Suicide prevention action plan 2018 - 2020: review

3. Findings

3.1 Review methods

The aim of this rapid review is to draw out learning from the implementation of the SPAP over the period September 2018 to October 2020.

Data for the review were collected using a brief schedule circulated to the delivery leads responsible for each Action (or sponsor where a delivery lead had not been appointed). A tailored schedule was also sent to, and completed by, the Lived Experience Panel co-ordinator. The data were collected in September/October 2020. Returns were received in relation to all of the Actions and from the LEP.

One of the key findings to note is that, although the aim was to capture activities over the first two years of the SPAP, the responses from delivery leads suggest that much of the planning and development was undertaken in year two. In year one, the bulk of public facing outputs was produced under the auspices of Action 2.^[7] A contributory factor to the comparatively early implementation of Action 2 was that the work and associated funding had been agreed with NES/NHS Health Scotland (subsequently PHS) before the Action Plan was finalised.

The longer development periods for the other Actions illustrate the amount of lead-in time that may need to be built in (together with supporting infrastructure) to any future strategy before it will be possible to see substantive change.

3.2 The SPAP infrastructure

As noted in section 1 above, the SPAP was launched in August 2018 with the National Suicide Prevention Leadership Group (NSPLG) being established in September 2018 to support the delivery of the plan. In July 2019, a Programme Manager was appointed, and, in September 2019, the appointment of delivery leads, with operational responsibility for implementing the Actions, was approved by the NSPLG. Appointment to the delivery lead posts was, however, gradual, with some being appointed in November 2019 and others not in post until as late as February 2020. As also noted above, to avoid overlap with parallel work being taken forward by the Children and Young People's Mental Health and Wellbeing Programme Board, detailed planning and the appointment of a delivery lead for Action 8 were postponed. Recruitment of a delivery lead began in December 2020.

Some delivery leads covered more than one Action, for all or some of the time over this period. Other Actions have more than one delivery lead: the AAG, responsible for delivery of Action 9, has two delivery leads, as does Action 3.

Several Actions recruited or attempted to recruit or commission supporting staff (in addition to commissioning agencies for particular types of work - see section 3.4 below). The AAG recruited two researchers who came into post in early 2020. Action 3 has recently recruited a social movement manager to support the public awareness campaign work. Action 7 also sought to commission an external consultant to undertake the engagement with people with lived experience of suicide from at risk groups. The requirement for a consultant was identified in the initial proposal for the Action in October 2019. The sign-off arrangements for the recruitment process were, however, prolonged, mainly due to a lack of clarity as to what was required for a decision on recruitment to be reached. The resulting delays in progress led to the decision to conduct the work "in-house".

While there is no Action that directly focuses on the involvement of lived experience in the work of the SPAP, there was a commitment from the outset to ensure that no Action should be progressed without the involvement of those with lived experience. Accordingly, a co-ordinator was appointed (hosted by SAMH) to develop and grow the Lived Experience Panel and its wider network.

3.3 The impact of COVID-19 on the delivery of the Actions

As noted in section 2.3 above, in response to the COVID-19 pandemic and associated infection control measures, some of the SPAP Actions were paused (e.g. Action 4 - now resumed) and some were of necessity delayed because the delivery leads were recalled to their substantive posts. In addition, local suicide prevention leads and other stakeholders were pulled back to more direct COVID-19 work or furloughed, limiting the scope for stakeholder engagement. A number of Actions continued, however, in spite of the restrictions, but the methods of working and the timing of outputs were affected. Methods of engaging with stakeholders, for example, had to shift to online working/digital engagement, with implications for safeguarding, particularly in relation to people with lived experience or at risk groups. The development of specific outputs was also delayed. For example, the production of an animation addressing mental health improvement and suicide and self harm prevention, aimed at the children and young people's workforce (part of Action 2), was held up due to the difficulty of getting a sound recordist into the studio; and a workshop to develop learning materials to support the animations was delayed. Mechanisms for disseminating campaign materials also had to be modified. The United to Prevent Suicide public awareness campaign (Action 3), for example, had to use different approaches for testing out the campaign options, with a slant towards digital and mixed media focus. The outlets for promotion were also more limited, with no print media or cinema promotion.

