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PART TWO FINDINGS AND COMMENTARY

This part of the report presents the main findings from the study in six chapters: sustainable infrastructures; allocation of resources; innovative and effective practice; sustainability; decision-making and learning; and perceived progress.

Analytic commentary by the evaluation team is clearly identified and separated from the descriptive text (through the use of boxes). In chapters four to nine, the descriptive text is based upon findings reported to the evaluation team via national interviews, case study work, coordinator surveys and workshops. The commentary boxes assess and reflect on the themes emerging from these data.

Where relevant, boxed examples of funded Choose Life implementation activities provide the reader with more descriptive examples from the case studies that reflect issues discussed in the main text.

CHAPTER FOUR SUSTAINABLE INFRASTRUCTURES

4.1. Introduction

The action plan to implement the Choose Life strategy attached considerable importance to the development of infrastructures at both local and national levels to ensure the achievement of objectives for suicide prevention in Scotland.

In this chapter, the development of national and local infrastructures to support suicide prevention is considered. At the end of each main subsection there is a table summarising the progress made in developing infrastructures to support implementation. This examines similarities and differences in approaches taken and identifies some of the challenges that remain.

4.2 Development of a national infrastructure to support suicide prevention

This section considers the development of a national infrastructure to support suicide prevention and considers the role of NIST, national Choose Life coordinators, cross-cutting links and collaborative working between NIST and national organisations and networks.

4.2.1 Role and placement of National Implementation Support Team

As described in chapter one, NIST was established to oversee implementation of the Choose Life objectives and to support local action. The start up process was lengthy (see the Choose Life timeline, table 1.2), largely as a result of the number of different strands of work that had to be established.

NIST reports to the National Programme for Improving Mental Health and Well-being which is situated within the Mental Health Division of the Scottish Executive Health Department. National informants (primarily NIST) highlighted ways in which alignment to Scottish Executive structures impacted upon implementation of phase one of Choose Life. Advantages of this model included:

The following disadvantages of this model were noted:

Goals for NIST

NIST described a number of goals (see figure 4.1) that were driving their work at national level to support implementation and contribute to the prevention of suicide. These were:

• To increase awareness of the Choose Life strategy and promote ownership and engagement across wide range of sectors and departments in the Executive
• To improve knowledge and understanding of suicide epidemiology and evidence of effective interventions
• To promote a better understanding of the contribution that different agencies and individuals can make to suicide prevention.

Clarity about these goals and the precise role of NIST in supporting national infrastructure development emerged over time. This was influenced by the following factors:

• initial delays with recruiting staff; as a result, key members of the team were not in post until half way through phase one
• newness of national operational model; as a result, the development of roles and functions was a lengthy process.

Figure 4.1 A composite national theory of change

Functions

In national interviews, four main functions of NIST were identified: awareness raising/campaigning; working with the media; improving and disseminating information; and supporting local implementation. These are discussed in turn below.

Awareness raising / campaigning

According to the Scottish Executive, an essential function of NIST was to bring national attention to suicide prevention, on the grounds that a purely local approach would not be sufficiently powerful to achieve the long-term suicide reduction goal. NIST considered that, in the early stages, this aspect of their work had tended to be reactive; over time, the team has taken an increasingly strategic approach.

NIST and their national partner organisations indicated that a great deal of awareness raising work had been undertaken and informants considered that Choose Life had been effective in raising the profile of suicide with the public and among services and in communicating the message that suicide is not only a medical problem. However, there was a shared awareness that further work was required. National organisations considered that closer coordination to link the awareness raising activities of different organisations would create a more effective united front in work with the media, with clear, consistent messages, and the opportunity to pool resources and expertise.

Working with the media

NIST's work with the media was regarded by national informants as important and highly effective. The team had made considerable progress towards the Choose Life objective of 'supporting the media' and NIST had worked actively to implement the NUJ media guidelines ⁴ (launched in July 2004) in local areas. These guidelines were developed collaboratively between NIST and the NUJ in order to help journalists report more appropriately on mental health and suicide.

National interviews and two case study areas cited examples of joint working between NIST and individual local areas, for instance where NIST had been able to work with local stakeholders and improve reporting practice following instances of previously poor coverage.

