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

Appendix 1: Site delivery in each area

This appendix contains three anonymised summaries of delivery in trial sites, labelled X, Y and Z to protect participants’ anonymity. The summaries focus on the context in which the trials were introduced, number and type of services and staff involved, successes and challenges, and future considerations.

Delivery of the NTTP in Site X

When Site X was selected as a trial delivery site in 2019, significant training and workforce development had already been undertaken in relation to ACEs (adverse childhood experiences). The additional funding secured through the NTTP enabled Site X to build on this and deliver extensive training across the local authority, to embed trauma-informed, skilled, and enhanced practices across children’s services workforce groups.

Site X aimed to reach 75% of the children’s services workforce with training relevant to the different groups of staff, and the children and families they support. To meet this aim, a consortium of third-sector organisations with expertise in trauma-informed practice was commissioned to design and deliver level 2 (skilled) and level 3 (enhanced) training. However, there were some challenges with this approach: the COVID-19 pandemic prevented the delivery of face-to-face training; there were contractual and administrative issues; and some practitioners within Site X felt that the advanced content of the trauma-enhanced materials lacked sufficient depth and quality.

Despite these challenges, Site X has used NTTP funding to facilitate a range of successful initiatives. For example, online training for trauma-informed practice was rolled out to the workforce, and all staff across the local authority working with children and families were provided access to a series of trauma-skilled online modules.

Uptake and response to this training was positive; a significant proportion of staff across health, early years, social work and education completed the training, and there was evidence of changes to a more trauma-informed approach within children’s services. For example, participants reported: changes to the language used in meetings and written records; more participation opportunities for children with care experience; better understanding of the root causes of children’s behaviour; and new measures introduced to support a more trauma-informed environment in schools.

“I think we had something like 95% of education staff had completed the trauma-informed level. And we also had access to the first module for the trauma skilled. There’s a much bigger awareness, we’re speaking in a different way now.”

“It seems to have had a really positive impact on staff wellbeing, and it seems to be being embedded into practice, which is really positive.”

“We’re trying to transform our child protection conferences and our looked after children reviews, so we’re looking at how do we shift language to be more trauma-informed, how do we make those meetings trauma responsive, how is everybody in the room A) trained and then B) how are we writing our minutes, what does the agenda look like, what does the room itself look like.”

Site X has also externally commissioned the delivery of Dyadic Developmental Psychotherapy (DDP) training to practitioners in CAMHS, Social Work and Educational Psychology. Training has been delivered in multi-agency groups, with practitioners from different services participating in sessions together. Feedback from participants has been positive; the DDP training was described as in-depth and high quality, delivered by experts in the field of DDP who shared useful tools, learning and resources. Participants have also had access to regular online drop-in ‘supervision’ sessions with the trainers to discuss DDP and how this relates to their practice; this was highlighted as vital in keeping the learning fresh and embedding the training in practice.

“We reflect on cases and it keeps what we learned in the training alive. It’s a lovely multi-agency approach where you get to know your colleagues from other agencies, and there’s a lot of shared learning. It keeps us grounded in the heart of DDP and the theory of trauma and its impact. I think that has been really successful in terms of the follow-up implementation support available for staff. That’s been really, really impressive and I think it’s made a really big difference.”

Site X also has one Transforming Psychological Trauma Implementation Coordinator (TPTIC) who has delivered STILT training to several colleagues across the local authority. Colleagues who participate in STILT training are also invited to a follow-up workshop, where they work to identify ways to embed learning into practice.

“We talk about all the different service elements, everything from the very first contact somebody has with a service to the relationships with the staff, to how their data is recorded. Everything up until they leave that service and everything in between. And we look at all those different elements and how might those be more trauma-informed.”

Within the past year, Site X recruited a trauma training coordinator who undertook an authority-wide needs analysis. This identified which of the four levels of trauma training is required across different areas of the workforce. The rollout of level one, level two, and level three trauma training has since begun.

Multi-agency working has been a priority for Site X in their approach to trauma training, with significant efforts made to share best practice between services. For example, Site X has a trauma strategy group with representation from health, social work, adult services and third sector partners. A trauma conference was held in November 2022, to celebrate best practice and highlight the achievements of the workforce in this area.

“It was really a big event. It was celebrated by lots of partners. We had some of our corporate parents there, our colleagues from the corporate parenting board from Children’s Union Scotland was there, we had the police, lots of people were interested.”

