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Choose Life, the National Strategy and Action Plan to Prevent Suicide in Scotland, was launched by the Minister for Health and Community Care on behalf of the Scottish Cabinet in December 2002. An independent evaluation of Choose Life was commissioned by the Scottish Executive in 2004. The broad purpose of the evaluation was to "assess … infrastructure and early impacts" (nationally and locally) and to "set the template for the next phase of the Choose Life strategy." This Research Findings highlights the main findings, conclusions and recommendations of the evaluation of the first phase (2003-2006) of Choose Life.

Main findings

• One distinguishing feature of Choose Life is that it is placed within a national public mental health programme, and is part of wider Scottish Executive commitments to improve population health, promote social justice and tackle inequalities. This allows suicide prevention work to be undertaken within a wider framework of policy objectives and initiatives that share the overarching goals of population mental health improvement
• The National Implementation Support Team ( NIST) has made demonstrable progress and built momentum in relation to all its key functions, particularly raising awareness, working with the media and the development and dissemination of information and knowledge
• NIST has made a number of achievements in building a sustainable infrastructure for suicide prevention. Mechanisms and activities in place to encourage and support the exchange and dissemination of information include the Choose Life website, annual summits and the Suicide Information Research and Evidence Network ( SIREN)
• Challenges for NIST in the future include building clinical involvement and engagement at national and local levels
• Community Planning Partnerships ( CPPs) have been the best available mechanism to take forward local planning, co-ordination and implementation of Choose Life objectives, in view of the importance of local, cross-sectoral ownership of suicide prevention activities
• At the local level, the most successful activity to be mainstreamed to date is suicide prevention training. Training is seen as a sustainable resource that benefits the wider community by building capacity and strengthening existing skills and knowledge
• Choose Life has stimulated a considerable amount of activity relating to self-harm, but there are widespread differences across local areas in definitions of what constitutes 'high risk' suicidal behaviour and in the range of activities developed to address the issue
• Baseline assumptions indicate Choose Life is likely to become cost saving if five additional lives per annum are saved. This suggests that investing in the strategy represents value for money, although evidence of effectiveness will be needed before any definitive claim can be made

Background

Although suicide incidence in Scotland is not exceptionally high by international standards, there has been a pronounced and dramatic increase in suicide among men in Scotland, the rate more than doubling over the past 30 years. In response to the need for more effective suicide prevention action, the Minister for Health and Community Care (on behalf of the Scottish Cabinet) launched Choose Life, the National Strategy and Action Plan to Prevent Suicide in Scotland, in December 2002. The strategy sets a target of a 20% reduction in suicide by 2013. A budget of £12 million was allocated by the Scottish Executive to support the implementation of the Choose Life strategy and action plans at national and local levels for phase 1 (2003-06). A further £8.4 million has been allocated for phase 2 (2006-08). Choose Life is a major component 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.

A designated National Implementation Support Team ( NIST) co-ordinates 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 issuing guidance for, 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 person (co-ordinator) has been identified with responsibility for liaising with NIST and sharing information with other local planning partners and stakeholders.

In 2004, the Scottish Executive commissioned a research consortium to evaluate the first phase of Choose Life (2003-2006).

Research aims

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 strategy and action plan (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 % reduction in suicides in Scotland by 2013, and the targeting of any funding available to support the next phase.

Approach and methods

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. 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

Scotland in context

Although there are many similarities between Choose Life and other national suicide prevention strategies, Scotland's approach is distinctive in several respects. Choose Life is placed within a national public mental health programme, and is part of wider Scottish Executive policy commitments to improve population health, promote social justice and tackle inequalities. This allows suicide prevention work to be 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 and guided by the findings of an early formative evaluation.

Sustainable infrastructures for implementation

NIST has made demonstrable progress and built momentum in relation to all its key functions, while recognising the need to be increasingly strategic. Challenges ahead for NIST include: 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.

Community Planning Partnerships ( CPPs) have been the best available mechanism to take forward local planning, co-ordination and implementation of Choose Life objectives, in view of the importance attached to local, cross-sectoral ownership of, and engagement in, suicide prevention activities. However, 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, 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 recognise 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 based 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
• Acting as a catalyst for co-ordination across boundaries
• Performance management to track and oversee progress
• Building capacity, in particular to use and generate evidence.