Some unintended 'positive' impacts of the pandemic were also noted, however. The increased need for action to address worsening mental health and greater suicide risk likely to result from the infection control measures put in place in response to the pandemic proved to be galvanising. LEP members, for example, felt it gave their work even greater impetus, even if it meant finding new ways of engaging and ensuring safeguarding in different ways. In relation to Action 1, it was suggested that the focus on mental ill-health and risk of suicide, which the pandemic has highlighted, helped to progress action locally, where previously local suicide prevention leads may have struggled to gain senior management buy-in. It was also suggested that the need to communicate in different ways could result in more efficient means of engaging, e.g. by saving on travel time.

3.4 Activities

As illustrated in appendix 2, the development and implementation of the Actions involved a range of activities, reflecting the stage they had reached in delivering on the Action. These included: initial scoping, planning and information gathering; development; implementation; and collaboration and engagement.

Given the COVID-19 context and evolving infrastructure, it is unsurprising that, while some Actions had progressed to implementation activities (such as Actions 2 and 3), others were still engaged in planning or development.

3.4.1 Scoping, planning and information gathering

Scoping, planning and information gathering were key activities across all the Actions over the first two years of the SPAP. Stakeholder engagement activities included focus groups, interviews and consultations undertaken across the majority of Actions, to help identify and clarify issues. Action 5, for example, undertook stakeholder engagement "to define main gaps, inconsistencies and barriers to effective suicidal crisis care". Action 7 engaged with representatives of at risk groups to explore "people's experience of suicide; helpful practice and interventions during periods of suicidality; unhelpful practice and interventions during periods of suicidality; [and] suggestions for positive change". Engagement involved a range of agencies and organisations, as well as with people with lived experience, including, but extending beyond, the LEP. The breadth of engagement activities is discussed further below. Scoping, planning and information gathering also included the rapid research reviews undertaken by the AAG, in support of Actions 6 and 7, as well as the analysis of consultation exercises in support of Actions 5 and 6.

3.4.2 Development

Scoping and information gathering were carried out by a number of the Actions to inform initial development work, including, but not restricted to: the extensive and intensive work of developing and testing the workforce learning resources (Action 2); and the development of the identity and campaign materials in support of the refreshed suicide prevention public awareness campaign that became 'United to Prevent Suicide' (Action 3). It also involved working with local suicide prevention leads to help shape planning guidance to link national and local suicide prevention actions (Action 1), or linking with other national agencies with death review processes to explore ways of learning from and aligning these processes (Action 10). In relation to Action 4, the engagement with the LEP and other stakeholders around the country, together with research commissioned by the Mental Health Foundation (MHF), shaped the service specification. Additional input from the AAG, as well as from the LEP, informed the design of the evaluation brief. An online consultation with people with lived experience and relevant organisations and professional groups was also conducted to inform the development of Actions 5 and 6. This generated over 200 responses.

3.4.3 Implementation

As noted throughout, not all of the Actions were at an implementation stage. Action 2, in relation to workforce development, and Action 3, the public awareness campaign, were the most advanced in delivering on their respective actions. Action 4 was ready to begin recruiting a lead for a pilot service for people bereaved by suicide, but this was delayed for around six months due the pandemic. This Action was resumed in October 2020, when a call for expressions of interest was issued. On a smaller scale, Action 10 was progressing towards implementing tests of change of a suicide deaths review process in two areas of Scotland (Grampian and Borders), with a third area (Dumfries & Galloway) added subsequently.

3.4.4 Collaboration and engagement

What emerges from surveying all the Actions is the extensiveness and intensiveness of joint and partnership working and active engagement, informing the shape and direction of each Action. The delivery lead for Action 5, for example, described how the stakeholder engagement process had involved:

"Numerous 3rd sector organisations, suicide prevention leads in many regions (Glasgow, Borders, Lothian), trauma organisations e.g. Rivers Centre, COSLA, NHS, Police Scotland. It included visits to rural areas (Lochaber, Elgin and Borders) and discussions with people with Lived Experience."

