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Chapter Ten The cost of ASIST in Scotland

10.1 This chapter will present information about the monetary cost of ASIST. It was beyond the scope of this evaluation to undertake a cost effectiveness analysis of ASIST. However, as part of our interviews with stakeholders across Scotland, we gathered data on their views of the costs of ASIST, and asked whether they felt ASIST was worth the investment. We have also included here some suggestions about how the delivery of ASIST could be done more cheaply.

10.2 The evidence presented in this chapter comes from documentation provided by NIST; interviews with national stakeholders and Choose Life Co-ordinators; interviews with trainers; and the local implementation studies.

National costs: payments made to LivingWorks

10.3 At a national level, the largest part of the cost of ASIST has been related to the costs of training trainers and purchasing materials. Until recently, all Scottish T4T courses have been delivered by LWE Coaching Trainers from Australia, Canada, USA and Ireland, and all materials have had to be purchased from LWE.

10.4 As of January 2008, payments to LWE related to the implementation of ASIST in Scotland have totalled £538,133. This includes £313,373 for 12 T4T courses (covering the cost of fees, travel and accommodation for the LWE Coaching Trainers), and £225,760 for materials. Table 10.1 provides a breakdown of payments made to LWE for delivery of T4T and for ASIST materials, from 2004 - present. In addition to the costs shown below, £10,000 was paid in 2005-06 to a consultant from LWE to carry out a survey of Community Planning Partnerships in Scotland.

Table 10.1: Payments to LivingWorks Education, 2004-05 to 2007-08, by financial year

* The cost of the T4T course in Nov 07 was CAN$100,706.32. This has been estimated, at the rate of exchange on 10 January 2008 as £51,120.

Note that payments made to LivingWorks in 2004 and 2005 were made by the then Scottish Executive through NIST. Payments made in 2006 and 2007 were made by Right Track.

The cost of ASIST materials

10.5 A single participant kit for the ASIST course contains a workbook, the Suicide Intervention Handbook, a prompt card, a certificate of completion and a course evaluation form. The full kit must be purchased for every participant, and the current price of a participant kit for one person is CAN$35. At today's rate of exchange, this is approximately equivalent to £17.50 - or £420 for a box of 24. According to a senior representative from LWE, the cost of the participant kit includes the cost of printing and shipping materials, plus a programme support fee of CAN$19 that covers all "Reader" support services. Also included in the price is a cost for "on-going services" provided by LWE and a contribution towards research and development costs related to ASIST.

How payments to LWE change with ICC membership

10.6 Once a country has attained ICC status, that country can choose to print its own materials, or can continue to purchase materials from LWE at a significantly reduced cost. (The support fee reduces to CAN$14 and the cost of materials reduces to CAN$8.04 (printing cost + 20%).) All other income and expenditure involved in organising ASIST courses, including the cost of T4T, becomes the responsibility of the ICC member country, although in relation to T4T costs, LWE continues to receive CAN$250 per trainer trained under a licence agreement with ICC countries.

Other national costs associated with the implementation of ASIST

10.7 In addition to the payments made to LWE described above, there have also been hotel costs in relation to the delivery of the 5-day residential T4T course. These have totalled £177,034 since 2004-05.

Introduction of NIST pricing policy

10.8 As mentioned in Chapter 4, NIST subsidised 100% of the costs of the first four T4T courses in April / May 2004 and October / November 2004. In addition, each pair of new trainers were given three boxes of 24 participant kits for free. This was done to support local areas in getting ASIST off the ground quickly.

10.9 However, the NIST team were keenly aware that there was an expectation upon them, as there was upon local areas around Scotland, to make Choose Life activity sustainable in the longer term. Therefore, from March 2005, NIST began to charge local areas £1,800 per trainer for T4T. And in April 2005, NIST introduced a pricing policy which had the aim of making the delivery of suicide prevention training sustainable - both at a national and local level.

10.10 The policy set out guidance to local areas about ways they could generate income from the delivery of ASIST by charging participants for attendance. ( NIST suggested £200 should be the maximum participant fee, but stressed that local fee structures should not exclude people who could not afford to attend.) In addition, it provided information about new charges that would be levied for ASIST materials - £605 for a box of 24 participant kits. (Materials were no longer to be provided free to new trainers.) In addition, in order to keep costs down, a decision was taken to distribute participant kits in boxes of 24, since 24 was considered to be the most effective group size for an ASIST workshop run by two trainers.

10.11 The £605 charge for materials covered the actual cost of the materials (approximately £420 paid to LivingWorks), and included a £180 administration fee, plus £5 for postage and packing. The administration fee was then used by NIST to part-subsidise the cost of T4T training, which cost a minimum of £2,000 per participant - at least £200 more than the £1,800 charged to local areas. (The cost per participant for T4T was, in fact, variable and depended on the number of participants and the hotel costs. However, local areas were only ever charged £1,800 per participant for the course.)

10.12 Following the introduction of the pricing policy, a few local areas did begin to levy charges for participants attending ASIST. However, most areas continued to subsidise the training with local Choose Life funding. This evaluation found that, more recently, local areas are beginning to consider the possibility of charging fees, although in many cases, the intention is to charge fees only for those who register for the course and then don't turn up. These issues are discussed below.

10.13 In general, the pricing policy was not popular and it contributed to a perception among local areas that ASIST was an expensive form of training. However, the aim of the policy was to make suicide prevention training sustainable in the long run. The policy was underpinned by the principle that any income generated from charging for ASIST would be invested directly back into training, both at a national and local level.

