Suicide Bereavement Support Service: final evaluation report

Executive summary

The findings of a 2018 research study suggest that up to 135 people are affected to some degree by a death by suicide. People bereaved by the suicide of a close friend or family member are estimated to be 65% more likely to attempt suicide than if the deceased had died by natural causes. In 2022, the number of people who died from suicide in Scotland was 762; a slight increase from the previous year (753), which was the lowest level since 2017.

The National Suicide Prevention Leadership Group (NSPLG) was established in 2018 to support the implementation of the Scottish Government’s Suicide Prevention Action Plan ‘Every Life Matters’. In 2019, the NSPLG’s Annual Report included a recommendation that the Scottish Government should fund a pilot to test a new model of suicide bereavement support. In response to this recommendation, the Scottish Government funded a pilot support service for families bereaved by suicide - the Suicide Bereavement Support Service (SBSS).

Following a competitive tendering exercise, Penumbra and Change Mental Health, working in partnership, were commissioned to manage and deliver the pilot. Change Mental Health delivered the service in NHS Highland and Penumbra in NHS Ayrshire and Arran.

The Scottish Government commissioned The Lines Between to deliver an independent evaluation to run alongside the SBSS pilot. The main aims of the evaluation were to capture learning generated from the implementation and delivery of the pilot to inform any future rollout of the service and to explore the experiences of people receiving support from the service and evidence any outcomes achieved.

Extension to the pilot and evaluation

The SBSS launched in August 2021 and was originally scheduled to end in April 2023. However, the pilot was extended to March 2024, and the evaluation extended to October 2023, to provide further learning that could inform decisions about any future service continuation and rollout.

Overview of service activity and referrals

At the end of September 2023, 132 people were receiving support from the service. A total of 2,670 support sessions and 2,089 hours of support have been provided, which equates to an average of 12.4 sessions per person being supported, each lasting an average of 47 minutes. The service has supported more females (71%) than males (24%), with an average age of 43.5 across the people being supported. Most people accessing support are immediate family members of the deceased.

The SBSS received 242 referrals over 25 months of delivery, an average of almost ten referrals per month, an increase from the previous reporting point in April 2023 when the average was eight per month. The three most common referral pathways into the service are self-referral (30% of all referrals), Police Scotland (26%), and health services (19%). Smaller levels of referrals from various other services and organisations make up the remaining referrals to the service.

Levels of referrals have not followed a consistent pattern, with periods where the average number of referrals has increased and periods when they have decreased. The most recent monitoring data for the period since the Year 2 evaluation report (Feb 2023 to end of Sept 2023) shows the highest level of referrals, with an average of 12 per month. This is a potential indicator that referral pathways are becoming more embedded, and awareness of the service is increasing.

Feedback from those who have referred people to the SBSS has been consistently positive, both in terms of the referral process and their perceptions of the service. The referral process is seen as straightforward, and communication from the service was reported to be effective. Referral organisations value the SBSS, believing it offers tailored support which meets the unique needs of people bereaved by suicide.

Service structure and model of delivery

The service is structured around a hub and spoke model. The hub is responsible for centralised functions that enable a rapid response to referrals, consistency in the approach and overall quality assurance of the service. Local delivery is carried out collaboratively across the two partner organisations, with each area representing a spoke in the hub and spoke model.

In both areas, the delivery model was reported to be fully embedded and underpinned by a person-centred and person-led approach that is compassionate and responsive to people’s needs and circumstances. The following critical components of the delivery model were identified:

• A compassionate, person-centred approach and having someone outside the immediate circle of friends and family to talk openly with.
• Being responsive to the changing practical and emotional needs of the supported person.
• The provision of flexible and person-led support in terms of session frequency, duration and format.
• Consistency in the person providing support, enabling the development of a trust-based relationship and an in-depth understanding of the person being supported.
• A rapid response to the initial referral and rapid access to support.
• No limit is placed on the length of time that someone can receive support.
• Robust and effective support for staff, coupled with opportunities for continuous development, which enables staff to carry out their role effectively.

Caseload and capacity

At the end of September 2023, 132 people were receiving support, an increase of almost 50% since March 2023. Individual caseloads vary, though most service staff report that they are approaching capacity. While staff are approaching capacity, they reported an emerging pattern of flow through the service that enables new referrals to be accommodated. For example, a reduction in session frequency among some people they support, service exits or planning for exits provides capacity for new referrals. The regular caseload review sessions in the service were also seen by staff as helpful in identifying cases where exploratory discussions about support frequency and transitions towards exit could occur.

Experience and outcomes for people supported by the service

Before the pilot extension, the evaluation had engaged with people receiving support from the service for periods ranging from three months to nine months to explore their experiences. This established that people using the service had positive experiences, receiving person-centred support delivered with sensitivity and compassion, which they found responsive to their changing needs. The support was found to positively impact the emotional and mental wellbeing of the people who access the service, as well as the extent to which they can cope with and return to day-to-day life and activities.

During this extension period, the evaluation explored the needs, experiences and outcomes of people receiving support from the service for a year or more. This found that the overall experience of those who had engaged with the service over a longer period remains positive. They value the trust-based relationship that develops through consistent support from the same staff member and the sensitive and compassionate delivery. The findings also suggest that outcomes reported by those who have engaged with the service over a longer duration mirror those identified in the shorter term among other supported people. While outcomes may be the same, the findings highlight the unique nature of each person’s experiences, needs and journey through trauma and grief.

Local priorities and the wider support landscape

Stakeholders in both pilot areas reported that the SBSS had filled a significant gap in the support available for people affected by bereavement by suicide and that the service has been able to meet the needs of people bereaved by suicide that other types of provision would not be equipped to meet. However, in both pilot areas, further work is required to fully map and understand the different pathways into, through and across the various suicide-specific support services as well as the wider bereavement, mental and emotional wellbeing and other support services that have a role in suicide prevention.

Stakeholders expressed a strong desire to see the SBSS continue in the pilot areas and considered it a key component in achieving local suicide prevention aims and aspirations. Without the service, according to stakeholders, significant gaps in being able to meet the varied needs of people bereaved by suicide would exist. Furthermore, the broader contribution of SBSS leads and managers in local suicide prevention planning and activity is highly valued by stakeholders.

Outline options beyond the pilot period

While a full options appraisal has not been conducted, discussions with service staff and stakeholders identified three potential outline options for the future of the service. In summary, these are:

1. Service rollout to all Health Board areas: This option would see the SBSS delivery model replicated in each Health Board area with a physical presence and local referral pathways. Delivery in each health board area would represent new spokes in the current hub and spoke model.

2. Single national service linked with local delivery to meet local priorities: The creation of a national team covering the whole of Scotland, though without the option of face-to-face support. A combination of local and national referral routes would be developed and implemented, supported through a suicide prevention website facilitating referral into the service.

3. Managed closure of the SBSS: Closure of the SBSS, with steps taken to ensure those receiving support from the service experience as little negative impact as possible. The learning generated through the pilot is shared with local suicide prevention leads to inform any local developments.

Overarching recommendation

The SBSS provides compassionate, sensitive, person-led and person-centred support that meets the preferences and needs of those bereaved by suicide. This approach has been critical to the positive experiences and outcomes reported by people who have accessed the service.

Based on the evidence and learning captured throughout this evaluation, the overarching recommendation is that the SBSS be made available to anyone in Scotland who has experienced a bereavement by suicide. In doing so, it is essential that the elements of the service delivery model identified as critical to providing a positive experience and generating outcomes for people receiving support are maintained.