Training has been delivered in online and face-to-face settings. While face-to-face training was described as generally preferred by both trainers and participants, the geography of Site X poses challenges in face-to-face delivery. Site X is covers a large geographic area with sparse population density. The size and remote geography of the area create challenges in terms of reliability, time and cost of transport.

Recruitment and staff retention is also a challenge, which has raised some questions over the longevity and sustainability of training; there is a concern that learning cannot be embedded across the workforce if there is regular turnover and gaps in staffing.

“In the more remote places, the small rural schools, it is a challenge to recruit there and quite often, that change isn’t good for the children either and then that adds to their trauma because they’ve got different people coming in and out and they don’t know where they are. So we do recognize that that is a problem, it can be hard to recruit to more remote areas.”

Future priorities for Site X include continued efforts to embed trauma-informed practice within its services, with ongoing discussion of potential expansion and rollout beyond children’s services to adult services.

Delivery of the NTTP in Site Y

Delivery in trial in Site Y initially focused on staff training and workforce development. The aim was to develop a shared understanding of and language around trauma among staff, and foster increased confidence to manage interactions with people with lived experience of trauma. There was an intention to build a foundation for wider implementation work around changing environments, structures, communication processes, and systems. The local authority also hoped the work could create a “ripple” of trauma-informed practice, which would spread across the wider community.

“Helping people to recognise and understand how common trauma is and feeling more equipped to manage and support interactions… For a lot of our staff in not such specialised roles, those interactions can be quite overwhelming for everyone involved…The hope was … for some of our workers to think about working in a different way (and) then further implementation work in terms of systems, communication, strategies.”

A major focus of the initial pilot was delivering levels one and two training. Initially, a local authority-wide focus was adopted, with training open to all staff. Level one training was intended to be universal and reach staff across services and directorates. Level two training was intended for staff in specialist roles, who are more likely to be working with those who have experienced trauma. Children and Families staff, for instance, had previously commissioned training focused on adverse experiences, attachment, and resilience, so were already familiar with trauma-focused training. However, the delivery trail was seen and an opportunity for an important refresher.

A pre-existing Health and Social Care partnership strategic framework, structured around beliefs and values, good conversations, understanding trauma, and addressing equalities, distils the strategic planning, service design, and delivery ethos of the partnership. The pilot was described as helping evidence work within the ‘understanding trauma’ pillar. In turn, the Framework was seen to keep trauma-informed practice on the agenda within the partnership.

A steering group was devised to support the roll-out of levels one and two training and a Pilot Lead came into post to implement this. Staff from the Health and Social Care Partnership became trainers. The original plan was for trainers to organise their own face-to-face training sessions with staff cohorts. However, the COVID-19 pandemic, which emerged just as the training was beginning to be rolled out, necessitated a reconfiguration of the training plan, and a switch to online facilitation. The pilot lead co-facilitated training sessions with available trainers for participants who signed up from across the council.

This move to online formats resulted in the delivery of more training sessions than would have been the case otherwise. However, the new approach required the Pilot Lead to support and co-facilitate all training sessions. This reduced their capacity to connect with service managers, deliver implementation support, and develop a more strategic aspect of the work.

During the pilot phase, and despite the challenging context of the pandemic, an estimated 400 members of staff received level one and/or level two training. This was supported by the development of a strong network of trainers.

“The amount of training (delivered) and the trainers that we were able to.. skill up to run training have been real achievements of the pilot.”

The establishment of the Health and Social Care Partnerships’ Recovery Hub as a trauma-informed building was also achieved as part of the wider pilot. The Hub brings together mental health, substance use, and justice services. People who access and use services and third-sector partners were consulted during the design phase, and a tiered approach to training its staff was adopted, to promote a trauma-informed environment and practice.

“It was very much our intention that that building was a trauma-informed building. … each individual who has a particular context with our service users, I believe is trained appropriately to the level which they require.”

The momentum for wider training rollout faltered, however, due to the short-term nature of the pilot lead’s contract (one year), and other steering group members left their posts. This left no one driving the agenda forward, and this impetus was seen as necessary to build on the achievements of the pilot.

The gap in delivery remained until the Trauma-Informed Practice Development Lead (TIPDL) came into the post at the beginning of 2023, following a slow recruitment process. The TIPDL was recruited utilising the additional Scottish Government funding (provided to all LA areas to support the development of trauma-informed services). The TIPDL is also supported by the Practice Learning and Development Manager. This was felt to be helping re-instigate forward momentum.

