Suicide prevention action plan: every life matters

Actions

Action 1. The Scottish Government will set up and fund a National Suicide Prevention Leadership Group (NSPLG) by September 2018, reporting to Scottish Ministers - and also to COSLA on issues that sit within the competence of local government and integration authorities. This group will make recommendations on supporting the development and delivery of local prevention action plans backed by £3 million funding over the course of the current Parliament.

The Scottish Government will give leadership to realising our vision for suicide prevention in Scotland by endorsing the agency and leadership of the NSPLG, by working closely with the NSPLG and partners to act on its recommendations, to influence change, remove barriers to progress and to ensure progress against the delivery plan. 

The NSPLG will:

• Include representation from services and stakeholders, including the third sector and people with direct experience of suicide through bereavement or those who have previously experienced suicidal thoughts or attempted suicide.

• Engage with integration authorities, local authorities, public health professionals and other stakeholders, to support the development of actions and priorities that will inform local strategic planning and partnership approaches to realise our vision. 

• Facilitate national improvement work to support local suicide prevention activity.

• Oversee a delivery plan of identified actions and priorities to achieve the vision. This delivery plan will be published in December 2018. 

• Coordinate the public debate and progress a programme of work to prevent suicide.

• Make recommendations to the Scottish Government on action needed within the responsibility of the Scottish Government, and to COSLA where there is a specific responsibility of local government or integration authorities. 

• Report to Ministers and to Cosla regularly on progress, including through a publicly available annual report. This will be published annually from September 2019.

The NSPLG work will be supported by dedicated officials from the Scottish Government. With Scottish Government funding, the NSPLG will establish its own secretariat from the organisations within its constituent members. From November 2018 this secretariat will take ownership of organising meetings.

Key strategies and work areas including the Mental Health Strategy (2017-2027), the Justice Vision (2017-2020), Policing 2026, and Scotland’s Drowning Prevention Strategy (2018-2026), will make a significant contribution to the NSPLG’s work. Mental wellbeing has been identified as a public health priority for Scotland, providing a strong focus for the wider public sector to take collaborative action focused on prevention and early intervention. Suicide prevention will be an important component of this and other public health priorities.

The shared ambition of the Scottish Government and its partners requires that the funding available across the health sector, the wider public sector and the third sector is harnessed efficiently and effectively. The changing nature of how local, regional and national services are commissioned, specifically with the evolution of integration authorities, means that a coordinated approach is vital.

Impact in health and social care will require active engagement with integration authorities, public health, NHS Boards, Police Scotland and local authorities. Local suicide prevention actions, plans and groups should sit inside existing planning arrangements and work plans in a way that makes specific activity on suicide prevention clearly visible.

The Scottish Government has been clear that NHS Boards, integration authorities and their partners must shift the balance of care to focus on primary and community services. This is relevant to how mental health services and support will be configured and delivered, and how suicide prevention is prioritised. 

Over the course of the current Parliament we will invest £1 million annually to support this action plan and the work of the NSPLG. 

Nationally, during 2017-2018, NHS Boards will have spent £1 billion on mental health services. This is a significant and valuable resource. The Scottish Government is also funding work which will be relevant to Suicide Prevention work. These include broader programmes such as:

• £35 million by 2022 for 800 additional mental health workers in key settings including Accident and Emergency departments, GP surgeries, police custody suites and prisons, as set out in the Mental Health Strategy.

• £5 million to support transformational change in child and adolescent mental health services across Scotland.

There are also several programmes funded in full or in part by the Scottish Government, or with a funding contribution provided, which will directly or indirectly support suicide prevention. The funding currently runs to over £2 million each year and is a component of the following work:

• The Distress Brief Intervention test programme. 
• NHS Health Scotland’s National Suicide Prevention Programme. 
• NHS24’s Breathing Space telephone and web advice service. 
• ScotSID (Scottish Suicide Information Database) through NHS National Services Scotland Information Services Division (ISD). 
• Healthcare Improvement Scotland's Scottish Patient Safety Programme – Mental Health.
• Samaritans free telephone service (funding contribution provided).
• The UK National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (Scottish element funded).

Action 2.The Scottish Government will fund the creation and implementation of refreshed mental health and suicide prevention training by May 2019. The NSPLG will support delivery across public and private sectors and, as a first step, will require that alongside the physical health training NHS staff receive, they will now receive mental health and suicide prevention training.

