National Trauma Transformation Programme - local authority delivery trials: follow-up evaluation - final report

Sustainability and future priorities

This chapter discusses participants' views on the sustainability of developments in trauma-informed practice, and developing trauma-informed services and organisations. It also discusses the identified threats to and enablers of this, as well as the priorities for further roll-out of their work in this area.

Sustainability

Across all three local authority areas, participants felt that their delivery trial had created a robust foundation from which to build. Most participants, however, emphasised that they were at the beginning of what would be a long journey.

"It's early days. We've got our building blocks at the moment, but we've not got our house in order quite yet."

"Good progress has been made. A good baseline of people have done the training, but… there's a long way to go."

"There's awareness and a good level of understanding, but the ability to actually implement and sustain it… that's missing....(We) need some time to really embed it and make sure there are changes (as a) result."

They explained that there is more work to ensure sustainability, highlighted variation in the extent to which trauma-informed practice had been embedded across teams and services or emphasised that cultural change takes time.

"In some areas (trauma-informed practice is business as usual)…. in other departments, it's not. But it's a very slow burn- I think it will come over time."

"There is a change there. We're just at the very beginning of the journey though… It's one thing to roll out training; it's a different thing to consolidate that training and make that culture change."

"It's going to take five to ten years before you can consistently walk through a service and feel that it is trauma-informed."

A few from the local authority which adopted an early focus on leadership training, conveyed a greater sense of certainty in the sustainability of trauma-informed developments. The participant below, for instance, shared an example of a team that has a clear plan and is "self-sufficient" in further implementation activity. Furthermore, the extent of leadership buy in and commitment from the outset is seen to be critical in keeping the work as a priority.

"It's been a journey for them, but they've now got a very comprehensive action plan and have already implemented change…. they're thinking about the whole system, really progressed things. (Delivery leads) have stepped back, and (the team) are largely doing that themselves now. It feels like they're quite self-sufficient."

Threats to sustainability and further roll-out

Participants across all three local authority areas identified threats to the sustainability and further embedment and roll-out of trauma-informed practice. Most commonly, they highlighted pressures facing public service staff- such as high workloads, understaffing, recruitment and retention difficulties, stressful work environments and competing policy workstreams.

"When you're working in a stressed environment… it's very hard to be trauma-informed. You need to keep some things in there that can hold the staff, slow them down, help them think about practice. Otherwise, we all go slightly into trauma mode and become reactive in our practice."

"There have been so many vacancies; we're constantly trying to recruit. You take three steps forward and two steps back. …(One service area) has so many vacancies the thought of rolling out training is probably not high up on their agenda - they're just trying to get people in to cover their areas."

"We've got lots of other national asks, political asks, legislative changes… for instance, the National Care Service will require a massive transition. It's about ensuring that the trauma agenda stays right up there with all the other ones - that's a challenge."

Further risks to sustainability included: over-reliance on lead officers, whose posts are often temporary or part-time; a lack of protected time for ongoing reflection and supervision; or the limited availability of staff to provide this, and the training capacity to meet the need of an entire workforce, particularly at the enhanced levels.

“(Delivery lead) is in post temporarily….. We've got mechanisms locally about providing the training beyond (delivery lead), but that's an addition to people's workload. How will that be sustained when you get short-staffed? Who's monitoring that? Who's getting the message out that this needs to be done? Who's evaluating that we see the culture change within our service?"

"We have delivered some training to a cohort of staff, but.. there's a gap for their supervision and ongoing coaching around the skills…..there are limitations to how much they'll be able to embed that in practice given that they're not having further coaching support."

Enablers of sustainability and further roll-out

A range of factors were identified as protecting against the above threats to sustainability or as helpful to maintaining momentum and further embedding trauma-informed practice. Participants frequently raised the importance of adequate and engaged lead personnel resource. This not only includes secure and sufficient delivery lead provision but also maintaining an active network of trainers, establishing teams of coordinators or champions, and ensuring appropriate steering or working representation.

