Suicide prevention action plan 2018 - 2020: review

4. Implications and learning

The findings of this review reveal the breadth and depth of activity which has been, and continues to be, undertaken to progress the 10 Actions in the SPAP. This appears to be in spite of, and perhaps even because of, the COVID-19 pandemic. Although requiring some re-thinking of priorities and of the mechanisms for developing and delivering on the Actions, the potential increase in suicidal behaviour as a result of the pandemic has given added urgency to the need for effective interventions to mitigate and respond to suicidal distress. The experience over the past two years also provides learning about how to progress this work into the final year of the SPAP and beyond. The review suggests opportunities for learning in relation to: scoping the Action; identifying and measuring outcomes; structures for delivery; and processes and mechanisms of engagement.

4.1 Scoping the action

As noted earlier, particularly in relation to Action 5, some of the initial time has been spent clarifying what is meant by 'suicidal crisis'. Both this Action and Action 6 (digital interventions) also alluded to the absence of high quality evidence of effectiveness on which to base proposals or recommendations. This suggests that there may be a value, in any future strategy and associated action plan, in undertaking some initial scoping of the action to be addressed, whether and what available evidence of effectiveness is available, and the implications for achieving desired outcomes. This would perhaps help reinforce the potential, evidence-informed, line of sight between an action and its contribution to outcomes, i.e. its rationale, before getting into the detail of whether, how and by whom it could be developed into a concrete, measurable intervention. This would not preclude innovation and the generation of new evidence through robust evaluation, but would perhaps ensure innovation with a purpose.

4.2 Identifying and measuring outcomes

An outcome is the difference that an activity makes (on its own or in combination with other activities). Short-term outcomes are typically couched in terms of changes in attitudes, awareness, skills and knowledge. Outcomes are distinct from outputs, which might be a product of some sort, e.g. a training resource. As noted above, Actions 1 and 10 included the development of logic models, suggesting that early thought had been given to the possible causal pathways from activities to outcomes. An evaluation specification and outline logic model had been developed for Action 4. On the basis of the information provided for this review, however, across the whole of the SPAP, there appears to be limited evidence of short-term outcomes, and measurement or evidence is still largely couched in terms of outputs or proposals for an "evaluation plan".

This may arise from a combination of factors. First, there may be a conceptual confusion between 'outputs', things done or produced, and 'outcomes', the difference made or changes introduced or brought about. Second, there may be substantive reasons for a lack of clarity around outcomes. Specifically in relation to the SPAP, it may, for example, reflect the stage or nature of the Actions, several of which were still largely developmental, or, as in the case of Action 5, one step removed from implementation (contingent on the take-up of the recommendations that are made). Third, and more strategically, it may also suggest that there is scope for thinking through, and making explicit early on in the planning process, the short-term, intermediate and long-term outcomes that actions are seeking or anticipated to achieve or contribute toward, and the indicators/measures that would provide evidence of achieving the outcome, including where change is likely to happen over longer periods. Starting from outcomes, whether of a strategy as a whole or of individual components, might, as suggested above, also help to ensure that activities have an underpinning logic - rather than starting from an action (or set of actions) and attempting to retrofit outcomes. This may suggest the value of building in evaluation capacity early on, to support outcomes-focused thinking. In addition to helping to clarify the 'logic', this may also encourage early consideration of the ways and means for demonstrating progress.

It should be noted that responses to the review identified opportunities for learning from specific evaluations. These included:

• A process evaluation of Action 3: what might be learned from the complex, intensive and extensive process of developing this campaign?
• The role of the LEP: The LEP was a key contributor to the majority of the Actions. The process of contributing was also felt to be of value to individual members and to wider groups of participants with lived experience. There would be value in evaluating the process and outcomes achieved, both to inform future suicide prevention work and also, potentially, for integrating lived experience into other areas of policy development. Given the innovative nature of this model, there may also be wider, international interest in the role of the LEP and what it has been able to achieve.^[15]

As suggested above, other Actions might consider the potential for more systematic monitoring and evaluation (process, outcomes and/or economic evaluation) to support understanding of what the Action is achieving, how, for whom and in what contexts. This may be particularly salient given the priorities identified in the NSPLG for pandemic-related suicide prevention action (see section 2.3.2 above), including specific suicide prevention campaigns (Action 3) and development of suicidal crisis interventions (Action 5).

4.3 Structures for delivery

The scope of the review did not include the development of the Action Plan itself, or the structure and functioning of the NSPLG, including the roles and responsibility of the Group, its programme manager and Scottish Government policy leads. Responses to the review do, however, suggest that early consideration of the structures to support delivery might have helped to reduce the lead-in times - particularly salient in the context of a three-year Action Plan.

As the summary of activities suggests, different Actions were at different stages of implementation. In part, this reflects the complexity of the tasks involved, but also the length of time to appoint delivery leads. Among some of those responsible for delivering on the Actions, processes for recruiting support staff could also be experienced as complex and prolonged. There is clearly a value in scoping out what is required early on in the process, and building requests for supporting capacity into the business planning process, but this needs to be underpinned by clear decision-making processes and governance arrangements.

4.4 Processes of engagement

The breadth and depth of activity being undertaken, notwithstanding delays in appointing delivery leads or other support staff and the impact of COVID-19, are notable. What is also evident is the extent of joint and partnership working with other agencies and organisations, and the extensive and intensive level of engagement with stakeholders with lived experience, as well as the "general public". As has been noted throughout, a key role has been played by the LEP, in contributing not just their expertise but also themselves, their voices. The importance of the LEP's contribution cannot be under-estimated; as a model, it is potentially at the forefront of suicide prevention activity globally. This may even further underline the value of capturing and disseminating the learning, both to inform its ongoing development in Scotland, and also so that other countries can learn from Scotland's experience.

In the short term, one of the issues to consider may be how to maintain the energy, commitment and continued engagement of a comparatively small group of people. Early consideration should be given to issues of sustainability over time, to enable a wider group of people to continue to contribute, to the extent and in ways that they wish.

Arguably, the extensiveness of engagement and collaboration deployed in the development of the Actions, and the cross-cutting work of the LEP, may indirectly extend the reach of the Action Plan, adding to the gathering 'social movement'. In effect, the processes used to develop and implement the Actions may themselves start generating outcomes.

4.5 Mechanisms of engagement

The COVID-19 pandemic has raised the profile of digital interventions. Consideration of the development and support for delivery of innovations in digital technology is a specific Action (Action 6), and also has implications for the other Actions, particularly in the context of infection control measures which discourage face-to-face contact. As the delivery lead for this Action notes, this Action has to be progressed in the context of limited evidence of effectiveness. It also raises the potential for digital exclusion, if people are unable or unwilling to use digital technology.

A shift toward online engagement has also had implications not only for how to engage with people, but also how to ensure their safety. For the LEP, the move to online engagement had meant adapting their safeguarding processes:

"We have a session on safeguarding before every meeting where we remind ourselves of how the meetings will run. We have a short debrief at the end of every session. We also do a series of welfare calls to Panel members. That is all part of a new system and has required a lot of adaptation."

Given the uncertain future, this is important learning for future programmes.

Indirectly, what the pandemic has also revealed is the need for Actions to be able to respond flexibly to the changing environment. The move to online processes is an indicator of the capacity to do so. The need for agility may become even more pressing as the impacts of the pandemic make themselves felt over time with a re-focus of some Actions.