The evaluation found that various models of local coordination had been developed and these had often been subject to refinement as local work progressed. A dedicated (full-time) coordination post tended to be preferred, for reasons of clarity of communication, capacity to be proactive and forge effective strategic and operational links, and to develop expertise. However, the evaluation has not been able to provide conclusive evidence that this model is more, or less, effective than alternatives.

The infrastructures developed in phase one were shaped by the need to build capacity and influence mainstream policy and practice. It is important now to reflect on the infrastructure and partnerships in place and to consider what is required to ensure the achievement of goals in the next stages of implementation, in particular how to widen engagement as part of the drive to influence mainstream policy and activity.

Allocation and use of resources

In the first phase of Choose Life,CPPs attracted considerable additional investment at local level (£1.6m), and there has been a substantial level of in-kind contribution. However, 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 of the allocation of resources.

There is a degree of unnecessary duplication of effort at the local level. 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.

From an economics perspective, under our baseline assumptions, the Choose Life strategy would become cost saving if five additional lives per annum were saved. This suggests that investing in the programme represents value for money and that the level of success required by the strategy is modest. 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 there are widespread differences across local areas in definitions of what constitutes 'high risk' suicidal behaviour and in the range of activities which have been developed to address the problem.

Innovative practice and the use of evidence

Many local areas provided examples of locally defined innovative community and voluntary practice. It is not possible, however, to assess the effectiveness of innovative developments initiated in phase one.

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 and there remains an absence of robust, definitive evidence of effective practice. This is not unique to Scotland.

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 and annual NIST summits. 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, the infrastructure is still fragile and 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.

At the local level, most success has been achieved in mainstreaming training activities. 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.

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.

Decision making processes and learning

Local stakeholder consultation was a key approach used across local areas 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.

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 Choose Life.

With regard to future planning, NIST has highlighted a strong commitment to evaluation. However, as a result of the lengthy process of establishing NIST and a lack of 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.

Perceived progress towards milestones

Local coordinators were more satisfied than dissatisfied with action on 12 of the 13 national milestones. Most satisfaction was expressed 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 a 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

We suggest that no radical changes should be made in the current funding 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.

At national level, key steps to promote mainstreaming in the next stages of Choose Life implementation might include 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 should include:

• Using intelligence from a range of sources, as tools in planning for sustainability
• Building in mechanisms to track and review progress towards objectives across policy areas.

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 NIST where key suicide prevention actions are not taken at the local level (e.g. failure to integrate substance misuse treatment services into delivery plans)
• Achieving a balance between the application of 'established' suicide prevention interventions and innovative practice
• The need to ensure the adoption of an evidence-based approach.

In phase two, more consideration should be given to the integration of self-harm into Choose Life. The evaluation team recommends that the strategy continues to encompass the high risk end of self-harm, but note that 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) ¹

While the Community Planning Partnership ( CPP) remains the most appropriate vehicle for developing strategy and overseeing delivery in relation to Choose Life at the local level, its limitations need to be recognised. CPPs need to review progress and examine the partnerships that have yet to be put in place in order to achieve their objectives. Priority should be given to establishing, or building on, effective links with clinical and drug/alcohol services. NIST 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.

Locally, the coordination function is crucial, The task of the CPP is to devise the most appropriate arrangement for delivering the 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 co-ordinate action. 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.

If you wish further copies of this Research Findings or have any enquiries about social research, please contact us at:

Tel: 0131 244-7560
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Email: socialresearch@scotland.gsi.gov.uk
Website: www.scotland.gov.uk/socialresearch

If you wish a copy of "Evaluation of the first phase of Choose Life: the national strategy and action plan to prevent suicide in Scotland", the research report which is summarised in this research findings, please send a cheque for £5.00 made payable to:

Tel: 0131 622 8283 / 0131 622 8258
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This document (and other Research Findings and Reports) and information about social research in the Scottish Executive may be viewed on the Internet at: http://www.scotland.gov.uk/socialresearch

The site carries up-to-date information about social and policy research commissioned and published on behalf of the Scottish Executive. Subjects covered include transport, housing, social inclusion, rural affairs, children and young people, education, social work, community care, local government, civil justice, crime and criminal justice, regeneration, planning and equalities issues. The site also allows access to information about the Scottish Household Survey.

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