The Scottish Government recently consulted on draft proposals for a new Suicide Prevention Action Plan. 

While we welcome the publication of this draft plan, we believe that the proposals need to be more ambitious.

Our full response is below.

 
Samaritans is the leading suicide prevention charity in the UK and ROI. Last year we responded to 5.7 million contacts from people across the UK. Our service is provided entirely by volunteers, in branches across Scotland.  
 
  • Around 2 people die every day in Scotland by suicide. There were 728 suicides in 2016, which is an 8% rise on the previous year - the first such rise in six years. While we can expect some year-on-year fluctuations we also cannot ignore any rise in deaths. (National Records of Scotland, 2017)
  • Suicide is the single biggest killer of men under 50 in the UK and young people aged 25 -34. 
  • Suicide is preventable. We have made progress in Scotland, however our suicide rate is still significantly higher than in England.  
 
To ensure the forthcoming Suicide Prevention Action Plan was shaped by those with experience of suicide, Samaritans, NHS Health Scotland, the Health and Social Care Academy and Scottish Government undertook pre-consultation events with those who have been directly affected in late 2017 – early 2018. The final report (which we from these events, including recommendations for the action plan, can be found here
 
Question 1) Do you agree that we should establish a “knowledge into action” group for suicide prevention? 
 
Don’t know/ Yes. 
There is a lack of detail in the paper as to what this group would look like. While we do believe that such a group could prove useful in testing new interventions, we must be mindful that suicide is a vastly under researched area. While developing and testing interventions is highly useful, a large part of the remit of this group should be identifying gaps in our knowledge and commissioning research on this. As a major public health issue, we must commit resource to researching and understanding suicide. We agree that the Scottish Suicide Information Database (ScotSID) provides useful data, however we can and must go further. 
 
An important part of putting knowledge into action is learning from what we do. If we want to know which interventions work, we must evaluate our work. There has been no evaluation of any of our previous suicide prevention work. We must set out how we will evaluate the new action plan. NHS Health Scotland’s monitoring and evaluation of the alcohol strategy sets out a useful, evidence-based way to do this. The Republic of Ireland’s suicide prevention strategy also includes a valuable plan for implementation and evaluation, including a strong, visible leadership team and clearly defined roles and responsibilities. 
 
The Knowledge into Action group should feed into the work of the proposed Confederation, with a particular initial role in establishing the case for different and specific local interventions and informing the actions would be suitable to address the suicide risks particular to that location.
 
2a/b) Do you agree that we should develop a new mental health and suicide prevention training programme?
 
Don’t know. 
The current training programme is widely considered to be effective.  If a new programme is to be developed, it must be a full suite of training including longer and shorter courses to fit around different needs, work roles and schedules. This also provides the opportunity to ensure the training fits the needs of all those who should be receiving training, from first responders to community groups. We have heard during the pre-consultation events for people with lived experience that the cost of the current training can be prohibitive: It is vital this new training is available to all.
 
Where this fits alongside wider programmes around mental health and wellbeing, including awareness and training around responses to self-harm, should be considered as part any development.  
 
The amount of resources required to develop such training specific to Scotland is a concern, when considered against the limited financial and human resources to affect change in this area.  Development of new packages such as this could take many months and years without sufficient resources.  We also need further detail on what would happen to the existing network of trainers across Scotland in the meantime and the potential gap in provision until a new package is ready to be introduced.
 
2c) To what extent do you agree that there should be mandatory suicide prevention training for specific professional groups?
 
Strongly agree.
We welcome this proposal, which was a recommendation from the pre-consultation report. We also know that 89% of Scottish adults would support some sort of mandatory suicide prevention training for certain professionals (YouGov/ Samaritans, 2018).
 
70% of people in Scotland have contact with a healthcare service in the 12 months before they take their own life, most commonly for a mental health drug prescription. (ScotSID, 2017)  Those professionals that people at risk are most likely to meet -including pharmacists and GPs- must be resourced and trained to recognise signs of potential suicide and to then respond appropriately. Additionally, a significant proportion of people who die by suicide have no recent contact with health services. From becoming homeless, losing your job or accessing social security, we know there are key points when people are at increased risk.  Training for professionals in these non-health areas can play a critical role in saving lives. We believe that staff in the new social security agency must receive suicide prevention training.   
 