Across the Actions, the types of collaboration and engagement included:

• Joint/partnership working. A number of Actions involve joint or partnership working with a range of agencies. Action 2, for example, was delivered jointly by PHS and NES, while Action 3 was jointly led by PHS and SAMH. Action 1 was working with local suicide prevention leads to develop planning guidance to align local and national plans more closely. Actions 4 and 10 were also working in close collaboration with local areas to pilot service models. In relation to Action 4, extensive work was being undertaken in Ayrshire and Arran and Highland preparatory to piloting a national service to support families bereaved by suicide. As noted above, the Action 10 delivery lead was also working closely with two (subsequently three) areas to implement tests of change of a suicide deaths review process, using the Shetland/Tayside model. Across the Actions, there was also evidence of engagement with agencies involved in parallel activities to explore opportunities for joint working, e.g. the Action 10 delivery lead was working with leads of other death review processes to map processes and consider a consistent database for collaboration and review; in relation to Action 6, initial partnership meetings had been held with NHS 24, to identify joint digital innovation opportunities.
• Engagement with other agencies. As the examples of Actions 5 and 10 illustrate, delivery leads for all Actions were in dialogue with a range of other agencies with overlapping interests. These included Police Scotland, the Mental Welfare Commission, NHS24, and Healthcare Improvement Scotland.
• Participatory: A key characteristic of all the Actions is the extent to which they sought contributions from a range of professional groups as well as stakeholders with lived experience of suicide. The development of workforce learning resources, animations and supporting materials (Action 2), for example, involved a range of different professional groups, including mental health nurses, Allied Health Professionals, dentists and pharmacists, as well as representatives from the children and young people's workforce. In addition to professional groups, events were held with young people to enable them to contribute to the development of the children's and young people's animations. The LEP made many, varied contributions to the majority of the Actions (see below). In addition, interviews, focus groups and consultations involved an even wider group of stakeholders with experience. To support the development of the identity and supporting materials for the public awareness campaign, Action 3 included:

"Engagement with over 400 external stakeholders pre and post campaign launch; …two virtual stakeholder sessions with almost 200 stakeholders to present the identity and campaign ... [ran] two YouGov surveys to support testing of final identity and support launch event into the identity and campaign assets. Over 2,000 members of the public engaged."

3.4.5 The contribution of the Lived Experience Panel

The LEP made influential contributions to the majority of the SPAP Actions.^[8] In relation to Action 3, for example, the LEP made a significant contribution to the development of the identity for the public awareness campaign, as well as providing an "authentic" voice to the campaign launch. In relation to Action 8, a video made by a LEP member's son on the experience of losing a sibling to suicide was developed with a view to disseminating it to secondary and tertiary educational settings. LEP members also helped to design data gathering tools: informing the Action 7 engagement proposal, for example; responding to evaluation proposals for Action 4; and informing the consultation questions in relation to Action 5.

The contribution of the LEP also suggests a potentially broader impact, independent of specific Actions. One member of the LEP, for example, gave training sessions on understanding people in suicidal crisis to Police negotiators in Glasgow and Edinburgh. Plans were in place to deliver training to a further 100 new negotiators in November 2020. In addition, prior to the first COVID-19 'lockdown', the LEP co-ordinator delivered safeTalk training to 20 Studio Something staff (the creative agency involved in the public awareness campaign development) and to the Mental Welfare Commission staff team (as part of his training delivery role elsewhere).

3.5 Outputs

Reflecting the purpose and stage of implementation, Actions 2 and 3 generated the bulk of external-facing outputs. Under Action 2, these included the KSF and workforce development plan, animations for the adult and children and young people workforces,^[9] an e-learning module and associated facilitators notes accessible via the TURAS Learn e-learning website,^{[10] [11]} and five COVID-related learning resources.^[12] Data provided by the delivery leads on the reach and uptake of these different resources indicate:

• As at end August 2020, adult animations were accessed by nearly 14,000 people on Vimeo and over 2,500 people engaged in the Turas Learn eLearning site.
• As at end of September 2020, three weeks post-launch, the Children and Young People animations views on Vimeo for all 3 animations - 1406.
• As at end of September 2020, 49 facilitators had submitted applications to lead local learning sessions using the animations and other learning resources. The majority of facilitators range from education, NHS and social care settings, with some standalone private facilitators.

Public facing outputs from Action 3 (in addition to the surveys initiated to develop and test the products) included:

• Identity and campaign stakeholder packs and promotional resources
• Online digital hub to host the campaign and social movement
• Dedicated campaign media and social media activities
• A 30 second campaign film for TV and digital channels.