Evidence based training on mental health and suicide prevention is essential. Mental health and suicide prevention training must be on a par with physical health training. 

The Mental Health First Aid Training programme has been led by NHS Health Scotland since its inception in 2004, while the suicide prevention training programme was inherited by NHS Health Scotland from the Scottish Government in 2007. Information from NHS Health Scotland indicates that over 92,000 people have been trained in either mental health or suicide prevention awareness across Scotland and over 2,000 trainers trained to provide the courses. 

Current training materials in Mental Health First Aid and the various suicide prevention training programmes available in Scotland, will be refreshed in order to make them more flexible, to ensure sustainable delivery, and to update their content and make them more relevant and accessible. 

An employment culture is required where mental health training is made available to staff on an equal footing to physical health training. Scottish Government will fund the creation of a core general module on mental health and suicide awareness. This will be developed and complimented with a suite of additional ‘bolt on’ modules appropriate for particular professional groups. Included within these will be modules on suicide prevention and trauma. These will be available by May 2019.

We heard through the “Views from people affected by suicide” report a recommendation for mandatory suicide prevention training for specific professional groups, particularly GPs^[10]. The importance of training for other frontline services including GP receptionists and NHS24 staff, pharmacists, prison officers, Jobcentre staff and social security entitlement advisors, teachers and school staff, university/college staff and lecturers, and transport workers was also raised. 

“More needs to be done to make everyone more confident in asking the question and offering support.”

“We need to challenge the assumption that suicide awareness and training is not essential.”

“Suicide needs to be everyone’s business, not just frontline staff.”

Mental health and suicide prevention training will be mandatory for all NHS staff who receive mandatory physical health training. These include doctors, nurses, psychologists, allied health professionals and pharmacists. The NSPLG will prioritise early action across other key sectors, including where staff are likely to interact with individuals from groups with a higher risk of suicide, to ensure parity of mental health and suicide prevention training with that of physical health training. 

Every organisation that has physical health first aiders should also train and provide mental health first aiders. Organisations should consider what mental health training is necessary, just as they do for physical health training, as part of the continuing professional development of their staff. These organisations should use their existing training systems to deliver mental health training and to provide assurance and governance. 

Specific support for children and young people is needed. Teachers, lecturers, and staff at schools, colleges and universities need to have the confidence to effectively support students who are in distress, or who have been affected by suicide in other ways such as bereavement. 

The Higher and Further Education sectors are already engaging with relevant partners, including NUS Scotland, on how to develop further, their responses to the mental health needs of students. 

Education authorities are required to ensure that schools are health promoting. This includes promoting physical, social, mental and emotional wellbeing by supporting pupils to make positive lifestyle choices in relation to their health and wellbeing. 

We commit to ensuring that, by the end of academic year 2019/20, every local authority will be offered training for teachers in mental health first aid, using a ‘train the trainer’ model to enable dissemination to all schools. 

Education Scotland will also continue to support schools in making the links between nurture, Adverse Childhood Experiences and trauma informed practice, to develop effective practice. This will complement the work to implement the National Trauma Training Framework.

For many people, their interaction with the social security system may come at a time of great difficulty – e.g. they may have lost a job, had their access to entitlement changed, or may have become disabled. All of these life events can be triggers for suicidal thoughts, and training for social security staff will enable them to recognise signs of distress, and to signpost people to appropriate support. Within our social security agency we will equip our people to confidently handle and talk about mental health generally, including suicide awareness and prevention. Working with partners, we will develop and utilise a range of learning opportunities that fully equip social security agency staff to have a wider awareness of the challenges and circumstances the person may be facing; to possess a knowledge of the systems and support functions that are available; and importantly, to be skilled in having sensitive conversations including suicide awareness. This will inform and drive the design of learning solutions and will include direct collaboration with those partners who can provide “lived experience” and examples. We will thread this through our learning portfolio and utilise a coaching approach, including the Mental Health First Aid concept and aligning with existing Scottish Government practices, to ensure continuous support to delivery colleagues.

A range of training approaches is required, ranging from awareness-raising to skilled intervention, depending on the population group being trained. Some people who complete suicide are not in contact with professional services beforehand but may have expressed their feelings to others. We want a Scotland where citizens have greater awareness of mental health and wellbeing to be able to support themselves and others.

Action 3. The Scottish Government will work with the NSPLG and partners to encourage a coordinated approach to public awareness campaigns, which maximises impact.

