The Scottish Government

« Previous | Contents | Next »

Listen

EXECUTIVE SUMMARY

Background

Over the past 50 years suicide incidence in Scotland has not been exceptionally high by international standards. In the mid-1990s the male suicide rate was about the average, and the female suicide rate below the average, compared with 17 Western European countries. Nevertheless, there had been a pronounced and dramatic increase in suicide among men in Scotland, with the rate more than doubling since the 1970s. The cost of suicide falls on everyone in society and can be substantial. In Scotland this is estimated to have been just over £1bn in 2004. There are considerable potential economic benefits if the number of suicides can be reduced. Every 1% reduction in the number of suicides (from the current level of 835 suicides) could avoid costs of up to £10.7 million (including tangible, intangible and indirect lost productivity costs) over the lifetimes of these individuals. Suicide also has a devastating emotional impact on surviving family members and friends, inducing feelings of abandonment, rejection and helplessness.

Choose Life

Choose Life: the National Strategy and Action Plan to Prevent Suicide in Scotland was launched in December 2002. The Choose Life plan is being implemented in phases, with an initial phase of three years (April 2003 to March 2006). A budget of £12 million was allocated by the Scottish Executive over this period to suicide prevention activities. Of this, £3 million was allocated to national activities and the remaining £9 million to local area partnerships for suicide prevention work. A further £8.4 million is being invested nationally and locally over the period 2006-2008.

Choose Life identifies the main suicide prevention actions that are required at both national and local levels. A designated National Implementation Support Team ( NIST) coordinates and supports development and implementation at national level. NIST's core functions include awareness raising/campaigning; working with the media; development and dissemination of information and knowledge; and supporting local implementation. In each of Scotland's 32 local authority areas Choose Life action plans have been developed by the Community Planning Partnership ( CPP) and a key lead/coordinating person has been identified with responsibility for liaising with NIST and sharing information with other local planning partners and stakeholders.

Evaluation of the first phase of Choose Life

In line with the growing commitment to evidence-based policy making within modernised government and the evidence-based practice within public health and health promotion, the Scottish Executive signalled the intention to commission an independent evaluation of Choose Life in the strategy and action plan. In 2004, following a competitive tendering process, the Scottish Executive commissioned a research consortium to evaluate the first phase of Choose Life.

The main aims of this evaluation study were to:

• Establish and apply measures to assess whether a sustainable infrastructure is being developed nationally and locally to support the Choose Life strategy in achieving its objectives
• Measure and review progress towards implementation of the 27 milestones identified in the Choose Life document (page 35) and set findings in context, nationally and internationally
• Examine whether and how Choose Life is stimulating effective forms of practice (nationally and in individual local areas)
• On the basis of findings, and in consultation with the Scottish Executive and the Research Advisory Group steering the evaluation, provide detailed and staged recommendations to guide the next phase of the action plan to achieve a 20 per cent reduction in suicides in Scotland by 2013, and the targeting of any funding available to support the next phase.

The evaluation focus was deliberately formative, rather than summative, with the evaluation team expected to contribute a detailed understanding of processes and to work collaboratively and developmentally with key Choose Life actors (nationally and locally).

Structure of the report

Part one of the report provides background contextual information, covering: suicide trends in Scotland, the cost of suicide, the Scottish Executive policy response and the Choose Life strategy ( chapter one); the aims and objectives of the study ( chapter two); and the study methodology ( chapter three).

The main research findings and commentary can be found in part two. Chapter four considers the development of national and local infrastructures to support suicide prevention. Chapter five covers the allocation of Choose Life funding both nationally and locally and provides a number of different breakdowns on how these resources have been used. Chapter six illustrates innovative practice underway in local areas, providing examples of relevant community, voluntary and self-help activities and describing how funding has been used for innovative ways of working. Chapter seven explores the progress towards, and prospects for, sustainability during phase two of Choose Life (and beyond), at both national and local levels. Chapter eight considers the different stages of decision making for Choose Life and provides an outline and discussion of the learning resources used at each stage. Chapter nine reports on local coordinators' level of satisfaction with progress towards national milestones and their self-assessment of performance for each of the local milestones.

The conclusions of the study and recommendations arising from the study findings are set out in part three ( chapters ten and eleven, respectively).

There are three annexes: annex 1 reviews national suicide prevention strategies across the world; annex 2 considers the economic costs of suicide in Scotland in 2004; and annex 3 assesses practical and methodological challenges associated with assessing the cost-effectiveness of area-based suicide prevention strategies.