3a/b) Do you agree that we should establish a Suicide Prevention Confederation? 
 
Yes. 
While the 2002 Choose Life Strategy established an initially effective model for national leadership and local delivery, this structure no longer exists in a meaningful way. Samaritans, SAMH and the Mental Health Foundation believe that the suicide prevention confederation model, if set out correctly, could begin to reinstate that national leadership and local delivery. We believe that a renewed structure for suicide prevention in Scotland should include:
 
1. A national body (the confederation) including statutory and third sector members
a. Taking findings and recommendations from the ‘Knowledge into Action’ group
b. Developing an annual set of recommendations for local activities
c. Reporting directly to Scottish Ministers. We believe this national body must also work closely with the new public health agency.
2. Local Delivery 
Local leadership and delivery should not be restricted to sitting with a single body (IJBs etc.), or it risks becoming lost -as we believe it is now. This requires a partnership approach.
3. Budget 
This must be both adequate and transparent. There is an urgent need to be able to track the funds we put into suicide prevention to ensure it is being used for that purpose. We understand that this is difficult post-local government concordat, however a nationally held innovation fund would allow the correct projects to be funded and evaluated. 
4. Evaluation
In England a process is being taken forward to audit local plans, however while we have had local suicide prevention plans in Scotland for far longer there is now no national oversight of plans or actions. The Confederation should mirror the approach in England, ensuring there is some evaluation of local work. This would allow further guidance and support to be provided where necessary. 
 
3c/d) Where do you think local leadership for suicide prevention is best located? 
 
Suicide prevention doesn’t sit easily within any of the structures outlined. It is also unclear how the Scottish Government could place local leadership within any of these. This is why the role of the Confederation and the place of suicide prevention within the forthcoming public health agency for Scotland is so important.
 
4) Do you believe that we should develop an online suicide prevention presence in Scotland?
 
Yes/ don’t know. 
Broadly, we support this aim, however there is however a lack of detail on this proposal. Research taken forward by Samaritans and Bristol University explores how people use the internet when suicidal and underlines the importance of online suicide prevention work. However, it was also noted during our most recent event with people with lived experience that while this may be useful it cannot be the only ‘tool in the box’. Those in crisis must have face-to-face support available when they need it. We need to see some further support provided those affected by suicide in the final action plan. 
 
We believe that an effective approach to providing an online presence would be:
 
  • To expand the sources of support to vulnerable people online 
The provision of safe online emotional support services has a number of potential benefits when compared to telephone or face-to-face services. These include increased privacy, accessibility, anonymity, confidentiality and decreased cost and barriers. For example, some people may find discussing personal issues on the phone more difficult than they would through an online chat. 
 
  • To encourage organisations which run popular sites to develop responsible practices and to promote sources of support
In recent years, Samaritans has worked in partnership with major online organisations to develop practical initiatives to support people at risk of suicide. This includes an initiative with Google in 2010 which ensures our phone number is displayed above search results when people in the UK use a number of search terms related to suicide. The Samaritans' Facebook page also contains advice on how to support vulnerable friends, such as how to spot when someone is distressed and how to start a difficult conversation. Nevertheless, we recognise that much more could be done to engage directly with people in emotional distress through online channels. 
 
  • To fund more research in this area as the current evidence base is too limited
The research evidence relating to suicide and the internet is currently too limited. As we move increasingly to ensuring support is also available digitally, it will be necessary to know what works. Fundamentally, we believe that any online intervention should be evidence-based. Whilst the locally orientated apps that have been developed in Scotland may be useful, we would question whether a good use of overall resources is the continued development of these on a local authority or health board level.  Better oversight and understanding of the effectiveness of such approaches would enable a better use of limited resources.
 
Question 5 - any other comments
 
We are disappointed at the scope and ambition of the draft proposals set out. While these broadly seem reasonable, we believe that there is much missing from the action plan as it is presented. Not least, the bulk of the recommendations from the pre-consultation events with those with lived experience are not well reflected in the proposals. 
 