The factors that contributed to NIST's ability to perform this function effectively were:

National informants emphasised the need to sustain media work and to take an increasingly strategic approach to partnership working and proactive intervention. This was important in order to avoid irresponsible reactions to suicides by the local media that might impede achievement of longer term objectives.

Improving and disseminating information

The Scottish Executive expected NIST to develop a performance management infrastructure to monitor activity (the NIST local action plan templates are discussed in chapter five). Over time, NIST had become more familiar with the information needs of national organisations and the National Programme for Improving Mental Health and Well-being, and more adept at meeting these needs. NIST had developed various approaches to improving and disseminating information:

• Choose Life website⁵

The Choose Life website was launched in suicide prevention week (September) 2005. NIST sought feedback from local coordinators on the design and content of the website to ensure that it was appropriate to local needs. The Choose Life Website acts a key mechanism to synthesise information on national and local activities, contacts, tools and resources and was intended to be accessible to both professionals and the general public. The website includes resources such as:

• • Information on local action plans
  • Data on suicide trends and statistics
  • Support booklet for bereaved families / friends
  • Information on research
  • Media reporting guidelines
  • Information on training
  • The resource database commissioned by NIST is a web-based resource of materials relevant to activity in suicide prevention, intervention and postvention (see also chapter eight).
• )SIRENSuicide Information, Research and Evidence Network (

The Suicide Information, Research and Evidence Network ( SIREN), launched in June 2005, aims to increase understanding of suicide and its prevention through information sharing and networking, and ultimately create a sustainable Scottish association for the study of suicide. SIREN is designed to improve access to research for non-research communities, and involves a range of stakeholders, including coordinators (national and local).

• Data on suicide statistics

Data on suicide statistics are made available to lay and professional communities via the Choose Life website and through circulation of data on suicide statistics to local Choose Life partnerships. In phase one, NIST has worked with the Scottish Public Health Observatory ( SPHO) to ensure that data on suicide statistics will be updated regularly. (The SPHO is a collaboration of key national organisations involved in public health intelligence in Scotland, which works to provide the public health community with easy access to clear and relevant information and statistics to support decision making.)

Strengthening of dissemination role

National and local informants were keen that NIST should continue to strengthen its coordination and dissemination role as well as to increase its efforts in supporting effective implementation. In particular, it should give further attention to:

• Providing information on 'what works' and on gaps in research
• Providing information geared towards stimulating partnerships and innovation
• Strengthening support for a 'community of learning'
• Collecting the type and level of information that would be useful as implementation progressed.

Supporting local implementation

NIST's role in supporting local areas is explored in section 4.3.

4.2.2 Role of Choose Life national coordinators

As discussed in chapter one, three organisations (ChildLine, the SPS and the Samaritans) have national coordinators funded through Choose Life. There was a general view among national informants that the establishment of these funded coordinators had strengthened the national infrastructure by:

• Stimulating the development of links between national organisations. For example, although the SPS and the Samaritans already had a good working relationship, Choose Life added value by providing opportunities for the Samaritans to consider new areas of work in 'anticipatory' support. ChildLine and the Samaritans worked together for the first time in considering preventative work targeted at young people.
• Facilitating the identification of joint goals with other national organisations in pursuit of a common vision. Choose Life helped the Samaritans to feel part of a wider infrastructure of support. For example, although the organisation was not directly working with Breathing Space (a free, confidential phone-line for people experiencing low mood and depression), closer links had been established and there was an understanding that the organisations were working towards achievement of a similar objective.
• Creating an identifiable key contact point. For example, the ChildLine coordinator had focused upon making links and consolidating relationships with Choose Life partnerships. This provided local areas with a point of contact for information about activities supporting young people and also helped to break down misconceptions, e.g. about how ChildLine is funded.
• In the early stages of phase one these three coordinators lacked clarity about how they were expected to report back to NIST and their parent organisation. One informant highlighted a further challenge in that coordinators had come into post at different times and had employed different models of coordination. This could create difficulties in establishing a common approach in overlapping areas of work. Another national organisation without a coordinator highlighted that there had been some uncertainty about how funding decisions for national coordinator posts had been made. Reporting mechanisms improved with the introduction of regular meetings with NIST. In addition, NIST was a member of the SPS Management Board and the Samaritans UK management group

Further work was still required to ensure that the expertise of the organisations was utilised optimally and links with other relevant national organisations continued. Although there was praise for NIST's work in relation to suicide prevention week in 2004 and 2005, there was also a view that activity around this event could be even better coordinated across national organisations to strengthen approaches to awareness raising.