Methods

The overall approach taken to the evaluation was theory-based, with particular use being made of Theories of Change (ToC), in which the evaluator, in conjunction with key stakeholders, seeks to identify prospectively the underlying rationale or 'theory' of the planned programme. Different models of how best to implement a suicide prevention programme were explored at both national and local levels, with a particular focus on why particular actions and activities were anticipated to lead to which kinds of goals.

Research methods used in the course of the study included electronic surveys of local coordinators, qualitative interviews with key informants at national level, workshops with local coordinators and national informants, observation and documentary analysis.

Main findings and conclusions

Sustainable infrastructures for implementation

At a national level, the NIST has played a pivotal role in working towards the mainstreaming of suicide prevention activity within the wider Scottish Executive policy arena. Despite a lengthy process to establish the team, NIST has made demonstrable progress and built momentum in relation to all its key functions, while also recognising the need to be increasingly strategic. There are challenges ahead for NIST, including: building clinical involvement and engagement at national and local levels; and facilitating local capacity building in key areas of identified weakness, e.g. monitoring and evaluation.

CPPs have been the best available mechanism to take forward local planning, coordination and implementation of Choose Life objectives, in view of the importance attached to local, cross-sectoral ownership of, and grass roots engagement in, suicide prevention activities. Progress has been made in encouraging the adoption of suicide prevention objectives in a range of local policies and service plans and Choose Life partnerships have generally sought proactively to achieve this, by building links with key partners, seeking engagement with key decision makers locally and linking into other relevant policy priorities. This has proved to be a gradual process that requires time and concerted effort. It cannot be said that, as yet, Choose Life had been mainstreamed, although it is making progress in that direction.

However, the variability in the maturity of local CPPs has had a critical influence on Choose Life progress at local level. CPPs have been less effective in engaging with clinical services and planning structures (both primary and secondary health care, in particular drug and alcohol services and mental health services).

It is important to consider the focus of activity required at national level for the future stages of implementation, to make use of resources of all national players, recognising what it is that NIST is uniquely placed to do and what contributions can be made by other agencies. The evaluation suggests that progress towards Choose Life objectives is predicated on effective activity at national level in respect of:

• Policy advocacy within the Scottish Executive and with other relevant national bodies
• Raising awareness and influencing those who shape opinions
• Promoting engagement and facilitating dialogue
• Coordination across boundaries, acting as catalyst
• Performance management to track and oversee progress
• Building capacity, in particular to use and generate evidence.

Various models of local coordination had been developed and subjected to refinement as local work progressed. A dedicated (full-time) coordination post tended to be preferred. However, the evaluation has not been able to provide conclusive evidence that this model is more, or less, effective than alternatives.

Allocation and use of resources

In the first phase of Choose Life, CPPs attracted substantial additional investment in suicide prevention activities at local level (£1.6m), and there has also been a substantial level of in-kind contribution. On the other hand, not all areas have been equally successful in raising additional monetary funding and a high degree of variability is evident among local areas in terms in the way resources are allocated to the key functions of coordination, training and support for voluntary and community sector, priority groups, and specific activities and interventions.

There are grounds to conclude that there is a degree of unnecessary duplication of effort at the local level: a greater effort to undertake some work on a collaborative basis would ensure that best use is made of common approaches and effective tools and resources. Steps towards building collaborative models of development are already in evidence.

Overall, the evidence would suggest that the emphasis to date has been on gaining local engagement with Choose Life and on supporting local initiatives that facilitate such engagement. The broad range of priorities set in the Choose Life strategy allowed local areas a high degree of latitude to determine their local focus. It may be that, in future stages of implementation, more attention needs to be directed towards considerations of equity on at least two counts: to take account of what is known about relative importance of particular risk and protective factors in determining suicidal behaviour; and to ensure that interventions are targeting inequalities and focusing on how to reach those for whom support is currently least accessible.

Seeking to make resources and responses more accessible and acceptable to certain groups who tend to be deemed 'hard to reach' will have implications for the types of interventions offered and methods and mechanisms of delivery, as well as for the partners who need to be involved.

From an economics perspective, under the evaluation team's baseline assumptions, the Choose Life would become cost saving if five additional lives per annum were saved. This suggests that investing in the strategy represents value for money. However, only when evidence of the effectiveness of individual initiatives is available will it be possible to claim definitively that investing in Choose Life represents value for money.