"Our network of trainers…how are we supporting them and assessing whether they would be interested in carrying on some of the work? Often that falls to a lead officer…but for sustainability, we need to think about how…we maintain the training offer to ensure it becomes embedded in practice across the council."

"(You need) the right people on the steering group… especially if I come back to issues around sustainability. That idea of working with our services rather than that responsibility falling to a lead officer to go in and implement things."

"Wouldn't it be good if you could have…a small group of nominated trauma champions from different organisations?….Whoever your champion is (could) go in and do a trauma survey of staff and policies…and work closely with one organisation. So, it's not funding a new post but using what's there."

“Authorising environments" were also described by some as central to sustainability. Participants felt these were signified by: senior leadership buying-in and modelling commitment to the agenda; funding and protected staff time; service and team leads engaging in, encouraging, and monitoring implementation activity; and staff wellbeing being prioritised.

"Leadership not only saying it's important but showing through their own actions... There being that space and time to give to the actual nitty gritty of what implementation looks like and there being space given to people to take that learning and put it in place."

"Because of the national drive and agenda, there's an acceptance around it that there should be sustainability. It just requires the resource, capacity, leadership buy-in, and support to keep that ticking."

"(Leader), who has been part of the pilot for some time, now chairs the working group. So there's leadership buy-in and recognition that (they) want to continue to be part of this journey and support the (team lead who) will operationalise it."

National-level leadership and funding were also considered key to conveying commitment and ensuring sustainability and consistency of practice, with a couple calling for more support here. This included a move away from a model of annual funding allocation, and confirming financial support over a longer period.

"If the Scottish Government had additional funding to sustain the trauma co-ordinator (post), it would give a message that we're actually invested in this…. it would be something that every local authority knew they had to have."

“There seems to be a… lack of leadership from the Scottish Government. You could get a completely different experience in (local authority) than you might do elsewhere -because we've been left to get on and draw up our strategic plan and actions."

Policy development, strategic planning, and effective governance were further aspects of leadership that participants identified as important to maintain momentum and secure further embedding of trauma-informed practice.

"Where it sits and how we report on it is something we still need to work…It sits in our strategic plan about how many people we have trained (but it's not) all about the training… The governance of how we weave trauma-informed practice through everything we do is more difficult…(but delivery lead) is drawing up a really good strategic plan around what's needed."

"Keeping it in all of the policies and as a priority because there's a risk of things being lost."

"It can't just be down to individual personnel interested in it. It needs to be a core part of our business. With some of the governance structures we've got in place, there will be an expectation from the head of service that we report on progress and that it's monitored over time. I would hope those structures ensure that we do keep momentum going."

Participants also felt that ongoing training, sustained reflective practice, and support for systems-level implementation were needed to ensure sustainability. Additional enabling factors included: staff buy-in, alignment of the trauma-informed practice agenda with other national strategies; the cross-sector reach of the agenda; and increased opportunities for the involvement of those with lived experience of trauma.

"(We need) five more (delivery leads) that could go out and be speaking with teams and walkthroughs and making action plans…it needs more in-depth support within teams and services."

"It's not (just our sector). Mental health colleagues are doing it, adult services are doing it, and criminal justice, et cetera. So, we will have peer knowledge across teams to start changing it. There's not been a size and scale change within this organisation like this before."

“More open conversations, more dialogue (with people with lived experience of trauma) lead to things further down the line being more secure."

Future priorities

There was strong support for further roll-out of the NTTP locally. A range of future priorities were identified, the most common of which was to train more of the workforce. Participants described hopes or plans for:

• rolling and mandatory training programmes to incorporate trauma training within staff induction or provide opportunities for refreshing and updating learning;
• training needs analyses to identify required training levels amongst staff groups and inform training plans;
• enhanced level training roll-out;
• train-the-trainer programmes to increase trainer capacity to deliver trauma-informed and trauma-skilled level training, avoid over-reliance on delivery leads, and free leads up to adopt more of a coordination and supervisory role, deliver enhanced level training, or prioritise systems-change work;
• protecting and creating space for ongoing supervision, coaching, or reflective practice to support staff in implementing training learnings. This included identifying or training managers and supervisors to facilitate this and reviewing and enhancing existing support and supervision structures.