“No one talks about it until it happens.”

“Positivity is more powerful than negativity.”

“The stigma around suicide is still overwhelming.”

“People would 'cross the road' to avoid someone who had been bereaved by suicide.”

National and local public awareness campaigns should focus on breaking down stigma and common misconceptions around suicide, and on encouraging people to talk more openly about their feelings with their families, friends and colleagues. Campaigns should enable people from local communities to talk to each other about suicide and to drive change.

The Scottish Government, informed by the work of the NSPLG, will identify key dates throughout the year to run campaigns nationally and locally. An important focus for raising public awareness is to ensure that campaigns are using the right channels and approaches to best reach and speak to target audiences – see Action 7 below. People need good knowledge of local and national suicide prevention groups and services so they can effectively use them or signpost to colleagues, friends and family. 

Those who present in crisis in whatever context should be treated with respect and care, and supported by compassionate professionals. Any campaign to tackle suicide should be set in a policy context of improving this culture across public services. 

This will build on the work of “See Me” and of NHS Health Scotland’s Suicide Prevention Programme.
The needs of children and young people should be explicitly included. 

Action 4. With the NSPLG, the Scottish Government will ensure that timely and effective support for those affected by suicide is available across Scotland by working to develop a Scottish Crisis Care Agreement.

“Suicidal people cannot wait for help.”

“We need everyone to be speaking the same language [around suicide].”

“The healthcare system needs to better consider how it creates pathways that are supporting people who self-harm, experience mild depression or bereavement, that can prevent escalation.”

The NSPLG will ensure that crisis support is available for those considering suicide. For those bereaved by suicide, the NSPLG will ensure that a Scottish Crisis Care Agreement across statutory and non-statutory bodies is developed that includes a common set of standards and referral pathways for trauma-informed support.

The period of time following a death by suicide or a suicide attempt represents a critical time for compassionate, high quality care. Good and timely support and information need to be available to people who have been directly affected by suicide. People who have been bereaved by suicide are themselves at a higher risk of suicide. Grief is intense and the emotions – particularly around stigma and isolation – experienced in the aftermath can differ considerably from those following other types of death.

The needs of the different groups of affected individuals require careful consideration. People who have attempted suicide and survived need compassionate and effective support. In addition people affected by suicide – whether completed or not – include:

• The person’s families and friends.
• People dependant on them, such as their children.
• Others who care for them.
• Staff involved in their care and treatment.
• First responders at the time of a suicide attempt.

The NSPLG will review good practice in this area – including the community triage model of support, which provides police with direct access to mental health professionals – with a view to ensuring that support pathways are in place across Scotland by the end of 2019.

Action 5. The NSPLG will use evidence on the effectiveness of differing models of crisis support to make recommendations to service providers and share best practice.

“Care only kicks in when people are in crisis.”

“Help is often offered too little and too late in the journey of a suicidal person.”

“You are unlikely to get immediate help unless you are an immediate danger to yourself or others.”

People in distress, including those who self-harm, need to find a respectful, compassionate response when they present to services for support. It is vital that clinicians and first-responders provide a positive encounter with people in distress and are vigilant to self-harm. While most people who self-harm will not go on to die by suicide, self-harm is strongly associated with a lifetime risk of suicide.

The Distress Brief Intervention (DBI) is one approach to improving the way in which services respond to people in distress. It is funded by the Scottish Government and is currently being piloted in Lanarkshire, Aberdeen, Borders and Inverness. The DBI is just one of a range of actions already set out in the Mental Health Strategy, to help deliver change. These include:

Investment in NHS24 and its development of improved responses to unscheduled mental health presentations.

Provision of 800 more mental health workers to provide mental health specialist access in a variety of frontline settings including Accident and Emergency Departments, primary care, police custody suites and prisons.

Primary care transformation, with an increase in link workers and mental health professionals in primary care teams.

Services and integration authorities should consider how people who are traditionally least likely to engage with statutory services can be reached and most effectively supported, in order to mitigate health inequalities. This includes consideration of the needs of people with protected characteristics under the Equality Act 2010. 

Services provided for remote and rural communities should consider the particular risks and needs of these areas. They should optimise their use of technology-enhanced care such as video-conferencing. The Scottish Government provides funding support to the National Rural Mental Health Forum; this Forum is key to addressing the unique challenges presented by rural isolation.