Recent work conducted by YouGov for Samaritans Scotland shows that the majority (61%) of the adult Scottish population have had experience of suicide (YouGov/ Samaritans, 2018). We may still find it difficult to discuss, but suicide is something that continues to have a huge impact in Scotland. The scope and ambition of the plan must match the reality of suicide in Scotland and seek to address it.
 
To reduce suicide further, we must produce a bold, ambitious and funded action plan. It is vital that it is accompanied by a clear plan for implementation with robust monitoring and accountability of actions.  
 
We believe that the final action plan must include:
 
1. Vision 
A good strategy or action plan must have an ambition. Our suggestion for such a vision is below.
‘We believe that our shared vision is of a Scotland where people affected by suicide are not alone.  Where suicide is no longer stigmatised and we work to change attitudes and behaviours around seeking help. Where those directly affected and those who care for them have access to timely, skilled, compassionate and well-coordinated support. And where we learn, improve and deliver activity across Scotland which reduces the risk of suicide.’
 
2. Provide leadership, oversight and coordination
Suicide is a public health issue which requires a cross-sectoral, partnership approach. The model for local suicide work in Scotland, in place since the 2002 suicide prevention strategy, has widely been seen as contributing to an 18% fall in the suicide rate over the life time of that strategy. While England and Wales begin to replicate this model, we now lack ownership and oversight of the work done to prevent suicide in Scotland. Funding  often does not reach frontline support and overall responsibility and leadership for this work does not sit clearly anywhere. England now have plans in place in most local authorities, with an evaluation process being developed: something we lack. Of 32 local authorities, there are links to just four plans in Scotland on the Choose Life website at time of writing. 
 
As part of the Confederation, and alongside the new public health agency, we have an opportunity to reinvigorate suicide prevention work in Scotland and reinstate a clear structure. This will need to be resourced and it is unclear what funding will be attached to any actions within this plan. As part of England’s Five Year Forward View for Mental Health, a dedicated fund of £25 million was dedicated to suicide prevention efforts over 3 years.  We see no reason why a proportionate provision shouldn’t be committed to in Scotland against specific actions.   
 
3. Cross government approach
The World Health Organisation (2014) tells us that: 
The overarching aim of a national suicide prevention strategy is to promote, coordinate and support appropriate intersectoral action plans and programmes for the prevention of suicidal behaviours at national, regional and local levels. Partnerships are required with multiple public sectors (such as health, education, employment, judiciary, housing, social welfare) and other sectors, including the private sector, as appropriate to the country. 
 
It is well established that suicide is an issue far wider than mental health and as such requires a partnership approach across different sectors. There are a variety of factors that can increase a person’s risk, from social security to alcohol availability. We believe therefore that the action plan must take a cross portfolio approach. 
 
Key areas are:
 
  • Tackling the link between socioeconomic disadvantage and suicide
As our Dying from Inequality (2017) report outlined, those who are disadvantaged are more likely to experience negative life events and less likely to seek help.  The rate of suicide is almost three times higher in Scotland’s most deprived communities. (NRS, 2017)  Suicide prevention activities should be targeted in areas of disadvantage however to tackle the underlying issues we also need efforts to reduce poverty and inequality overall. We urge that suicide prevention be part of policy development in these areas.
 
  • Tackling social isolation and loneliness
Suicide prevention initiatives in other countries have recognised this link and sought to tackle it, as noted in the Scottish Government’s draft social isolation strategy. Evidence from Samaritans also supports a link between loneliness and isolation and suicidal ideation. In emotional support contacts in which people expressed suicidal thoughts, loneliness and isolation were mentioned in 28% of contacts compared with 21% in contacts overall. Mentions of loneliness and isolation were also higher among contacts in which people expressed that they were planning to take their own life, mentioned in 26% of contacts.*  As part of the cross-government approach to both issues, interventions must be taken forward based on encouraging connectedness within communities  at higher risk of suicide. As noted in our response to the recent loneliness and social isolation strategy consultation, we must also ensure that those who are affected by chronic loneliness have access to emotional awareness programmes. Available evidence suggests that access to programmes such as Cognitive Behavioural Therapy offer the best means of tackling loneliness in this group.
 
