Scottish Government

7. The future of Choose Life: key messages and conclusions

7.1 In this chapter we will summarise our main findings and conclusions, consider the implications for the future direction and priorities of Choose Life, and offer recommendations for taking Choose Life forward.

Performance and achievements: main findings

7.2 Suicide is a difficult and sensitive issue. The Choose Life strategy and action plan was ambitious in its aim to raise awareness and understanding of suicide, and to promote and support action on suicide prevention among agencies and services, and in communities. A notable feature of this evaluation has been the commitment and enthusiasm shown both by individuals and agencies at national and local level. Much of the progress made by Choose Life can be attributed to that commitment.

7.3 Before considering progress against the specific objectives of Choose Life, we look first at national and local leadership and co-ordination.

National

7.4 Participants felt that, towards the end of Phase 2, the changes in the national landscape (the loss of 'dedicated' funding and guidance, the move of NIST) had undermined the strong framework that had supported Choose Life. In the view of most participants, a strong policy lead from Scottish Government is essential to maintaining the profile of Choose Life and sustaining suicide prevention activity for the remaining period of the strategy. While the publication of TAMFS has now gone some way to meeting that perceived need, most participants believe that Choose Life and, post 2013, suicide prevention, will continue to require that lead from Scottish Government.

7.5 There was a strong view that there needs to be a distinct focus on suicide prevention at both national and local level if it is to get attention from all the relevant partners. There were, however, differing views about the need for a separate strategy for suicide prevention. The majority felt that it was important to retain a separate strategy and the Choose Life brand until 2013. While many participants saw suicide prevention beyond 2013 as part of the mental health improvement agenda, others emphasised the need for suicide prevention also to have a place within other policies and strategies on mental illness and socio-economic issues.

7.6 The support and guidance provided by the national support team was widely regarded as a valuable contribution to the implementation of Choose Life. Despite concern about its current role and location in NHS Health Scotland, participants still wanted a national support team to give direction and support, e.g., on targeting, training, evaluation, and to facilitate information sharing.

Local

7.7 As we noted in Chapter 4, the effectiveness of local co-ordination arrangements, and associated strategic and operational links, are fundamental to the implementation of the strategy and to its future sustainability.

7.8 Although, overall, CPPs have had little direct involvement in Choose Life, they are seen to be the appropriate strategic body to take forward Choose Life because of their role in health improvement, including mental health improvement. However, because CPPs are high level, there needs to be a clearer understanding of the co-ordination function and how it can be carried out most effectively.

7.9 The role of the Co-ordinator appears to be pivotal in taking forward and sustaining the Choose Life agenda. There are a number of ways in which that role has been implemented successfully, including full-time and part-time posts as well as adding the remit to an existing post-holder. Where local co-ordination was considered to be working well, a number of factors appear to contribute (although they may not all be present) :

• a strategic lead from the CPP, local authority or NHS
• the seniority of the Co-ordinator (or strategic line manager with a specific remit for Choose Life)
• the location of the Co-ordinator in health improvement, mental health or social work where suicide prevention is relevant to the core agenda
• the Co-ordinator having the capacity/ability for strategic networking and influence
• clear reporting lines and accountability
• good links to decision-making committees or sub-groups of the CPP/Council/ NHS Board
• personal skills and qualities of the CLC such as communication and ability to build relationships.

7.10 Local Choose Life Steering Groups have been an important element of the local infrastructure in many areas. There are different models ranging from decision-making groups to information exchange forums. They can be a useful way to foster inter-agency links, but it is important to have both strategic and operational interests represented (or connected). There is some evidence that there is added value and a greater profile for Choose Life if the Chair is a senior manager in strategic role.

7.11 There was progress in mainstreaming and sustainability - in areas where Choose Life is given a separate post or dedicated time, where it is integrated into Council and NHS structures, and where there are good links to local partnerships and local strategies. Where there was reported to be less progress, it appeared that Choose Life had not been aligned with the "right people" or structures. Our findings suggest that, to ensure that suicide prevention continues to be addressed in the longer-term, it needs an infrastructure in which the strategic lead and responsibility, people, time and resources are clearly identified.

Performance against the specific objectives

7.12 Our evidence suggests that, although in each of the areas below there is further work to be done, they represent significant achievements.