4.2.3 Establishing the foundations for collaboration

This section considers progress made by NIST in establishing cross-cutting policy links and in building collaborative working with and between national organisations and networks.

Cross-cutting policy links

Choose Life promotes a public health approach to suicide prevention that rests on broad ownership and shared responsibility across Scottish Executive policy departments. National informants had expectations that awareness raising by NIST with policy colleagues would lead to increasing inter-departmental commitment to suicide prevention objectives. An overarching structure to facilitate this had been built through the development of good relationships between NIST and other initiatives and organisations linked into the National Programme. However, data generated in the national interviews suggested that links with non-health departments of the Scottish Executive had been slow to develop in the first phase of implementation. NIST was aware that there was still 'a lot of work to do'. A lack of capacity within NIST was held to be the main factor: the head of implementation had worked single-handedly for the first eight months. In addition, with the agreement of the National Programme, the team had initially prioritised building links with local areas. Consequently, the development of contacts with other national policy developments were largely opportunistic.

In recognition of the problem, the head of the Mental Health Division and the director of the National Programme assumed responsibility for influencing and developing cross-cutting policy. It was agreed that the policy division of the National Programme would act as a catalyst to identify links between policy areas and NIST would take forward the operational implications.

As Choose Life progressed, increasingly extensive links were made between Choose Life and other Scottish Executive policy departments and policy arenas. This included shared links with criminal justice to the National Confidential Inquiry into Suicides/Homicides by People with Mental Illness. Outside NIST and the National Programme, however, there was little awareness of the cross-cutting work that had been undertaken. The change in approach documented above had also not yet trickled down to other national or local stakeholders.

Collaborative working between NIST and national organisations and networks

Following the active participation of many national organisations in the development of the Choose Life strategy, there was perceived to have been a loss of momentum in maintaining levels of engagement and communication during the early implementation stages, when NIST was being established and the primary focus was on local areas. This had resulted in a loss of communication with organisations such as the Royal College of Psychiatrists. National organisations had been disappointed by this initially but reported subsequent improvements.

Organisations without a direct link to NIST (e.g. those without a national Choose Life coordinator) suggested that NIST should continue to expand its use of the expertise within national organisations. This was though to have potential in terms of leading on specific topics such as crisis, bereavement or self-harm.

National informants considered it a matter of urgency to develop stronger links with several key sectors, including drug and alcohol agencies and mental health services. Latterly, the creation of a clinical advisor post within NIST was seen as a welcome indication of progress in generating clinical involvement at national level. NIST had also identified the recent report on Taking action to reduce Scotland's drug-related deaths (Scottish Executive, 2005b) as an opportunity to raise awareness of suicide prevention on this agenda. A representative from NIST had also been asked to join the newly formed National Forum on Drug Related Deaths.

Figures 4.2a and 4.2b show, respectively, the links that NIST had established by December 2004 and the partnerships that evolved in the following year.

4.2.4 Progress made in developing national infrastructures

Overall progress made in developing national infrastructures to support implementation is summarised in table 4.1. This considers progress and emerging issues/gaps in relation to awareness raising/campaigning, media work, information and knowledge, influencing cross-cutting policy, building capacity in national organisations, and collaborative working between NIST and national organisations and among national organisations.

Table 4.1 Progress in developing a national infrastructure to support implementation

4.3 Development of local infrastructures

This section considers the development of local infrastructures to support suicide prevention. It begins by illustrating key goals for suicide prevention as articulated by local areas. The implementation of Choose Life through community planning processes and variations in the characteristics of the infrastructures are outlined. The section returns to consider the role of national organisations (including NIST) in terms of support for local implementation and concludes by reviewing progress in relation to local infrastructures.

4.3.1 Goals

In the longer term, the local vision for change to be achieved through the implementation of Choose Life, as described by coordinators and case study stakeholders, was to reduce suicide and to improve the mental health and well being of local populations (see figure 4.3). There was recognition of the continuing need to strengthen capacity and commitment in communities and in mainstream services and to challenge and change attitudes.