“Personnel who were in post at the time (of the pilot), they were real drivers… that positive kickstart helped with sustainability. But you’ve got a renewed sense of commitment towards it with the new people who are now in and around that world.”

“Now (the TIPDL) has come on board things are progressing, there is more of a structure and a drive”.

Face-to-face training has resumed, with a further 156 people having been trained by the time of this evaluation. Relationships with the network of trainers have been re-established and they are supporting a rolling programme of training. Some bespoke training for staff in the Place directorate (which covers housing, libraries, waste, roads, green spaces, and leisure) has also been instigated. This is to broaden the staff groups taking up the training as the pilot initially had better reach among staff in Children and Families and Health and Social Care services.

Work is also underway to ensure alignment between NTTP implementation and other similar workstreams in Site Y, such as The Promise, Getting it Right for Every Child (GIRFEC), and the Nurture Strategy. Alongside this, there is recognition of the need to go beyond training to embed and sustain trauma-informed practice.

“To ensure the workforce is trauma-informed in an ongoing way, so not (just) an initial training…(but also) ongoing conversations that are continually based on an understanding of the potential impact of trauma and the role of compassion, empathy, etc…. All the systems around meetings, reflective spaces, the implementation of trauma-informed thinking.”

Site Y’s Trauma-informed Practice Development Strategy and Action plan 2023-2024, has three priority areas:

1. Supporting a skilled, knowledgeable and confident workforce: Here, the focus is on staff training and workforce development by: ensuring staff who didn’t access training during the pilot phase are reached; and supporting staff who have completed training to implement learning within their practice.

2. Workforce care, support, and wellbeing: The aim here is to create supportive work environments for staff, recognising that they may have their own trauma experiences and/or experience vicarious trauma linked to their roles. For example, staff from a newly established service in Site Y are offered peer support through monthly reflective practice workshops. This is under a new initiative being piloted in partnership with IRISS, the research arm of social care. From this, a template will be developed to cascade to other council services to share with their staff.

3. Supporting Leadership: This area focuses on developing trauma-informed leadership by, for instance,: supporting leaders to ‘model and implement trauma-informed principles’; and developing systems of accountability around the trauma-informed practice agenda. By the time of the evaluation, the Chief Executive had supported the facilitation of development sessions with elected members and the entire leadership team across the council. The TIPDL had also attended leadership forums with heads of service and group managers to promote the Scottish Trauma-informed Leaders Training (STILT), although uptake had not been high. Future plans include a ‘Leadership Pledge of Support’ and a learning event to showcase local practice and share learning.

The role of those with lived experience of trauma in programme delivery is also gradually developing. A stakeholder with lived experience of trauma attends the steering group and provided feedback on pilot training materials and the recent Strategy and Action plan. They explained that they valued this opportunity to be meaningfully involved in the future direction of the programme.

“To be included within this piece of work is important to me. They’re looking for me to read through it, give my recommendations and provide a quote. From my perspective, there’s a bit of meaningful involvement taking place.”

Going forward, there are plans to develop a network of Trauma Ambassadors. The TIPDL and the Learning and Development Manager are also considering a more targeted approach to implementation support within teams. The suggestion is to engage with a service motivated to be involved and where close working with managers can be established. It is hoped success with this approach may help to showcase the work and create a snowball effect of uptake. It is also felt that delivery and uptake could be enhanced by more bespoke training packages or through completing a needs analysis/assessment that identifies the appropriate level of training required across different roles.

Delivery of the NTTP in Site Z

The original proposal for trial delivery in site Z was informed by a training needs analysis^[3] that had recently been conducted. The site proposed working city-wide with four health and social care adult services. Following discussions with the Scottish Government it was agreed that a city-wide approach was overly ambitious, given the number of staff involved in service delivery from the four selected adult services, and the timescale and resource available for the trial.

A revised proposal was prepared, which focussed on the same four health and social care adult services but only in the Northeast of the city. The Northeast of the city was chosen as it has the highest levels of deprivation and, therefore, correlation to the prevalence of trauma among service users. The four adult services that the trial focussed on (homelessness, addiction services, community mental health and community justice) were also recognised to have service users with high levels of lived experience of trauma, who often accessed more than one of the selected service areas for support.

The delivery trial started before the emergence of COVID-19, and the initial plan was to roll out level-one and level-two trauma-informed practice training to all frontline staff across the different service areas. A launch event for the delivery trial was planned for March 2020, followed by a roadshow to pave the way for implementation. However, the emergence of COVID-19, the associated lockdowns affected service operations and delivery, so the trial was paused.