"My aim for the service is to have a trauma-informed workforce delivering a strength-based service….I see the roll-out of training as a way of achieving that."

"We have an e-module development, which is about to be finalised… we would hope that that would become a mandatory induction for council and NHS staff."

"The trauma team…have just completed a training needs analysis and identified trauma Skilled as the highest in terms of level of demand. We've been able to present that data to the steering group and say, 'This is this resource we have. This is the level of demand. Where do we prioritise? This is what our recommendation is for priority areas in the next 16 months.'"

Some also raised the issue of defining aims and outcomes or measuring progress towards these as a priority. This included: establishing clarity around levels staff should be trained to and goals concerning trauma-informed leadership; recording and monitoring training uptake via e-learning platforms; and evaluating the impact of training or ongoing implementation support with teams and services.

"How do we define 'trauma-informed leadership' in (local authority area), and what are we doing to strengthen it?"

"I would hope (there will be a legacy and continued development around trauma-informed practice), but my experience tells me that we quickly fall into our old ways of practice, particularly when we're under pressure…So it needs a sense of clear direction and objectives and responsibilities and a target of what we're trying to get to and how we will know we've got there."

"(Trauma coordinator) has been asked to help out with evaluation… to keep (support consultation sessions) and prove that they're effective, we need to create some kind of evidence base for that."

Others called for or discussed plans to widen the reach of NTTP activity to include more staff groups and service areas and work across more sectors and the wider community- to ensure consistency of practice.

"The admin staff… are the very, very frontline. They are the people picking up the telephone. ….. They've been missed. I want them to recognise the value that they bring. (And) they need to understand about trauma."

“The vision is that it needs to be a trauma-informed community, so how do we make sure that our extended partners in the community are part of that? The next bit is planning a workshop where we'll bring other people in who would be keen to do it. So we're spreading the word bigger and wider."

"We're going to proactively train police officers… in a trauma-informed approach."

"Other areas of the council….. What have they got going on in terms of the trauma agenda? I think there needs to be a mapping, scrutiny, and evaluation of that. And where there are gaps, that gives (lead) an inroad to ensure that those areas are supported to keep things on the agenda."

Further future priorities outlined by participants included:

• Implementing trauma-informed systems-level changes in environments, documents, letters, policies and processes through ongoing implementation support, working groups, roadmaps and action plans, and the trauma lens tool;
• Engaging leadership in the trauma-informed practice agenda, including by further roll-out of STILT training and establishing senior leader representation on strategic groups;
• Aligning trauma training and the broader agenda with other workstreams and strategies to avoid duplication;
• Organising events and workshops and other opportunities to share learning and good practice; promote awareness of and engagement with the agenda; widen networks; identify shared goals and outcomes; and promote consistency of practice across local authority areas;
• Promoting staff wellbeing, including by attending to vicarious trauma and providing reflective practice and supervision.

Finally, the involvement of those with lived experience of trauma in ongoing service development work was considered a priority in each local authority area. Suggestions for increasing opportunities for this, included: including a wider range of stakeholders, linking in with pre-established lived experience groups, drawing on testimonials from people with lived experience of trauma to advocate for funding, or enlisting their support to deliver training and provide feedback on letters, processes, and training packs.

"More open conversations with people from lived experience and creating safe spaces…for them to feed in in a non-judgmental capacity… There's a lot that can be learned from people from having different forms of trauma and adverse experiences. They're the ones that live with this and continue to go on with life, and they've got an important perspective to share."

Central to many of the above priorities, participants expressed the wish to "integrate trauma into everything that we do.