In taking forward the Choose Life strategy, local areas articulated three main sets of objectives to be pursued in phase one:

• Capacity building among services and professionals in order to: build networks and alliances; improve service response particularly for risk groups; raise awareness and confidence among staff; support development of the voluntary sector; and enhance systems for training
• Mainstreaming suicide prevention both in policy and in practice, and promoting awareness of the connection between health improvement and social justice priorities and activities and those of Choose Life
• Capacity building in the community by: reducing the stigma associated with suicide and mental health problems more generally; and raising awareness among the general public about when and how to seek, and give, help and support.

Figure 4.3 A composite theory of change pathway for the local areas

With these short- and long-term goals in mind, the following sections consider approaches taken to phase one implementation within local community planning structures and review progress in establishing a sustainable local infrastructure for suicide prevention.

4.3.2 Structures to support Choose Life implementation

Implementation of Choose Life was primarily conducted through the establishment of a Choose Life coordinator and partnership in each local authority area. National guidance stipulated that the development of local Choose Life action plans should be linked to Community Planning Partnerships ( CPPs). Suicide prevention was a new priority for many local policy makers and planners. CPPs were deemed the most appropriate vehicle for ensuring that the necessary linkages were made with overarching policy priorities, such as health (including mental health) improvement, social justice and social inclusion. Devolving responsibility to local CPPs was intended to encourage broad ownership in the interests of sustainability, to promote cross-sectoral collaboration, and create synergy by making best use of expertise and skills of local and national players.

Impact of CPPs

In some areas, partners had already worked together as part of the wider process towards integrated health and social care. Similarly, some Choose Life partners already came together in fora relating to mental health and health improvement. In the survey, half of the coordinators reported that the amount of local partnership working had increased as a result of working on Choose Life. A key development was increased partnership working with the voluntary sector. In some areas, Choose Life provided the first opportunity for a wide range of partners to came together to discuss a public mental health issue. For other areas, the process of participation in Choose Life had strengthened partnership working as part of CPPs.

The placement of Choose Life funds within community planning structures had both advantages and disadvantages. CPP engendered broad ownership of suicide prevention: as a result of its potential to be sustainable, Choose Life tended to become part of wider agendas. More practically, Councils could permit greater carry forward of unallocated funds. This was helpful when projects were delayed due to personnel issues or if areas required further time to reflect and review implementation decisions. However, the operational model could create delays in implementation. In one case study area, the local authority required each Choose Life funded project to submit a portfolio; and a requirement for funding was that these were signed off by a Community Planning committee that did not have regular meetings.

Links to CPP and Joint Health Improvement Planning

In the first phase of implementation there were variations in infrastructure development in relation to the coordination function, partnership development, links to CPP and other relevant structures, and levels of authority and decision making.

Most areas established a new strategic partnership with a specific remit for Choose Life implementation. Elsewhere pre-existing partnerships that focused on suicide prevention were allocated responsibility. The majority of partnerships reported directly through Joint Health Improvement Planning ( JHIP) structures of the local CPP. There were some exceptions. One area reported through community safety and in three areas the Choose Life strategy group was accountable to the mental health strategy group. In general, local coordinators and NIST considered that links into the JHIP had developed well, enabling the objectives of Choose Life to be incorporated into future health improvement activity and related areas of policy and planning (e.g. regeneration, housing and equalities). Local coordinators thought that the positioning of Choose Life in CPPs through the JHIP was a sign of multi-agency strategic commitment and responsibility. This presented an opportunity to generate or lever additional funding from other sources to ensure that the aims and objectives of Choose Life were promoted and mainstreamed across sectors and agencies.

A range of examples illustrate how the alignment with CPP and JHIPs has been used:

• Inclusion of Choose Life objectives as a priority in JHIP
• Incorporation into Children's Services Plans, regeneration plans and other health improvement strategies for key risk groups
• Piloting of health improvement work with local social housing providers including suicide prevention work
• Assimilation of the strategic components of Choose Life coordination into the local authority health improvement post.

Links to local mental health improvement strategies

The long-term goals expressed locally were to address suicide prevention as part of wider activity on population mental health improvement. In phase one of implementation, links had been established between Choose Life and broader mental health improvement activity as one of a set of key relationships. This needed to be balanced with links into clinical mental health services where there were fewer inroads (see sections 4.3.6 and 4.3.7). Choose Life had served in some areas as a vehicle to encourage wider awareness and commitment to the mental health improvement agenda and here implementation activity tended to focus on mental health improvement work within the local community. Choose Life had also facilitated development of more formal mental health improvement structures and had been able to support those working in other strands of mental health improvement, such as see me. In a small number of areas the coordination and supporting structures of Choose Life were becoming more closely aligned with mental health improvement.