“Initially in [local authority area] pre-pandemic the plan had been to just roll out the level one training, and I think that was very much influenced by the expectation from Scottish Government because it was about level one and two delivery trials. So there was kind of a feeling that you just had to get out there and deliver to everybody and the plans were in place to do that, and in March 2020 we were due to have a big launch event and do a roadshow and then really start implementing training. Of course we all know what happened at that point that year so we had to kind of start again, but I suppose what that did offer was a real opportunity to pause and reflect on the approach that we were taking”.

This stall in implementation provided the trial delivery leads with an opportunity to reconsider the initial plans and their approach. They carefully considered the available evidence on good practice approaches to supporting trauma-informed service development and delivery, and the findings from a recent trauma training needs analysis.

“We had quite a wealth of evidence by that time that we were able to then take to the Senior Management Team in [local authority area] and say look we actually don't think that mass delivery of level one training is going to be a terribly successful approach. We think that taking an approach that takes managers and leaders through some of this first and foremost is going to be much more successful when you then come to the staff training element.”

This resulted in the development of a new approach, which focussed on training leaders and managers, creating trauma-informed services, and looking beyond just equipping staff to work in a trauma-informed way. It was also intended to create and secure the buy-in, commitment and support across service areas when implementation moved towards the rollout of trauma-informed practice training to frontline staff beyond the trial period. Essentially, this approach aimed to create the conditions that would help to ensure the future sustainability of the programme.

“Having managers going through the STILT training, so again you were getting managers who were kind of buying into this approach and starting to think about, you know, taking a trauma lens to your service and thinking about processes and procedures from a top-down kind of approach.”

“I think we made a conscious effort, first of all, that we had to start from the leadership and go down, because they were the people that will make it happen for the staff, and they were the people that will help and enable policies to be changed, practice to be changed, all the stuff that needs to be changed, as well as allowing staff to be trained and given them, and they need to give them the organisation's agreement that they can deliver and they can practice in a trauma-informed way.”

The approach was also aligned to existing evidence which demonstrates that equipping leaders in this way enabled a more holistic approach to develop trauma-informed services, which would be reflected in all aspects of a service, not just the approach and practice of frontline staff.

“And [senior leader] was keen that we started to look at not just about how you trained people, but how you changed the organisation from what it was currently, to a trauma-informed organisation. So how you looked at policies and procedures, how you looked at recruitment and training, how you looked at the engagement of lived and living experience in the city.”

This new approach was being formed while NHS Education for Scotland had developed the Scottish Trauma-Informed Leaders Training (STILT). This formed the basis of a new proposed approach to provide STILT sessions and support to all heads of service, service managers and team leaders in the four service areas involved in the trial.

The proposed new approach was approved by a steering group which had been established to oversee and support the implementation and delivery of the trial. The group was made up of staff in leadership roles across the service areas involved in the trial, as well as representation from wider stakeholders and partners. The new proposal was also taken to the Health and Social Care Partnership senior management team, who also provided their approval.

“And we brought together heads of service and service managers from the different services that would be involved in the trial. So they were predominantly adult mental health, alcohol and drug recovery services, criminal justice, and homelessness services. So they were kind of the mix that we had in terms of the steering group and the pilot. We also had some interested stakeholders from other organisations.”

Throughout the remainder of the trial period, STILT training was delivered to all heads of service, service managers and team leaders across the four service areas involved in the delivery trial. To generate support from the top of the organisation, the first STILT session delivered involved chief officers of the HSCP and the chief executive of the local authority.

“So we started with the chief officers of the HSCP but also the chief executive of the council. So we held what we called the executive leadership STILT session, that was the first one that we did…….we had really good engagement and actually really good discussions through that process and that session, and I would say that really set us up to be successful in the subsequent sessions that we had.”

All but one session was delivered online due to COVID-19 restrictions in place at the time, with follow-up workshops facilitated by the delivery trial leads. The follow-up workshops were intended to support reflections on the STILT sessions and what it meant for each service area. This included considering key drivers, how further work would be taken forward and planning for service review and development to be carried out through a trauma-informed lens. Reports were generated by the pilot leads following each session so findings from discussions could be fed back.

“There was no expectation from us, we asked them to set expectations of themselves and of their peers and some of that was then built into an action plan for the implementation groups that were supporting the delivery trial. What that has resulted in is a lot of discussion about trauma-informed practice, trauma-informed systems at different levels of the organisation and I guess an impetus to drive some of the non-training elements forward in a bigger way.”