Action 6. The NSPLG will work with partners to develop and support the delivery of innovations in digital technology that improve suicide prevention.

If used positively, the internet and other technologies can be used to influence suicide prevention both locally and nationally^[11]. This could include providing online support to people who may be at risk of suicide, raising awareness of sources of support, facilitating individuals’ ability to manage themselves and develop resilience, and encouraging safe use of the internet. 

We need to maximise the positive influence of social media and its potential for key messaging, working with NHS24, NHS Health Scotland and other interested partners to develop a strong online suicide prevention presence across Scotland that caters for all ages. 

Action 7. The NSPLG will identify and facilitate preventative actions targeted at risk groups.

“People need to be treated as human beings during their support.”

“Money worries can lead to helplessness.”

“One size does not fit all.”

The NSPLG will consider how risk of suicide is elevated for groups within the broader general population, and identify specific action to address this. 

The high rates of suicide among males, people in their ‘middle years’, people who are not married/partnered and people who live in areas of socioeconomic disadvantage point to the challenges of health inequalities and groups at risk of suicide^[12,13]. Research suggests that adults and young people who identify as gay, lesbian, bisexual or transgender have a greater risk of suicidal ideation and suicide attempts^[14,15].

A complex range of factors can contribute to people contemplating suicide. Many are not to do with mental ill-health and can instead relate to stressful life circumstances, events or changes in a person’s life, where there are 

prevention opportunities for public bodies and communities. Healthcare settings will continue to be important for supporting prevention and interventions. However, the NSPLG will also consider wider settings where at-risk individuals can be supported – such as Jobcentres, Citizens’ Advice Scotland offices, solicitors’ offices, etc.

The following characteristics and factors are known to contribute to raised suicide risk. They can be cumulative and overlapping. Services and individual clinical contacts need to be aware of them in their response:

• History of self-harm
• Bereavement from suicide
• Adverse childhood experiences (ACES) and later trauma
• Deprivation, poverty, and social exclusion 
• Isolation
• Living with or developing an impairment or long-term condition
• Middle aged men
• People affected by drugs and/or alcohol
• Migrants 
• Lesbian, gay, bisexual and transgender (LGBT) adults and young people
• Gypsy/Travellers
• Homelessness 

Workforce training as discussed in Action 2 is one means by which we can help develop this awareness and target the right support to these individuals. 

Action 8. The NSPLG will ensure that all of the actions of the Suicide Prevention Action Plan consider the needs of children and young people.

“There needs to be more support for children affected by suicide – parents can’t do it all, and are going through their own grief as well.” 

“We need to prioritise support for children in schools so that they become emotionally aware and resilient.”

Young people tell us that mental health is one of their biggest concerns. It is therefore crucial that the NSPLG engages with young people to prevent suicide. 

We have established a Youth Commission on Mental Health, in partnership with Young Scot and the Scottish Association for Mental Health (SAMH). The Commission is made up of young people aged 14-22. Commissioners will take an in-depth look at mental health services in Scotland and will develop recommendations over a 15-month period, for Ministers to consider in 2019.

As part of the Year of Young People 2018, we are also working with See Me to hold the biggest conversation Scotland has ever had on mental health. We have asked young people to help design a forthcoming campaign for 8 to 26 year olds, which will ask what mental wellbeing means to them. 

We know that demand for mental health support is increasing, and that services which meet that demand need to be flexible and work collaboratively with delivery partners. The needs of children and young people require specific focus. The Children and Young People’s Mental Health Task Force, chaired by Dr Denise Coia, will have a key role in bringing together the strands of work relating to children and young people’s mental health from the Mental Health Strategy 2017-27, galvanizing a modern, joined-up and practical response to a real public concern.

Our aim is to transform Child and Adolescent Mental Health Services (CAMHS). In doing so, we will expand the range of help and settings in which young people can be assisted – and develop a means of providing high volume, low intensity support. 

Suicide rates have been falling in children and young people but some concerning evidence has been emerging. This includes worsening self-reported mental wellbeing, especially in teenage girls.^[16]

Early education for children and young people is critical – focusing not just on suicide prevention awareness, but also on emotional intelligence and resilience. As highlighted in Action 2 of this plan, educational providers (both at schools and colleges/universities) have an important role in identifying and supporting at-risk young people, and those affected by suicide; training and continuous professional development should be provided to support them with this. We commit to ensuring that by the end of academic year 2019/20 every local authority will be offered training for teachers in mental health first aid, using a ‘train the trainer’ model to enable dissemination to all schools. 