Links to mental health services planning structures

In a minority of areas Choose Life was located within mental health strategic planning. In two areas, the Choose Life partnership is a sub group of the mental health strategy group and, in another area, the principal link was to a planning group that oversees the management and development of mental health service. This model appeared to give the NHS a stronger role in the planning and allocation of resources than in the health improvement model but, based on case study data, resulted in weaker links into the CPP at strategic level. One area decided to restructure in phase two in order to integrate Choose Life more closely into the CPP.

4.3.3 Coordination of Choose Life implementation

The diverse professional background and differing remits and levels of responsibility of local coordinators influenced their approach to the coordination of implementation. Broad approaches included: employment of a full time coordinator; coordination through a professional's existing remit; and shared responsibility for the function of coordination. This section examines the implications of these three models of coordination.

Employment of a full time coordinator

Some coordinators highlighted that dedicated time and resources created an opportunity for effective networking and the proactive development of collaborative work. For example, if a coordinator was approached by a local partner who expressed interest in taking forward suicide prevention activities, then the coordinator was able to respond quickly and capitalise upon unanticipated opportunities.

National organisations valued the accessibility that a local funded coordinator afforded them, in seeking routes into local planning structures. It was important, however, that the coordinator possessed influence and access to strategic partners.

Local and national informants tended to favour a full-time coordinator to ensure sufficient capacity, knowledge and continuity to make full use of opportunities to promote Choose Life objectives proactively. Several areas noted that the establishment of dedicated development capacity had been extremely valuable.

A perceived disadvantage of this model was that partners might ascribe responsibility for suicide prevention to the individual coordinator and be less prepared to acknowledge their own potential contribution.

Coordination through existing remit

Where coordination was undertaken as part of an existing remit, this was perceived to enhance the opportunity to draw on coordinators' links into other structures and to contribute to the mainstreaming of suicide prevention in local policies and plans and on other agendas. On the negative side, this model could have disadvantages where a coordinator had poorly developed links into relevant partnerships and organisations (e.g. NHS), although this could be offset by ensuring that the Choose Life partnership had appropriate cross-sectional representation from relevant organisations (from health improvement to clinical services). Sufficient capacity to carry out all aspects of coordination was a further challenge with this model. In a number of areas, partnerships where coordination was undertaken as part of an existing remit had moved to, or were considering, employing a full-time or part time coordinating post.

Shared function of coordination

In this model, the function of coordination is shared by two or more people. In some areas, the role was shared 'vertically'. Here, a coordinator or the Chair of Choose Life partnership provided 'top down' support and links into strategic planning partnerships. The second coordinator had operational responsibility for day to day coordinative functions, e.g. writing minutes of meetings and overseeing project monitoring. In other areas the function was shared 'horizontally', as in a job share arrangement.

Shared coordination afforded greater capacity for coordination and brought the richness of different perspectives from diverse professions (e.g. in one case study areas, coordination was represented in health improvement and clinical services). It could also ensure that both strategic and operational aspects of coordination were included in the function.

Issues arising

Local coordinators recognised that, while coordination was important, it was also essential to take a proactive role to stimulate development in policy, partnerships, networks and service delivery and a number of areas had taken steps to increase capacity to undertake developmental work. The discontinuity resulting from change in personnel had been a challenge in several areas in maintaining key relationships, although some considered that having a well defined local action plan as a clear framework could help to minimise disruption.

4.3.4 Leadership

In the early stages of phase one implementation, leadership at a local level tended to be associated with the coordinator and chairperson of the Choose Life partnership. Case studies illustrated the importance of leadership style in being able to bring together a range of agencies, including those whose role and contribution were less clearly defined, and focus on action without overly influencing decisions.

Over time, there was growing recognition that leadership needed to be shared by those who were members of the strategy group, championing suicide prevention in their own organisations and services, and should involve senior players able to link into strategic partnerships. This was seen as crucial in being able to diffuse responsibility for Choose Life objectives into policy priorities, planning and resource allocation decisions. Local coordinators saw leadership development as a necessary part of building capacity in selected agencies working with key priority groups.

