Suicide prevention leadership group: annual report 2019

Delivering the vision of the suicide prevention action plan

NSPLG Delivery Plan

We published our initial Delivery Plan in December 2018^[9]. This set out an initial, high-level summary of our work to support the delivery of the 10 Actions in Every Life Matters. We published an updated version in July 2019, and intend to publish regular updates, in addition to our annual reports to Ministers and COSLA.

In this, our first annual report, we outline our emerging observations and recommendations for future activity, including where links need to be strengthened with other work.

Diagram 2: Planning Cycle

Embedding Suicide Prevention in local planning

We engaged with Community Planning Partnerships (CPPs) and local suicide prevention leads across Scotland to develop our understanding of existing local suicide prevention planning activity, networks and resource capacity. We received a wide range of responses to our enquiries and are grateful to everyone who took the time to engage with us.

Local areas are refreshing or developing suicide prevention plans

There is currently no requirement for local areas to produce dedicated suicide prevention action plans and there is a mixed picture across Scotland of local activity which aims to meet local need.

Most CPP areas are in the process of refreshing existing or developing new plans. Some have embedded activity in broader planning mechanisms. We heard that some areas have assessed, or intend to assess, local suicide prevention planning activity against Every Life Matters. We heard about a range of monitoring, evaluation and reporting approaches. In terms of resource, we also heard about a range of workforce and funding situations, with much of this embedded in broader roles and budgets. We also heard about a variety of local activities to raise awareness, develop networks and commission local services.

Recommendation 3: We recommend that the Scottish Government fund local test-sites to develop, deliver and test local suicide prevention activity in line with the guidance being developed under Action 1 of Every Life Matters. This will contribute to continuous development of that guidance, identifying good practice and learning across all areas of the Suicide Prevention Action Plan.

Recommendation 4: We recommend that the Scottish Government and COSLA enhance the learning from locally developed and delivered suicide prevention action plans by introducing a consistent evaluation model, based on academic research and an outcomes based approach, through which learning can be identified and shared.

This information has provided us with a helpful insight into the current position and has informed our consideration of key principles to support local suicide prevention planning. These include: putting the voice of lived experience at its heart; taking a public health approach; empowering leadership; making use of available evidence and focussing on quality. We have already started work to develop guidance to support local suicide prevention planning shaped around these principles.

Each death by suicide is a tragedy and no suicide should be considered inevitable. It is important that organisations understand their responsibility to learn from every suicide and to use that learning to prevent suicides in future. Every Life Matters sets out a commitment to develop appropriate reviews into all deaths by suicide, and ensure that the lessons from reviews are shared and acted on.

We examined the landscape of review that exists in Scotland for unexpected deaths and the extent to which this currently includes deaths by suicide. We were also aware of a range of other recommendations about how to improve the review of deaths and dissemination of learning from such reviews. These include:

• Review of the arrangements for Investigating the deaths of patients being treated for mental disorder^[10]
• Expert Review of Mental Health Services for Young People in Custody^[11]
• Children and Young People's Mental Health Taskforce recommendations^[12]
• Scottish Government improvement programme for adult protection
• Independent Care Review
• Child Death Review report .

We considered the different settings and circumstances in which a person might die by suicide, as a way of identifying gaps in existing review arrangements. We sought the views on where our work could be focussed from those responsible for providing health and social care, and children's services as well as justice organisations including Police Scotland and the Scottish Prison Service.

• Community settings, where the deceased had no contact with mental health or social services
• Health settings
• Leaving justice settings (noting the requirement for Fatal Accident Inquiries in respect of deaths in custody)
• Leaving social services support (for example, discharge from care settings for care experienced young people or vulnerable adults receiving local authority support).

We recognise that there is a requirement to consider undertaking an adverse incident review and a supplementary learning summary when a person dies by suicide and they have been discharged recently from mental health services . We believe it is important that learning from these tragic events is shared promptly and effectively. We therefore strongly support the recommendation from the review of the arrangements for investigating the deaths of patients being treated for mental disorderthat there be improved external scrutiny and national dissemination of the learning from reviews.

Recommendation 5: We recommend that COSLA support the introduction of multiagency reviews of all deaths by suicide which take place in a community setting. We consider that Chief Officers responsible for public protection in each local area would be best placed to be ensure that these are undertaken, with the support of guidance developed under Action 10 of Every Life Matters.

Recommendation 6: We recommend that Scottish Government determine how best to put in place multiagency reviews to be undertaken of all deaths by suicide which occur during a defined period after being discharged from prison or police custody.

Recommendation 7: We recommend that the Scottish Government and COSLA determine how best to put in place reviews of all deaths by suicide of young people which occur during a defined period after leaving the care system. This should include identifying an appropriate national body to work with local authorities to ensure effective scrutiny and dissemination of learning.

Increasing suicide prevention awareness, knowledge and skills

Every Life Matters calls for a renewed focus on suicide prevention training and for a coordinated approach to public awareness campaigns to reduce stigma and maximise impact.