  • Ensure schools and teachers are equipped to discuss mental health
Suicide is now the second leading cause of death for older adolescent girls worldwide. (WHO, 2017)  Education on mental and emotional wellbeing can act as prevention and early intervention, however the Education and Skills Committee’s inquiry into Personal and Social Education (PSE) demonstrated that young people do not feel that mental health is adequately discussed at school.  We know from our work in schools,  that teachers often don’t feel equipped to deal with the questions that talking about mental health can raise. The ongoing review of PSE must ensure mental health aspects are strengthened and, crucially, that teachers have the confidence and skills to take this forward.
 
4. A consistent response to those people in crisis
We frequently hear from friends and families of those who have taken their own lives that their loved one hadn’t known where to turn when they were struggling. In fact, around 40% of us wouldn’t know where to turn if we were supporting someone in crisis (YouGov/ Samaritans, 2018). A number of concerns around the response to those in crisis were highlighted as part of the pre-consultation events,   with participants emphasising a lack of joined up working and out of hours services. Samaritans has seen, along with others, a significant increase in the number of people reaching out to us, however a volunteer led organisation cannot fill in gaps in crisis care. We believe that a national agreement between services involved in the care and support of people in mental health crisis, such as the Crisis Care Concordat  in England and Wales, would help ensure a more consistent, compassionate and available response as a first step. 
 
5. Identify vulnerable groups and target interventions
The World Health Organisation outlines effective objectives for national suicide prevention programmes. Part of this must be identifying those at higher risk and targeting interventions and support. (WHO, 2014)  As noted by the pre-consultation report, as well as the follow-up submission, those who are bereaved or survivors of suicide often do not feel supported. These groups are at higher risk of suicide, as are LGBT individuals.  Accessible support must be provided across the country in a more meaningful and consistent way for those at increased risk. 
 
Local suicide audits offer an effective way to determine those at increased risk within a community, providing insights on local trends that are not available from national statistics. They also allow us to identify locations of concern (sites where people may be taking their own lives, such as high bridges without barriers) or failings specific to local services (for example, GPs and hospital services not informing each other about at-risk patients who later go on to die by suicide). This data is not collected in a systematic way in Scotland at either location or local authority level. Through local suicide audits however, NHS Tayside and Shetland have started to take forward work based on findings from individual deaths. 
 
We believe that there is real value in supporting work like this to take place in health board areas across Scotland. A tool and guidance for suicide audits should be developed, building on work already done in England. Roll-out, evaluation and support must be provided at a national level, to ensure findings translate into action. (Owens, C. et al., 2014)    
 
6. On-going conversation and importance of lived experience
We heard from participants in the pre-consultation events that they hoped this would not simply be a ‘tick-box’ exercise. However, the findings of the report from this work were not well reflected in the Scottish Government’s proposals. The lived experience of survivors, as well as those bereaved and who have contemplated suicide, is one source that could be examined more extensively. Their unique insights are often absent from studies of suicide and the formulation of suicide prevention policy. 
 
The Scottish Government should commit to changing this and ensuring that these voices are involved, recognised and valued throughout the implementation and evaluation of this plan.  We can learn from the experience of Australia and the USA, who have made progress in including the voices and experiences of those who have survived suicide attempts and those close to them. The National Action Alliance for Suicide Prevention (an American suicide prevention organisation coordinating national efforts to advance the national strategy) took forward work with survivors in 2014 to meet the following strategy objective: ‘Engage suicide attempt survivors in suicide prevention planning, including support services, treatment, community suicide prevention education, and the development of guidelines and protocols for suicide attempt survivor support groups.’ **  
 
We would like to see a similar objective. 
 
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*Baker, N. Isolation and Loneliness. Samaritans (2017) Contact systems data, UK & ROI. Unpublished.
** National Action Alliance for Suicide Prevention: Suicide Attempt Survivors Task Force. (2014). The Way Forward: Pathways to hope, recovery, and wellness with insights from lived experience. Washington, DC: Author
 
For more information, contact Jen Gracie on J.gracie@samaritans.org