Although there were some concerns relating to the loss of continuity where there were changes to leadership structures, the local view was that such changes tended to be beneficial, resulting in better defined processes for strategic planning and development, a higher profile for the suicide prevention and a broadening of the range of interests and areas of expertise involved.

4.3.5 Partnerships to support Choose Life implementation

Membership of Choose Life partnerships was left to local discretion, although implementation required cross-sectoral representation. In practice, Choose Life partnerships generated interest from local champions and activists, and those engaged in other related National Programme activity. The size and diversity of partnerships and differences in perspective could pose challenges in reaching consensus in the local action planning process. Local stakeholders in some case study areas indicated that the commitment of partners to suicide prevention was crucial in ensuring that partners remained at the table. Where there was strong divergence of opinion, some partnerships had involved NIST and found this helpful. For example, in one area, consultation with NIST helped overcome disagreement in the action planning process where there were disagreements between NHS and council representatives.

Local informants and NIST regarded the development of local partnerships as a significant contributory factor in achieving progress in phase one implementation towards:

• Raising the profile and promoting ownership of Choose Life at all levels within partner organisations and in the eyes of the public, as Choose Life work widened its reach in local communities
• Creating a 'focus for action' and a forum for discussion on suicide prevention, among people and organisations who had not worked together previously
• Better mutual understanding and clarification of roles and areas of expertise
• The development of a range of practical initiatives including joint work on training
• Embedding Choose Life in the plans and activities of local services and teams.

A key factor in success indicated by local areas was that the partnership had sufficient status and links into relevant strategic planning groups and service delivery fora to ensure influence over other agendas. Nearly half of local Choose Life partnerships reported complete decision making authority. All partnerships had authority to identify and advise on local priorities and most partnerships had decision making authority on the allocation of Choose Life funding resources.

Changes to partnerships

Local areas were reviewing their partnerships in the course of phase one in order to ensure that partners who did not immediately understand their role in suicide prevention work were increasingly engaged. In some individual areas, partnerships were revised in response to sustainability issues (e.g. to ensure sufficient strategic representation from statutory organisations).

Two out of three local areas reported that their Choose Life partnerships had evolved in the course of phase one by:

• Extending the range of partners involved to include other strategy groups (e.g Children's Services Planning groups, Community Care partnership groups, criminal justice services and addiction services) and key service providers
• Strengthening existing partnerships: partnerships had become more structured as a result of better coordination and more effective use of local resources; there was more cross-boundary working; local networks had been established among partner agencies to review what works and to develop action plans; policies and procedures had been developed between key agencies; and there was closer involvement of senior officers.

4.3.6 Involvement of mental health services and clinicians

As a consequence of the location of Choose Life within community planning structures, engagement with statutory mental health services in Choose Life planning and activity proved to be challenging for many local areas. National level feedback suggested, however, that psychiatrists across Scotland generally welcomed the approach taken by Choose Life and enthusiasm for the policy at a national level was supported by psychiatrists interviewed in case study areas.

The national programme Doing Well by People with Depression ( DWBPWD) was launched in April 2003 and is supported by funding from the Scottish Executive's Centre for Change and Innovation ( CCI) (McCollam et al, 2006). The CCI has funded 12 local development projects across Scotland. The DWBPWD programme aims to:

• Improve mental well-being for people with depressive disorders
• Improve access to interventions which have an appropriate evidence base.

Many areas with operating DWBPWD programmes have established links between the two initiatives, including: joint funding of a bibliotherapy service; supporting domestic abuse work; and review of existing guidelines and support packages for depression management. In one case study area, a key rationale for this joint approach was that this provided a strategic way of targeting similar priority groups.

Other approaches used to facilitate and strengthen clinical involvement in suicide prevention included:

• Building on the early participation of local representatives from mental health services in national consultations on the development of Choose Life to promote awareness and commitment in mental health services to local Choose Life objectives
• Some Choose Life partnerships established informal feedback loops and cross-representation with mental health clinical structures
• In a minority of areas, Choose Life built on prior work on suicide prevention that was led by clinicians
• Links through the Choose Life coordinator with the implementation process for the Mental Health (Care and Treatment) (Scotland) Act 2003
• Through structural change, e.g. shifting strategic leadership for Choose Life to new, devolved partnerships for health and social care (including mental health), so that Choose Life becomes imbedded within and led by these structures, to engender closer links with NHS statutory partners.