Work is taking place to refresh existing training materials for professionals, alongside the development of new learning resources that respond to the experiences and challenges faced today by people across Scotland. We will continue to work with partners to help them create a set of training resources that are relevant, effective, accessible, impactful and empowering.

NHS Health Scotland has oversight responsibility for the delivery of Scotland's Mental Health First Aid and Suicide Prevention Training programmes. They and NHS Education for Scotland are jointly working to improve training resources, informed by engagement with individuals with lived experience and those working nationally and locally in suicide prevention.

The first phase of this work saw a package of new resources to support workforce development in relation to mental health improvement and suicide prevention launched in May 2019.

We were pleased to support NHS Health Scotland, NHS Education for Scotland, the Minister for Mental Health and the COSLA Spokesperson for Health and Social Care at the launch of these products on 28 May 2019.

Diagram 3: Knowledge and Skills Framework for Mental Health and Wellbeing

Suicide prevention forms a key part of revised mental health and wellbeing training in a framework from universal awareness raising to specialist training

Scottish Football, Local Authorities and the NHS are committed to raising awareness of suicide prevention

The new suicide prevention awareness raising resources are available to everyone in the form of short animations accessible online . We welcome the positive response from so many individuals and organisations who have already taken the opportunity to view, use and share them. The resources are aimed at reducing stigma about suicide, encouraging people to ask for help and providing everyone with the tools to give that help when it is needed. By encouraging and enabling their workforces to view and use these resources, organisations are rising to the challenge of making suicide prevention everyone's business.

We also welcome increased interest in the existing training such as Scotland's Mental Health First Aid, Suicide Prevention and Mentally Healthy Workplace training programmes. There was an increase to the existing bank of trainers for these programmes and a significant increase in demand for the training.

The second phase of this work has now started and will run until September 2021 . Early action includes extending awareness raising across the wider public sector workforce and developing training resources for specific practitioners. We welcome the learning needs analysis that will be part of this work and the focus on helping the public sector workforce to mentally flourish.

The animations have been used in a range of settings since launched, including in GP waiting rooms in Fife during Suicide Prevention Week

Recommendation 8: We recommend that the Scottish Government and COSLA provide strong support for work to transform and modernise suicide prevention branding and identity in Scotland, so as to support the delivery of the Suicide Prevention Action Plan and to build a social movement in which suicide prevention becomes everyone's business.

We note that this work will support the recommendations of the Children and Young People's Mental Health Taskforce, including developing specific resources to support staff who work with children and young people and the review of existing suicide prevention resources for young people. We particularly welcome that, in keeping with the principles of the Taskforce, this work will be undertaken in partnership with young people.

Having listened carefully to people who welcome the renewed focus on suicide prevention in Every Life Matters we have been considering what is needed to give suicide prevention the brand and identity it needs to support Scotland's ambition to make suicide prevention everyone's business. Importantly, this must include the steps to be taken to transition from the current Choose Life brand, building on its achievements over the years since its creation.

Raising awareness of suicide prevention in the general population through consistent branding and messaging was key to Choose Life's success and it is now time to build on those foundations to transform and modernise suicide prevention identity in Scotland, to support the delivery of the Suicide Prevention Action Plan. We are grateful to everyone who has contributed to Choose Life, not only for the lives their work has saved over the years, but also for their openness in helping to develop this new approach and social movement.

Improving support for those in crisis or bereaved by suicide

Every Life Matters is clear about the importance of ensuring the right support is available, at the right time, to people who are affected by suicide. We have engaged with a broad range of organisations involved in the field of support for those bereaved by suicide, who welcome our focus on this area. The police are often the first agency to engage with the loved ones of the person who has died by suicide and Police Scotland have worked with us to improve their service for families by using lessons from those who have been bereaved by suicide.

To inform our work, the Mental Health Foundation is currently undertaking research to understand the range of services and support available across Scotland to people living with the impact of suicide. The research will also gain insight into the lived experience of people who have needed to access such support. Fieldwork is currently underway, including interviews with people who have been bereaved by suicide and organisations who support families after suicide.

In addition, we have been examining evidence informed models elsewhere that aim to alleviate the distress of those bereaved, prevent further suicides, reduce the economic cost and support a community response to any suicide clusters. The research and findings from this work will come together in the coming months and we will be making recommendations for a pilot programme to begin in early 2020.

Every Life Matters emphasises that people in distress, including those who self-harm, need to find a respectful, compassionate response when they present to services for support.

We have examined the provision of crisis support for people nationally, gathered a broad range of information about local provision and noted with interest the Distress Brief Intervention (DBI) pilot programme. Our review has identified wide variation in the availability and nature of crisis support, which may be because of variation in local need or opportunity, or because of local barriers to delivery.

Recommendation 9: We recommend that the Scottish Government make funding available to pilot a new model of care for those bereaved by suicide which is effective in reducing distress, self-harm and suicide. It should include evaluation and appropriate mechanisms to ensure that learning is shared.

Distress Brief Interventions are in four pilot sites in Scotland to provide compassionate connected support.

We intend to test with stakeholders a working definition of 'crisis support' in the context of effective suicide prevention, beginning with key evidence from current practice and academic research . We will be asking the recently created Lived Experience Panel to help support and shape our work. We will aim to define effective service provision which meets the needs of users and the intentions of Every Life Matters.