The primary aim to deliver STILT sessions and follow-up workshops with Heads of service, service managers and team leaders across the four service areas was achieved during the trial period. Furthermore, the opportunity was also taken to deliver a small number of pilot sessions to trial level 1 delivery online, as well as providing enhanced level training for some team leaders and managers to equip them to support their staff in working in a trauma-informed way. The development of an e-module providing learning at the trauma-informed level and the establishment of a lived experience collaborative group were also cited as key developments.

“We tried to capture staff who needed level one training in those pilot sessions that we ran just to make sure that we had the right approach and that it was accessible online.”

“Because of the prevalence of trauma that existed within those client groups, it demanded that staff required more than level two training in a lot of instances. So for example in justice services [pilot lead] and her colleague ran the safety and stabilisation training level three for justice service team leaders and we're starting to look at how they could roll that out for staff.”

Since the achievement of the primary aim, each service area has made varying levels of progress towards developing action plans to support service review and development, and the provision of trauma-informed practice training for staff at the appropriate level. Each service area has established or is establishing implementation or working groups involving a cross section of staff, coupled with the ongoing support of the trial delivery leads.

“For example justice services have established a working group that looks at trauma-informed practice across all of their services in [area of the local authority] and that's got staff at every level of their service coming together, to think about where the challenges and barriers are, and some of the real opportunities. and they're already driving a lot of that forward using a trauma-informed lens. They are thinking about the information that they provide to clients, the format that is, is it accessible?, does it alleviate some of the anxiety for clients coming into the service?, You know a whole range of things they've really kind of, they’ve really taken it all. Similarly the homelessness services are looking to do something similar. They've had a really challenging few years with all the hotel kind of accommodation that's um had to be used in the city and a lot of changes within the service themselves but they're really embracing that and they're discussing it as a peer group. I think addictions are slightly different again because they've got the MAT standards published now and that obviously drives trauma-informed practice through that as well.”

“In the background, [pilot lead] was making connections with alcohol and drug recovery services, for instance, and we've just about fully completed that training with their staff, because we've got psychology in there, so they were able to do the training for their staff groups as well."

The local authority has utilised additional Scottish Government funding (provided to all LA areas to support the implementation of trauma training) to recruit a Trauma Lead Coordinator, and has also allocated additional funding to recruit administrative support role and three Senior Learning and Development Officers who will provide a training resource to support the rollout and implementation of level 1 and level 2 trauma training and build capacity for training within the HSCP. The team are supporting the programme of work and have completed a training needs analysis and mapping exercise. They have identified priority area groups in which to focus activity, and this has been signed off by a re-configured steering group.

“We really knew we needed a small, centralised team that could help coordinate, not to deliver all the stuff for people, but to look at where services were, start off with the training, but also looking at their standard operating procedures, their policies and their practice, all the stuff you need to look at, not just about overall training for a trauma-informed organisation, 'cause that's not going to do it.”

“And they've come along to some of our meetings and been part of the discussion. So the plan moving forward is that they would be a bit of a link for us, you know, and if we've got any training development needs, then we've got someone that we can kind of contact and get in touch with to answer those questions or to take those actions forward.”

More widely, and beyond the service areas involved in the initial trial, the aspiration of the local authority is to become a fully trauma-informed organisation across the whole of the city. Rather than trying to involve and engage every part of the organisation from the outset, the initial focus will be on services and staff within the Health and Social Care Partnership, which still represents significant scale and ambition.

“We decided that rather than trying to involve every part of the organisation and the council, we would try and concentrate on HSCP staff, first of all, and then we would move on to corporate staff and some of our partners.”

To help drive and support the realisation of the local authority’s ambition several structures have been put in place. The original Steering Group for the delivery trial has been reconfigured and is now a city-wide multi-agency steering group chaired by an Assistant Chief Officer, who is also the trauma champion for the local authority. An advisory group made up of people with lived experience of trauma has also been established to help inform the change that is required to become a trauma-informed organisation, and furthermore, the network of trauma coordinators is also recognised as having a key role in helping to facilitate the sharing of good practice.

“We set up an Expert by Experience group, and we're talking to them about what would they want to see in terms of an organisation being trauma-informed?

“So we've got the steering group up and running. We've also got a network of trauma coordinators across the board, so that we can share best practice, look at challenges. And that meets every, I think it's maybe every three months.”