Suicide Bereavement Support Service: final evaluation report

7. Conclusions

This chapter sets out the conclusions, aligned with and responding to the evaluation questions set for the extension period.

What are people’s longer-term experiences of receiving support from the service, and what outcomes are achieved?

The overall experience of those who engage with the service over a longer period remains positive. They value the trust-based relationship which develops through the consistent support from the same staff member, and the sensitive and compassionate delivery. The flexibility and person-centred nature of the support means the service is responsive to their changing needs. It is also important to acknowledge that the person-centred and person-led delivery model was informed through the involvement of people with lived experience of bereavement by suicide. This emphasises the importance and value of ensuring the involvement of lived experience in any service design and development.

While a relatively small sample of supported people were engaged to explore longer-term outcomes, three common themes emerged. These centre on an overall improvement in mental and emotional wellbeing, feeling better able to cope day to day, and a reduction in the negative impact of the emotions they experienced. Other significant benefits of the support included being able to remain in employment and increased participation in social activities and events.

Most outcomes reported by those who have engaged with the service over a longer duration mirror those that have been identified in the shorter term among other supported people. While outcomes may be the same, the findings from the evaluation highlight and reflect the individual and unique nature of each person’s experiences, needs and journey through trauma and grief.

To what extent has the following changed over time:

• Number of people being referred
• Sources of referral
• Frequency and length of support sessions
• Form of support re. telephone or face to face etc

Levels of referrals have not followed any consistent pattern across the pilot. There have been periods where the average number of referrals has increased, followed by periods when they have decreased. However, 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.

Referral sources have differed in the two pilot areas over time. In the initial stages of the pilot, the only two referral routes were through Police Scotland and self-referral and these pathways represented the highest proportion of referrals during the early reporting points for the evaluation. As other referral routes were introduced, a greater variety of sources were observed in the service monitoring data. While Police Scotland and self-referral continued to represent the two most common pathways into the Highland service, this has not been the case in Ayrshire and Arran. Self-referral has continued to represent a high proportion of referrals into the service in Ayrshire and Arran, but levels of referral from Police Scotland have continually reduced while referral pathways through health services have increased. The experiences of the service, and the fluctuations in referral activity across different services and organisations, has highlighted the sustained and varied activity that is required to initially establish, maintain, and embed effective referral pathways.

The average number of support sessions gradually increased over the first 18 months of the pilot, though this could be reasonably expected as the overall caseload grew and a ‘steady state’ of delivery was reached. At the last data collection point for the Year 2 evaluation report (Feb 2023), the average number of sessions per supported person was 12.6, and the latest monitoring data as of the end of September 2023 shows very little change, with the average number of support sessions being 12.4. There is also very little variation in the average length of support sessions, with the lowest average of 44 minutes and the highest and most recent average of 47 minutes per support session.

While the service introduced the option of face-to-face support sessions following the removal of COVID-19 restrictions, telephone-based support has continued to be the preferred method for receiving support among most people accessing the service. Feedback suggests that this is due to the sense of anonymity that speaking on the phone provides, while also enabling people to receive support in a space where they feel comfortable and safe. The strength of evidence that has been presented in previous evaluation reports relating to the positive experience and benefits reported by people supported through the service demonstrates how effective telephone-based support can be.

What can the profile of those using the service tell us about who benefits most from the service and who may be missed within current approaches:

• How has the profile of people accessing the service changed over time?
• How recently have people experienced suicide bereavement before accessing the service and has this changed over time?

The consistent qualitative evidence from people supported would suggest that their varied needs are being met by the service through a person-centred approach. The evidence does not provide any insight into whether there are some people who benefit more from the support than anyone else.

Data collected by the service demonstrates that most people who access support through the service are immediate family members, with smaller proportions of extended family, and finally, a very small number of friends and colleagues of the deceased also accessing support. During the initial months of the service going live, a small number of people that had experienced a bereavement more than 18 months prior accessed the service for support. However, over the pilot period most people accessing the service had experienced a bereavement either in the same year they accessed support or in the year prior.

What are the views, experiences and key learning amongst frontline practitioners, particularly on issues around training and supervision, and how can this inform wider service delivery beyond the pilot?

In exploring experiences and learning with frontline practitioners, feedback predominantly related to their learning about the needs of the people accessing the service, and which aspects of the delivery model and approach helped to ensure those needs were being met. This feedback is reflected in section 4.6, which sets out the critical elements of the service delivery model.

The support provided to frontline practitioners has been highly praised throughout this evaluation, with supervision a valued component. Likewise, the environment whereby all staff are encouraged and enabled to continually access opportunities to build their confidence, knowledge and skills is also valued. Both these components – effective support and opportunities to continually develop – were also highlighted as critical components of the service model and are seen as essential for any future rollout. The hub and spoke model has helped to facilitate and ensure a consistent approach to this across each of the pilot delivery areas.

What are the barriers and opportunities associated with different referral pathways into the service, and what is the key learning for the development of new pathways for referrals?

Self-referral has remained a consistent pathway into the service, accounting for around a third of all referrals received in both pilot areas. The low visibility of the service among the public has been the most common criticism from supported people throughout this evaluation and is likely the one area that, if addressed, could enhance this pathway further. Should the service be rolled out across Scotland, the hub and spoke model would support the delivery of a national marketing campaign aligned to the single point of access that the centralised function for receiving and allocating referrals provides.

In each pilot area the referral pathway through Police Scotland has performed differently though it is unclear why given that in both areas, the service teams have a close working relationship with Police Scotland. Furthermore, Police Divisions in both areas have similar approaches to monitoring the level of referrals and follow-up processes in place to ensure a referral is offered if the initial opportunity has been missed.

The focus of establishing additional referral routes into the service has been with services that are likely to be touch points for someone who has been bereaved by suicide. Primary care services and other health services have featured strongly in this, particularly in Ayrshire and Arran, though a wide range of other community-based organisations and services have been active in both pilot areas.

Development of referral routes at different touch points that someone affected by suicide could engage with helps to provide vital safety nets that minimise the likelihood of someone slipping between the cracks and not being able to access the support they need when they need it.

What are the opportunities and limitations of the current hub and spoke model for service delivery with respect to wider service rollout?

It is difficult to reliably identify the full range of opportunities and limitations of the hub and spoke model in terms of wider service rollout. This model has been piloted with only two spokes and combines a partnership approach to service delivery, which limits the extent to which the hub and spoke model has been tested during the pilot period.

However, when considering this in the context of the central functions that are carried out by the hub, the following areas reflect the potential strengths of the model in terms of a wider rollout:

1. A quality assurance function that can ensure consistency in the initial training, skills and competencies of staff, and the overall delivery model and its effectiveness.

2. Ensuring effective models of staff support and continuous development are embedded in local delivery.

3. A central point for managing and coordinating referrals into the service.

4. A centralised collection of local delivery and monitoring data that can be collated to provide a whole service picture of delivery activity across Scotland.

5. The local functions of the spokes in the model supports and enables development of local referral pathways and for the service to be active and contribute to local suicide prevention forums and activity.

How does the service fit within the wider ecosystem for support and provision for suicide bereavement and suicide prevention?

Further work is required in both pilot areas 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.

However, the findings from this evaluation strongly suggest that the SBSS filled a significant gap in support for those bereaved by suicide, which will re-emerge if the SBSS ceases to operate.