Beyond these, Action 4 commissioned and published research by the Mental Health Foundation to inform the development of a service for people bereaved by suicide.^[13] Together with other colleagues in an international collaboration, some AAG members were co-authors of a systematic review of the evidence concerning the impact of previous infectious disease-related public health emergencies on suicide-related outcomes. The review is now available online.^[14] Arguably, making this available to a wider audience extends the reach and potential impacts, in terms of knowledge and awareness, of the SPAP. As noted in the context of the review of activities (section 3.4), the AAG also undertook several rapid evidence reviews and contributed to the design and analyses of consultations on behalf of several Actions.

Other outputs were more internal-facing, such as project plans and timelines.

3.6 Short-term outcomes

In relation to Actions 1 and 10, led by the same delivery lead, reference was made to developing a "logic model" as part of the preparatory work. Action 4 also developed an outline logic model to inform both the service specification and evaluation design. This is not to say that other Actions did not, or were not, working through the anticipated links between the intended outcomes and the activities they were planning. As part of this review, delivery leads/sponsors were asked to indicate what short-term outcomes they had achieved to date, how implementation of the Action would contribute to the prevention/reduction of suicidal behaviour, and what evidence they would use to demonstrate progress towards the achievement of the short-term outcomes by September 2021. The responses are summarised in appendix 3.

The different 'types' of Action, as well as the different stages of development/implementation, may explain why, as indicated in appendix 3, there is presently limited information on relevant short term-outcomes (as opposed to outputs, such as take-up/reach). While able to describe the aspirations for how the Actions would or could contribute to the overarching goal of a reduction in suicide rates, plans to collect evidence to demonstrate what has been achieved (in terms of difference made), up to the end of the period covered by the SPAP (September 2021), appeared to be less well developed. Indirectly this perhaps reflects the nature of the SPAP itself. As discovered in the course of the attempt by the AAG and NHS Health Scotland (now PHS) to undertake an evaluability assessment, there are difficulties in evaluating the individual and additive impacts of this series of Actions in the absence of an overarching and comprehensive suicide prevention strategy to which the Actions are intended to contribute.

3.7 Facilitators and barriers

To get a sense of what may have helped or hindered the implementation of the different Actions, delivery leads/sponsors were invited to indicate the barriers and facilitators they faced prior to the COVID-19 'lockdown'. There are some clear commonalities across the Actions.

3.7.1 Facilitators

Effective co-operation and collaboration

For Action 4 the facilitator was "the unanimous support of everyone involved in this project. The clear understanding by stakeholders of the value of this initiative." This is echoed across the Actions, and includes accounts of:

• Good internal support and communication between delivery leads, sponsors, the AAG, NSPLG and the Scottish Government policy team. Leads for Actions involving partnerships between organisations described the value of having a range of complementary skills and experience, enabling work to be taken forward. One delivery lead, for example, referred to "good teamwork and time investment" as facilitating progress.
• The support of external partners and of other stakeholders, including local suicide prevention leads and other agencies/organisations, was identified as facilitating progress. This suggests a groundswell of support to achieve change, summarised by one delivery lead as the "motivation of stakeholders to improve the current suicide support landscape."
• As noted throughout, the active engagement of people with lived experience, particularly through the LEP, as well as beyond, was consistently identified as a strength.

The supporting infrastructure

• Having a dedicated, "albeit limited", budget, and flexibility around budget spend "as long as it was in line with agreed direction of travel", and having an agreed plan of action "signed off" by the NSPLG, were identified as helping to achieve progress.

3.7.2 Barriers

In response to the question regarding (pre-COVID-19) barriers, one delivery lead commented positively: "None, there was (and continues to be) support for this Action from both national and local partners" (Action 1). Several issues were, however, raised by other delivery leads/sponsors: some reflected the complexity of the issues the Actions were seeking to address, while others, as noted earlier, related to the operational infrastructure.

Defining the issue and absence of evidence

Substantive issues included, for example, the difficulty of defining 'suicidal crisis' (Action 5), but also the lack of evidence of effective interventions (Actions 5 and 6). In relation to workforce development (Action 2), the complexity of the workforce within the scope of the Action was felt to have been "challenging".

Infrastructure issues

Identified infrastructure issues included a delay in appointing a delivery lead for Action 6. Difficulties or delays due to the perceived complexity of recruitment processes were also noted (Actions 7 and 9).