self-harm remains a focus of Choose Life, there should be guidance about how incidence is to be measured (which depends in turn on the operational definition - see above) and what target for its reduction is to be set (see below).
11.5 The role of the Community Planning Partnership
The limitations of the community planning partnership ( CPP) as the key Choose Life coordinating body at local level need to be recognised. In particular, CPPs have been less effective in engaging proactively with clinical services and planning structures (both primary and secondary health care, in particular drug and alcohol services and mental health services). How can these and other currently excluded partners be integrated into the Choose Life effort and be encouraged to 'own' the Choose Life agenda?
- CPPs need to review progress and examine the partners and partnerships that have yet to be put in place in order to achieve their CL objectives. Priority should be given to establishing effective links with clinical and drug/alcohol services where these are found to be absent to inadequately developed.
- In order to counterbalance the limitations of using CPP mechanisms, the Scottish Executive might adopt a more directive approach in relation to key priorities, using other policy implementation mechanisms to ensure engagement of key partners in clinical services and following through the proposed integration of clinical perspectives within national Choose Life support capacity.
- Despite the above, the CPP remains the most appropriate vehicle for developing strategy and overseeing delivery in relation to Choose Life at the local level. However, NIST, on behalf of the National Programme, should continue to work closely with CPPs in order to ensure that Choose Life budgets are fully spent on suicide prevention activities, reducing the risk of claw back of unspent allocations by parent local authorities.
- The coordination function is crucial, but that does not necessarily imply that there has to be a dedicated coordinator post. The task of the CPP is to devise the most appropriate arrangement for delivering the function.
11.6 Options for delivering the national coordination function
Some type of central coordination body will continue to be required (at least in the immediate future) to provide national oversight/guidance, assess and support performance and ensure accountability at local level, promote learning/review/reflection and effective knowledge transfer, and coordinate action, i.e. act as the 'glue' that holds together the various Choose Life elements, nationally and locally. While we recommend the continuation of a central coordinating function, we propose a review of how this is delivered and where it is situated. The ideal location would maximise mainstreaming opportunities and promote an integrated approach to suicide prevention, incorporating both general population health improvement (public health) and risk group (e.g. clinical services) perspectives.
- A key question is whether this function should remain as a separate section/department within population mental health policy. Currently Mental Health Division is the policy and delivery home for suicide prevention. However, because core Scottish Executive Departments focus on the making of policy, the delivery of policy is more usually carried out by Scottish Executive agencies, local authorities and other bodies. Awareness raising, working with media, improving information capture/dissemination and supporting implementation are functions that relate to mental health improvement work more generally. Thus, some of these functions could also be taken on by organisations which already have delivery responsibilities in these areas, e.g. NHS Health Scotland and the Scottish Public Health Observatory. Such changes could improve opportunities for mainstreaming suicide prevention.
- However, suicide prevention is by no means secure. There is a danger that the momentum and progress gained over the past few years will be quickly dissipated. Another consequence of the dilution of a dedicated coordinating body might be the withering away of a public health perspective and privileging of a clinical, high risk approach. This could be counteracted if the policy home for suicide prevention were moved to Health Improvement Strategy and Support. But (assuming that some of the functions of the national coordinating body were still taken on by other organisations) this might be a similarly unbalanced solution, leading to the continued marginalisation of clinical services.
11.7 Outcomes and targets
Although this is not an area which was explored in great detail in the course of the evaluation, we draw on a wider literature to offer some recommendations concerning the development and operationalisation of outcomes and targets for the second phase of Choose Life. Many issues need to be addressed, including:
- At the national level, the definition (and therefore measurement) of suicide should be clarified (we recommend that undetermined deaths are 'counted' as suicide for the purposes of tracking progress towards the strategic target), an appropriate measure of high suicide risk self-harm should be established (see above), and a target for reduction of self-harm should be adopted (assuming that targets for Choose Life continue to be set - see below)
- At local level, there are very large 'natural' major fluctuations in suicide incidence and small numbers of deaths (therefore wide 'confidence intervals' around 'average' trends). As a consequence, it makes no sense to translate the 20% suicide reduction target at national level into a similar target at local level. It will be virtually impossible in the majority of areas to demonstrate that such a target has been reached or, if reached, that the reduction in suicide is attributable to Choose Life interventions. We suggest that, if targets are to remain, consideration should be given to the identification of a 'proxy' measure that is more robust in terms of establishing and monitoring trends. Hospital-treated self-harm is probably the best candidate, but the problems with this measure have been noted above.
- In view of the difficulties of establishing trends at the local level, more attention should be paid to the collection of data on measures of process (implementation) and output, ensuring that: (a) the measures are few in number and, as far as possible, agreed through negotiation with local Choose Life planning teams; (b) the measures are logical intermediate steps towards the ultimate outcomes (reduction of suicidal behaviour); and (c) relevant data can be collected routinely through existing datasets. Evidence of positive change in these measures (e.g. more professionals and public receiving suicide intervention training) would help to establish a plausible case of progress towards ultimate (but difficult to measure) suicidal behaviour outcomes.
- While targets can be helpful in 'concentrating the mind' and galvanising action, disadvantages also have to be recognised. Not all national strategies have adopted targets (Ireland is a recent example). If Choose Life is to continue in its use of a target, care needs to be taken to ensure that this is set at a level, and presented in such a way, that it inspires (rather than demotivates) key national and local actors. This suggests the need to consider the appropriateness of setting the intended reduction at 20% (which is exceptionally ambitious, given the trends during the previous three decades) and replace it with a lower quantitative target or even a directional (i.e. non-quantitative) target.
« Previous | Contents | Next »