Choose Life has stimulated a considerable amount of activity relating to self-harm, but the findings suggest the need for further consideration by NIST about how to integrate action on self-harm into the wider suicide prevention strategy.

Innovative practice and the use of evidence

Twenty-one local areas provided examples of locally defined innovative community and voluntary practice. Activities covered prevention/promotion, intervening/ supporting vulnerable groups, developing new partnerships better to support those at risk, and improving the capacity of those working with vulnerable groups. Almost all areas that provided examples of community and voluntary initiatives reported that they had achieved what they set out to do or exceeded this.

Fifteen local areas provided specific examples of self-help activities. In four areas, links were established with the local Doing Well by People with Depression project. Group support was a common approach and included mental health service user-led support groups; groups in arts, drama, poetry and writing; and support for those who had experienced childhood sexual abuse. Supporting the development of self-help initiatives tended to be regarded as means to add value to existing interventions and services. Developments were often initiated in response to local need or demand.

The process of setting up community, voluntary and self-help initiatives generated important learning points, including: the importance of bringing agencies together at an earlier stage to decide on priorities; allowing time for needs assessment before commissioning in order to establish requirements for a service prior to funding; the value of proactive engagement with national/established organisations; and the need to support the infrastructure of self-help groups and budget for unanticipated costs associated with this.

Coordinators reported that good progress had been made in respect of innovative partnership working. Partnerships with and between voluntary organisations continued to be seen to reap benefits. Improved partnership working within local authorities and across the neighbourhood authority was commonly highlighted as a factor contributing to success. Some areas pointed to an improved ability to impact on vulnerable risk groups through the development of new ways of working.

There was limited progress at local level in generating evidence of impact. Multiple sources of information and types of evidence, including research, were used to inform local planning and activity. However, research was rarely used systematically. There remains an absence of accessible, robust, definitive evidence of effectiveness.

Sustainability

NIST identified a number of achievements in building a sustainable infrastructure for suicide prevention. Several mechanisms and activities are now in place to encourage and support the exchange and dissemination of information, including the Choose Life website, NIST summits held annually and the resource database. NIST has worked in partnership with other elements of the National Programme, such as Breathing Space, HeadsUpScotland and see me, to promote activities. The Suicide Information, Research and Evidence Network ( SIREN) is intended to improve access to research. NIST has established a national resource to oversee development and integration of training. The main programme used to date, Applied Suicide Intervention Skills Training ( ASIST), is seen nationally as a vehicle for raising awareness, building longer term capacity, and widening ownership of suicide prevention beyond professional health specialists.

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. 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.

At the local level, most success has been achieved in mainstreaming training activities (particularly ASIST) (18 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. At least 27 local projects have been earmarked for mainstreaming, covering:

• Children and young people
• People who have been bereaved, including those bereaved by suicide
• People with mental health problems.

Suicide prevention has most commonly been incorporated in Joint Health Improvement Plans and Community Plans. 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 Reports and mental well-being and improvement strategies. Inclusion of Choose Life in local policies was thought to support mainstreaming of suicide prevention.

With respect to future plans for mainstreaming Choose Life activities, the need to raise the profile of Choose Life with strategic (particularly Community Planning) partners was highlighted. 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).

Decision making processes and learning

Local stakeholder consultation was a key approach used across local areas in order to set priorities for implementation. Around half of the local areas stated that some form of needs assessment was undertaken to identify local priorities in terms of risk groups and gaps in local services and/or to inform overall planning. Practitioner/professional led approaches were highlighted as a key resource in decision making about interventions. There appeared to be infrequent use of international research evidence in order to aid decision making about interventions. Some local areas were keen to generate innovative approaches to suicide prevention and this affected the approach taken to decision making. Local knowledge could also inform the development of interventions. It was believed that, if the intervention was developed in response to locally defined needs, it would be more likely to gain acceptance from the local community in which it operated.

A key challenge acknowledged both locally and nationally was the short timescale in which to develop the first action plan (December 2003). It is evident that plans in local areas reflected a broad set of priorities that were then refined in the implementation stage. Where initial planning had stayed primarily within the confines of the Choose Life partnership (without wider consultation) some stakeholders expressed unease about the transparency of the decision making process.