We are pleased to note that the Scottish Government intends in its Programme for Government 2019-20 to provide crisis support for children and young people and their families. We believe that in common with the provision of community services for children and young people set out in the Programme for Government 2019-20 there will be learning from the development of these services which could be applied more broadly. It will be important to consider, as the services are developed and brought in by the Children and Young People's Mental Health Implementation Board, how this provision can be made available to people of all ages.

Recommendation 10: We recommend that the Scottish Government and COSLA consider how the crisis support for children and young people and their families to be taken forward by the Children and Young People's Mental Health Implementation Board can be made available to people of all ages across Scotland.

43% of probable suicides in 2018 were people 35-54 years

Roughly three-quarters of all probable suicides are men

Improving understanding of what works, particularly for those at risk

Every Life Matters sets out a list of characteristics drawn from analysis of suicide statistics which are known to contribute to a higher risk of suicide. However, it is important to say that someone may possess many of these characteristics and still be unlikely to die by suicide. These characteristics, or risk factors, are not the whole picture.

For example, we know that suicide and economic inequality are strongly linked. People living in Scotland's poorest communities are more likely to die by suicide than those living in the least deprived communities. Yet thankfully - and while every single death by suicide is a tragedy – it is still a small proportion of people in those poorest communities who die by suicide. How can we improve our understanding of suicide risk and of what works to prevent suicide for those at risk?

There are many academic and other models of suicide and risk. In this respect we have found a model developed in Scotland - known as the Integrated Motivational Volitional (IMV) model - particularly helpful. It has helped us to think about the particular life circumstances that may motivate a person to consider suicide and to think about what then could move those suicidal thoughts to action.

This has helped us to consider the traditional risk factors for suicide alongside how our activities in taking forward the actions in Every Life Matters can help people to feel less trapped, defeated or humiliated at particular points in their lives.

Every Life Matters commits to targeting interventions toward specific risk groups which are over-represented in suicide statistics. We will reach out to a range of people - including those who are seldom-heard - who have characteristics and experiences which may indicate increased risk of suicide. This will include those in these risk groups who have lived experience of suicidal thoughts or attempts, and those who have experienced the defeat, humiliation and entrapment which the IMV model identifies as important in understanding why people may feel suicidal. This will complement the work of the Lived Experience Panel and help to target effective interventions for people at elevated risk of suicide.

Recommendation 11: We recommend that the Scottish Government fund additional engagement targeted at groups of people with characteristics and experiences which may indicate elevated risk of suicide.

Diagram 3: Integrated Motivational Volitional model

Adapted from O'Connor, R.C., Kirtley, O.J. (2018). The Integrated Motivational-Volitional Model of Suicidal Behaviour. Philosophical Transactions of the Royal Society B. 373: 20170268

15% : Rise in the number of suicides in a single year 2017-18

Just over half of that rise was people 15-34 years

Meeting the needs of children and young people

Every Life Matters rightly recognises that it is vital to ensure the needs of children and young people are embedded in each of its Actions. We are taking steps to ensure that activity to support delivery of each Action in Every Life Matters includes consideration of the needs of children and young people.

There has been a strong focus in the past year in Scotland on the mental health of children and young people. The Children and Young People's Mental Health Taskforce was jointly commissioned by the Scottish Government and COSLA in June 2018 with the aim that children, young people, their families and carers should know that they are supported in good mental health and will be able to access services which are local, responsive and delivered by people with the right skills. The Expert Review of Provision of Mental Health Services at HMP YOI Polmont has specific recommendations in relation to suicide prevention for young people in custody.

We know that each suicide is a tragedy which affects not only the loved ones of the person who has died but also many people more widely. 2018 statistics sadly indicate that more young people have lost their lives to suicide and we must therefore acknowledge the wider impact on other young people in their schools, workplaces and communities. We welcome and support the recommendations of the Taskforce and the establishment by the Scottish Government and COSLA of a Children and Young People's Mental Health and Wellbeing Programme Board to deliver those recommendations. We will work with them to reduce suicide amongst young people and its impacts on other young people across our communities.

Every Life Matters highlights that, if used positively, the internet and other technologies can be used to improve suicide prevention both locally and nationally. We all live at least part of our lives online. For young people particularly, the internet may be the place where friendships are played out, where they learn and where they would go to seek help if feeling low. However, many children and young people are unsure of what credible trusted sources of support exist online.

We have been examining what digital support is available currently to people who may be at risk of suicide. This includes how to raise awareness of sources of such support and of online resources facilitating individuals' ability to manage their own mental health, resilience and wellbeing. We have also seen innovative use of social media by the police to promote suicide prevention and help to spread the message that everyone can help.

We also responded to the UK government consultation about online harms in July of this year . We emphasised the need for research in this area and the need for balance in regulation. There is a balance that must be struck in any regulation between removing content which provides information on methods of suicide or promotes suicide and self-harm, and preserving the positive role internet use can play in encouraging users to seek help and access support.