Different data sources, national workshop and case studies highlighted the importance of further collaboration with primary care and A&E which also support people who self-harm, attempt suicide or have mental health problems.

Case studies demonstrated mixed success in the ability to link to and engage with these frontline services. Success was evident when the partnership had strong links to NHS planning structures or there were representatives from clinical services championing Choose Life in their parent organisation. In one case study area, for example, this resulted in a new model of service delivery between A&E and the Samaritans. In a handful of areas, GPs or A&E managers/nurses were members of the Choose Life partnership. In another area, where risk management training was funded through Choose Life, there was good attendance from clinical services.

Less successful attempts to engage clinical services were attributed to time constraints among health professionals, lack of national leadership that encouraged local clinical engagement and a lack of capacity within frontline services to carry out preventative work.

4.3.7 Involvement of substance misuse services

Evidence from case study areas suggests that representatives from substance misuse services have not been consistently engaged in local suicide prevention partnerships. Stakeholders from case study areas suggested several explanations for this, including:

Throughout the course of phase one, many areas fostered engagement with the substance misuse services. This was particularly encouraged by NIST. The operations manager for NIST met with Choose Life partnerships and actively encouraged local areas to make links to their Alcohol and Drug Action Team ( ADAT). National guidance for phase two highlighted the importance of engagement with clinical and substance misuse services.

Increased engagement is also thought to have been facilitated by:

In some instances, national partners considered they had not been engaged with local area partnerships in a way that made effective use of their expertise and ensured continuity of support for key risk groups that used the services of national organisations. The turnover and variability in availability and accessibility of local coordinators was regarded as a contributory factor. It was also considered that further work was required for national organisations and local partnerships to identify common priorities.

Choose Life partnerships provided the Samaritans with their first major opportunity to become involved in local decision making partnerships. As a result, the organisation had more interaction in local areas and felt more 'visible' in local communities.

For ChildLine, networking undertaken by the coordinator had improved links to, and understanding of, the organisation in local areas.

Nationally, the SPS was considered to have networked well in local areas and, in one case study area, this had led to joint funding of a Choose Life initiative. In some areas, SPS had found it challenging to engage with local partners. This was attributed to prisoners not having been identified as a local priority in the community. Local areas also reported that funding had often not been allocated to this priority group locally because of the national Choose Life funding available to the SPS. However, opportunities for the SPS to present at the NIST summits had increasingly built relationships with, and generated interest from, local areas.

4.3.9 NIST support to local implementation

National interviews highlighted that there were several dimensions to NIST's role in supporting and guiding local implementation and working alongside local infrastructures. Key elements of this role included:

• Promoting consistency of approach within the framework of objectives and priorities specified in Choose Life
• Providing guidance and advice and advocating for Choose Life objectives and priorities with local decision makers
• Enabling and supporting local coordinators and other key players to lead developments regionally and nationally
• Maintaining an overview and coordinating developments that have local and national relevance, e.g. training initiatives
• Building capacity to generate and use information and research
• Acting as a conduit between the National Programme and local areas.

NIST members adopted different approaches in their work with local areas, depending on the nature of the task:

• Taking a 'hands on' approach to support local areas (e.g. working closely with individual coordinators) in translating the strategy into local planning systems
• Building alliances with interested coordinators and encouraging leadership independent of NIST, e.g. through membership of SIREN
• Striking a balance between being directive and being nurturing.

4.3.10 Progress in developing local infrastructures

Local areas recognised that it was important to continue to review and refine their approaches to implementation in order to achieve greater integration with other areas of policy and service development. Towards the end of phase one, some areas were actively working to shift Choose Life to a structural/policy context within the authority, thus promoting longer term sustainability ( see chapter seven). Closer contact among partners was also considered necessary to promote the exchange of learning at different levels.

Progress made in developing local infrastructures to support implementation is summarised in table 4.2 below. This considers progress and emerging issues/gaps in relation to the positioning of Choose Life in the CPP, development of local action plans, coordination, partnerships for implementation, local visions and NIST support to local areas.

Table 4.2 Progress in developing a local infrastructure to support implementation

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