10.14 In November 2007, NIST updated their pricing policy to reflect reductions in the cost of materials which resulted from attaining ICC membership. From July 2007, the cost of a box of 24 participant kits was £319.00, which included £5.00 for postage and packing. In addition, the cost of the T4Ts in October / November 2007 were also subsidised by the Scottish Government in order to help local areas to meet the requirements of Commitment 7 of Delivering for Mental Health. Moreover, local areas have now been advised that participant fees should be set no higher than £150 per participant.

Income received by NIST

10.15 Since March 2005, when NIST began charging participants on T4T courses, a total income of £457,955 has been generated in relation to ASIST. This includes £223,000 for places on T4T courses, and £234,955 for the sale of ASIST materials in Scotland.

10.16 Table 10.2 below shows that, at a national level, once all expenditure and all income was taken into consideration, NIST has spent a total of £159,974 on ASIST since the introduction of the course in April 2004.

Table 10.2: National cost of ASIST, April 2004 - January 2008

Local costs: venue hire, catering and trainers' fees

10.17 At the local level, the main costs of ASIST have been related to the cost of training trainers (£1800 per trainer), the purchase of materials (£605 for a box of 24 participant kits), venue hire and catering. In some areas, there have also been costs related to trainers' fees.

10.18 The costs of venue hire and catering have varied from one area to another. In some areas, there have been no venue costs because trainers have been able to use rooms available to them for free within their own organisations. In other areas, workshops have been held in external venues. We heard of at least one area which has, until now, delivered the two-day ASIST course as a residential course (with an overnight stay in the middle). Preferential rates from a local hotel were negotiated for this. At least one other area did not provide lunch to participants; instead participants are asked to purchase or bring their own lunches.

10.19 In most areas, there has been no additional cost related to trainers' fees, since trainers in these areas have generally delivered the course 'for free' as part of their paid employment. However, where there has been a shortage of trainers, some areas have had to buy in trainers. This was done either by paying a fee directly to the trainer (who is effectively self-employed), or by entering into partnership agreements with other agencies. For example, several local authorities, including North and South Lanarkshire, Angus and Glasgow have partnership agreements with the Scottish Association for Mental Health ( SAMH). SAMH has a large pool of ASIST trainers who are available to deliver training in these areas.

10.20 It should be noted that in some rural and island areas, participants must often travel great distances to attend ASIST. We heard that in some areas, decisions had been taken to subsidise the cost of travel and overnight accommodation for participants in this situation.

Views on the costs of ASIST

10.21 As mentioned above, ASIST was perceived to be an expensive course. Concerns were expressed by individuals across Scotland that if there was no more funding from Choose Life, it would be difficult or possibly even impossible to sustain ASIST in the long-term.

10.22 There were conflicting views about the benefits of implementing local charges for ASIST training. Some local areas had attempted to do so, but found there was a fall-off in demand for ASIST following this. At the same time, some trainers argued that fees should be charged to discourage people from booking on the course and then not turning up on the day.

How the cost of delivering ASIST can be made cheaper

10.23 Trainers and Choose Life Co-ordinators from around Scotland had a number of suggestions for how the cost of ASIST could be reduced. In general, these suggestions related to reducing the cost of materials. However, one individual also argued that the requirement to attend a two-day course was, for some individuals (for example, self-employed taxi-drivers, hairdressers, etc.) a significant expense which involved a loss of income. This individual suggested that the time required for the course could be reduced, and aspects of it delivered via the web or DVD.

10.24 In relation to the cost of materials, many people felt frustrated that all ASIST participant materials had to be purchased in boxes of 24, irrespective of how many kits were actually needed. One trainer in a rural area reported that because participant numbers on her courses were often less than 24, she and her training partner had been able to stockpile left-over kits, and run a number of courses over the past few years "for free" (i.e. without having to purchase a box of materials for each course). ³¹

10.25 There was also a feeling that much of the material in the participant kits could be purchased or produced much more cheaply than was currently possible. For example, the view was expressed that it is unnecessary to provide certificates and feedback questionnaires in all participant kits. These could easily be photocopied at a local level, or downloaded from the web when needed, rather than paying LivingWorks to print one for every participant.

10.26 There was also a perception among trainers that the Suicide Intervention Handbook was little used by course participants. This view was confirmed in some of our interviews and focus groups with ASIST participants. When directly asked if they had ever read the handbook, few participants said they had even looked at it after the training. ³² It was suggested that, where an entire office or project team was trained in ASIST, it was unnecessary (and a poor use of resources) to have one handbook for every person. The feeling was that a single copy of the handbook in the office library would have sufficed for everyone.

10.27 There was also a suggestion that the Suicide Intervention Handbook could be sold separately to participants who were interested in purchasing it, or making it available on CD or even on-line. (The Handbook is, in fact, already available in audio CD format, but the cost of this in Scotland is the same as the cost of the printed handbook.)

10.28 None of these suggestions would undermine the integrity of the course, but would enable it to be delivered more cheaply.

Reducing the costs of trainers

10.29 Some local areas had arranged for the delivery of ASIST to be attached to posts within certain organisations. These posts were often in health improvement or health promotion departments, which had a wider training remit. In general, Choose Life co-ordinators in these areas seemed to perceive the delivery of ASIST as less expensive than those areas where there was a high turnover of trainers, or where external trainers had to be brought in to deliver the course.

10.30 Finally, as mentioned in Chapter 9, 77 of the 271 individuals who had completed a T4T course in Scotland were no longer active trainers. At a cost of approximately £2000 per trainer, this represents a significant loss of investment, and it is clearly important in relation to the sustainability of ASIST to find ways of addressing the difficulties that trainers have faced.

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