• Raising awareness and understanding of suicide risk and suicide prevention. Choose Life is widely regarded as having broken down barriers and enabled more open discussion about suicide within and between agencies, and in the community. However, participants also felt strongly that there were still barriers to be broken down to reduce stigma and saw awareness-raising as an ongoing priority.
• Developing a more strategic approach to training. Arguably, training is the most successful element of Choose Life and has been described as "the real sustainable legacy." The wide availability and uptake of suicide prevention training was seen to have increased skills and capacity in agencies and services and in the community. It has also helped to build partnerships, e.g., with CHPs and substance misuse services. Issues identified for the future are:
  • the need for a training strategy with a focus on training after HEAT 5
  • tackling lack of trainer capacity in some areas, for example, by introducing a more flexible T4T (Training for Trainers) programme
  • better targeting of training (e.g., to those working with high risk groups), but also continuing to make training available to everyone
  • post-training follow-up and support to ensure that training is actually put to use
  • expansion and flexibility of training to support participation by other key groups, e.g., current GPs, pre-registration GPs, police, ambulance workers.
• Improving the knowledge and evidence base. The development of the evidence base through the research programme managed by the Scottish Government and the dissemination of the findings and the promotion of local research by SIREN in Phase 2 were seen as major achievements. There seems to be a strong case for re-invigorating the work done by SIREN in some form. There is also still a need to develop a consistent approach to local evaluations.
• Improved reporting of suicide in the media. The development and use of media guidelines at both a national and local level has helped to produce more sensitive reporting of suicide and has supported Co-ordinators in talking to their local media.

7.13 On other objectives, the evidence shows a more varied picture.

• Targeting high-risk groups. There was some progress on targeting high-risk groups at national level through, for example, work on remote and rural issues. At a local level, targeting was done to some extent in many but not all areas. One of the barriers to targeting was reported to be a lack of formal national guidance on how to do it. Some participants also thought that there were now too many target groups, making it difficult to determine priorities but this may be linked to a need to distinguish between locally identified and national priorities.
• Making better connections with key services. There was limited evidence of progress at both national and local level, particularly with clinical and primary care services, especially GPs. There was a mixed picture in relation to substance misuse. Overall, a re-energised approach seems to be needed to making connections.
• Supporting local community groups to build capacity. This has mainly been done through training and project funding and there has been some success in achieving sustainability for services or posts.
• Performance management. At national level, NHS Health Scotland has put monitoring systems in place, for example, in relation to training. At a local level, there was little evidence of development in performance measurement and management for Choose Life activities. However, there were indications that new structures are being developed to monitor the outcomes of the SOAs would create a framework that could include suicide prevention.

The future of Choose Life: how can it become sustainable

7.14 The big questions for participants, in the light of the changes in the policy and organisational landscape, were, "Where does Choose Life fit now?" "How can it become more effective?" and "How can suicide prevention activity be sustained?"

7.15 It may be useful to reflect on whether, at this stage of the 10-year strategy, there is a need to move away from the Choose Life brand and give more prominence to suicide prevention as the key message. Our evidence strongly suggests that the brand has been largely successful in bringing attention to the issue of suicide prevention both in national bodies and in local agencies and partnerships. However, any brand may lose its currency over time and it may be worth considering whether, as the strategy period draws to an end, a staged approach to shifting the emphasis to suicide prevention as the message would be productive.

7.16 As has already been recognised by TAMFS, it is timely to review the Choose Life strategy. However, given that the strategy is now past the half-way stage, it would also seem appropriate for the review to consider how suicide prevention can be sustained within the overall policy framework and in local strategies and plans beyond 2013.

7.17 In Chapter 5, paragraph 5.79, we noted some factors identified by participants which indicate progress towards sustainability. We have also identified some drivers and opportunities that could support sustainability :

• The new strategic priority given to suicide prevention in TAMFS and the review of the Choose Life strategy
• The implementation of Equally Well and Delivering for Mental Health could provide an opportunity to make explicit links to suicide prevention
• The successes of Choose Life, particularly in awareness-raising, training, supporting the media and improving the knowledge base
• The experiences and knowledge held by longer-serving Co-ordinators and other local stakeholders
• The findings of the National Confidential Enquiry on the close links between mental illness, drug and alcohol misuse, and suicide, which provides the opportunity for productive dialogue
• The development of different types of local infrastructure which have had some success in developing and maintaining suicide prevention as an area of activity recognised by local strategies and plans
• The engagement with the NHS and substance misuse services facilitated by HEAT 5
• The creation of the National Suicide Register to improve information about the factors that lead to suicide, which will help with targeting.

7.18 We have also identified some risks and potential barriers:

• The perceived low profile of Choose Life in the Scottish Government among participants (who have interpreted this as a sign that suicide prevention is no longer important)
• The review of the HEAT targets which may have implications for HEAT 5
• The likelihood of public sector funding constraints in the next few years
• The weakness of the local Choose Life infrastructure in some areas
• The difficulty of issuing guidance on the direction of Choose Life because of the Concordat.