Transitional periods in the lives of children and young people are vulnerable periods. This includes the transition from adolescence to adulthood (often expressed through moving from school to further and higher education or employment), and from children’s to adult services. The Scottish Youth Parliament has worked with young people to develop a resource to support transitions from CAMHS to adult services. 

Action 9. The Scottish Government will work closely with partners to ensure that data, evidence and guidance is used to maximise impact. Improvement methodology will support localities to better understand and minimise unwarranted variation in practice and outcomes.

Currently national policy and local services use the following:

• Data. This comes from a wide variety of sources – local, national and international. The Scottish Government funds the Scottish Suicide Information Database (ScotSID)^[17] at NHS National Services Scotland’s Information Services Division (ISD). The UK National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH)^[18] is part funded by the Scottish Government. Annual data on population suicides are reported by National Records of Scotland^[19] and the Scottish Public Health Observatory^[20]. The information collected gives a picture of suicide rates, demographics and trends.

• Evidence. Academic and analytical studies provide an evidence base for what makes a difference to suicide rates. This can be used to improve practice and make positive and effective service change. Examples include the toolkit from NCISH on organisational factors affecting suicide, and work done by Healthcare Improvement Scotland on their “Reducing Suicide Risk – Mental Health Team Discussion Framework”.^[21]

• Guidance. There is useful guidance available on issues such as transitions^[22], self-harm^[23] and depression^[24]; as well as on Locations of Concern^[25], suicide prevention in rural areas^[26], media reporting on suicide^[27,28], and Choose Life local activity.

There is a strong learning culture on suicide and its prevention in Scotland and elsewhere in the UK that supports a community of evidence-based practice and shared learning^[29,30]. The Scottish Patient Safety Programme (Mental Health) at Healthcare Improvement Scotland (HIS)^[31] is doing work on ward safety and transitions to the community. 

We have good evidence now about suicide, highlighting risk factors and providing an evidence base of effective interventions. The Leadership Group will promote the continuing use and application of these resources locally, to ensure opportunities for improvement are seized. All of the principles of Realistic Medicine^[32] are applicable, but in particular we need to reduce unwarranted variation in practice and outcomes.

Action 10. The Scottish Government will work with the NSPLG and partners to develop appropriate reviews into all deaths by suicide, and ensure that the lessons from reviews are shared with NSPLG and partners and acted on.

There must be review and learning from every death by suicide, translating into action at national and local levels. We will ensure that reviews into deaths from suicide are implemented into a learning approach and involve multiple agencies where necessary. 

Deaths by suicide where the person has been in contact with statutory services should all be subject to investigation. The nature of this investigation will depend on the particular circumstances of the incident and the organisation(s) involved. Examples include:

• Local adverse event reviews/critical incident reviews by NHS Boards.
• Investigations by the Mental Welfare Commission for Scotland under section 11 of the Mental Health (Care and Treatment) (Scotland) Act 2003.
• Fatal Accident Inquiries initiated by the Procurator Fiscal.

HIS provide guidance on the components of good reviews and they host a suicide reporting and learning system^[33] that harvests the lessons learned and actions from NHS Boards, and communicates this nationally.

The Scottish Government has committed – in Section 37 of the Mental Health (Scotland) Act 2015 – to a review of the arrangements for the investigation of deaths of patients detained or voluntarily in hospital for mental health treatment. The NSPLG will action recommendations from this review and consider how they should be applied to the wider group of people in touch with mental health services who are not in-patients at the time they complete suicide will action recommendations from this review.

Deaths by suicide where the person has not been in contact with statutory services should be reviewed timeously, in a multi-agency format where necessary, through considering available information in police and NHS reports. There is considerable challenge in defining a universal approach to deaths by suicide of people who have not had contact with statutory services. The NSPLG will consider this challenge and the potential to standardise investigation reporting both for deaths by suicide in contact with statutory services and those not in contact. NSPLG will report its recommendations on best practice in suicide reviews to the Scottish Government.

ScotSID acts to harvest information at national level. The NSPLG will need to ensure that evidence emerging from all sources including ScotSID and the Confidential Inquiry into Suicide and Homicide by People with Mental Illness^[34] is fed back locally and translated into action.

It is essential that appropriate data about individuals is able to be shared, translating into effective service response for those at risk, and for those affected by suicide.