The implementation stage resulted in the design of new processes to share learning and knowledge. Sharing between local areas, e.g. at national events or though regional networks, led to instances of learning and uptake of training across different areas. National support for learning has been delivered through several channels, including: NIST hands-on support to local areas, commissioning research reviews, developing a web-based resource database of relevant resources/materials, establishing SIREN and commissioning an independent national evaluation of the first phase of Choose Life.

With regard to future planning, NIST has highlighted a strong commitment to, and emphasised the importance of, evaluation. However, as a result of the lengthy process which had to be undertaken to establish NIST, and limited capacity within the team, a national framework for evaluation remains to be completed. In local areas different levels of priority and attention have been attached to evaluation. Challenges in evaluating local action plans were identified by both local and national informants, particularly in understanding how effectiveness of interventions should be evaluated. A lack of capacity locally to develop evaluation was also noted.

Perceived progress towards milestones

Local coordinators were more satisfied than dissatisfied with national action on 12 of 13 milestones. Coordinators were most satisfied with action on publishing guidelines for the media; with education and awareness raising; and supporting, disseminating and developing national and local indicators, figures and trends on suicide and deliberate self-harm. Most coordinators reported some level of implementation action in relation to 10 of the 12 local milestones. The most reported progress has been made with establishing local action plans to implement Choose Life; and developing and implementing local training programmes in line with national and local strategy and plans.

Recommendations

Future investment in suicide prevention

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.

Immediate decisions about the allocation of funding for Choose Life in 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. Consideration might be given to an increase in funds to the national coordinating body, since current capacity means that development of existing and new partnerships is not being maximised. This has a potential impact on future sustainability.

Sustainability

Key steps at national level to promote mainstreaming in the next stages of Choose Life implementation might encompass the following:

• Using opportunities presented by recent developments in national health and social care policy to demonstrate the relevance of Choose Life to overarching policy goals
• Involving clinical services in population-based suicide prevention activities
• Strengthening the engagement of national bodies
• 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 and local 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, key steps to promote mainstreaming of Choose Life activities might include:

• 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.

Targeting of action

There should be more focused targeting of action in order to maximise the value of the ring-fenced Choose Life investment. Issues to be taken into consideration include:

• The need to avoid unnecessary duplication of effort at local level
• The importance of intervention by the national coordinating body where key suicide prevention actions are not taken at the local level (e.g. failure to integrate substance misuse treatment services into delivery plans)
• A more 'experimental' approach to assessing the merit and worth of local suicide prevention interventions should be adopted
• The need to distinguish between what is best done at local level and what is best done at national level. 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
• The achievement of a balance between the application of 'established' suicide prevention interventions and innovative practice
• The importance of assessing local priorities and taking these into account in local action plans, even if the priorities differ from those identified at national level.
• The need to reinforce the equity focus of current priorities. In particular, socio-economic deprivation and low socio-economic status, which are known to be highly associated with the incidence of suicidal behaviour, should be given more prominence
• The need to ensure the adoption of an evidence-based approach at all levels.

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.
• The less 'serious' component of self-harm cannot be ignored, even if it is not included in the scope of Choose Life. In particular, the Scottish Executive/ NHS Scotland should ensure that health and social care professionals in Scotland adopt the NICE guidelines on the treatment of self-harm ( NICE, 2004)
• If self-harm remains a focus of Choose Life, there should be guidance about how incidence is to be measured and what target for its reduction is to be set.

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).

• 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 or 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.

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.

Choose Life: a ground-breaking approach

Although there are many similarities between Choose Life and other national suicide prevention strategies, Scotland's approach is distinctive in several respects. Choose Life forms one element of the Scottish Executive's National Programme for Improving Mental Health and Well-being, which was established as a key driver of the commitment to improve health, tackle health inequalities and achieve social justice in Scotland. The location of Choose Life within the Scottish Executive ensures that suicide prevention work is undertaken within a wider framework of policy objectives and initiatives that share the overarching goals of population mental health improvement. Choose Life sets out a clear approach and plan for implementation, which includes dedicated national capacity to support and coordinate implementation, underpinned by an earmarked national and local budgetary allocation.

Scotland has also been committed from the beginning to reviewing progress and taking forward learning. This formative evaluation has been a key part of the process. By reviewing the situation after three years, Scotland should have a clearer picture about the strengths and limitations of the unfolding strategic approach and what the next steps should be. The methodology and findings of the evaluation are also intended to contribute to international understanding and knowledge about effective national suicide prevention (at both strategic and operational levels).

« Previous | Contents | Next »