The future of Choose Life: conclusion and recommendations

7.19 From our findings we have formulated the following conclusions and recommendations :

• There is a continuing need for a strong national lead from the Scottish Government on the policy and strategic direction of suicide prevention. This lead could be given through the appointment of a national "champion" as suggested by the second Sounding Board. While it is not appropriate for the Scottish Government to issue direction to local areas, there may be scope for some form of advice on how to take forward Choose Life beyond 2010, for example, good practice guides.
• The separate Choose Life strategy should continue until 2013, but consideration needs to be given to where suicide prevention fits in the wider, developing policy framework and how a distinct focus for suicide prevention can be retained. There may be a case for reviewing the role of the Choose Life "brand".
• The National Suicide Prevention Review Group should review and re-focus the current objectives to ensure that Choose Life fits into the new policy and organisational environment. The objectives should be clearly articulated and capable of measurement or performance tracking.
• The utility and relevance of the 20% target should be reviewed. A non-quantitative directional target may be more appropriate. In addition, there is a need to improve performance monitoring and management within Choose Life. This could be achieved by setting milestones and indicators against which performance can be tracked.
• The connections between suicide prevention and other relevant policy areas should be communicated more clearly. On the one hand, there would be value in clarity about how suicide prevention activities can contribute to achieving the objectives of those policies. On the other hand, it could encourage engagement by local partners if there was a more explicit message about how the objectives of other policies e.g., to reduce health inequalities, contributed to reducing suicide risk. This would support the inclusion of suicide prevention in local strategies and plans, and strengthen the case for local funding of relevant projects.
• A national support function is still needed to provide leadership and direction for local work but there may be a case for the purpose and functions of the national support team to be reviewed. Areas where national support were felt to be needed were in relation to: training strategy and infrastructure; (national) communication and awareness-raising; guidance on targeting of high-risk groups; performance management; building and disseminating the evidence base; and supporting networks (possibly regional networks) for sharing learning and experiences.
• The role of the local Choose Life Co-ordinator should be retained as it seems to be central to future sustainability. The role can be fulfilled in a number of ways. Local areas should also consider whether their current arrangements for the direction and implementation of Choose Life activity promote the most relevant and appropriate strategic and operational links.
• In light of the changes in the organisational landscape, local areas may wish to consider whether to revise the role and composition of their Choose Life Steering Groups, or whether there are other more effective ways to involve strategic and operational representatives, and voluntary sector and user groups in suicide prevention.
• There should be further work, both nationally and locally, to link with drug and alcohol services, primary care and clinical mental health services. Improving links with clinicians is particularly important in the light of the findings of the National Confidential Enquiry about mental illness and suicide risk. In addition, Choose Life (nationally and locally) should consider engaging with new partners. Other important links will be to economic strategy and employment services (especially important in the current economic climate).
• The approach to targeting high-risk groups needs to be reviewed. Choose Life should continue to balance a population-wide approach with the targeting of high-risk groups. However, there is a tension between nationally identified target groups and local need that should be resolved. It will be important to ensure that information from the new National Suicide Register is easily accessible to local areas. NHS Health Scotland should also develop guidance on targeting of high-risk groups. This should include guidance on how to carry out a local needs assessment which would inform the design of services.
• There is a need to share experience and learning. Co-ordinators would value more opportunities to meet and discuss the issues that affect Choose Life and what has been learned from local developments. More support for new CLCs was also identified as a need.
• Local areas should consider where there are gaps in awareness-raising activity and how they can be addressed. Awareness-raising was also one of the main areas in which national advice and support was felt be helpful.
• There should be continued investment in training with particular consideration given to the development of a long-term training strategy. Efforts could usefully focus on increasing the uptake of training among key groups such as GPs, A&E staff and substance misuse workers; increasing the numbers of trainers; and addressing the problem of trainer turnover and lack of capacity among current trainers.
• The Scottish Government should continue to support national research on suicide prevention and consider with national and local partners what should be the focus of this research for the remaining period of the Choose Life strategy. The Scottish Government and NHS Health Scotland should also consider how best to take forward the work previously done by SIREN to promote local research, disseminate evidence and support its application in practice.
• NHS Health Scotland should consider the feasibility and practicality of developing a consistent approach to evaluation, or an evaluation framework, to assist CLCs in evaluating their own local Choose Life activities and to promote shared learning from local initiatives.

7.20 Finally, there is now a considerable body of experience and knowledge about suicide prevention and how to take it forward both strategically and operationally. It is important to acknowledge that, but also to consider how to capture that collective knowledge and experience to inform the remaining period of the strategy and beyond 2013.