Suicide Bereavement Support Service: final evaluation report

4. Service model and delivery

This chapter summarises the overarching service structure and delivery model and presents key learning about the needs of those accessing the service detailed in previous evaluation reports. It also presents reflections from service staff and stakeholders based on service delivery during the evaluation extension period (February 2023 to August 2023), how the service fits in the wider support landscape and its alignment and contribution to local suicide prevention priorities and activities.

4.1 Overarching service structure – Hub and spoke model

The overarching service structure reflects a hub and spoke model. The hub is responsible for centralised functions, which are managed and delivered in collaboration by the service leads and managers from Penumbra and Change Mental Health. The centralised functions of the hub support and enable local delivery and include:

• Quality assurance of service delivery.
• Links with national networks and partnerships.
• Receipt and allocation of referrals.
• Core staff training and development.
• Service team meetings.
• Service branding.
• Service monitoring and data collection.

Service leads reported that the centralised functions helped to facilitate a rapid response to referrals that are received, while ensuring consistency in terms of the approach to delivering the service and the quality of support that is provided.

The spokes in the service structure represent each of the two pilot delivery areas. Each spoke is responsible for various local functions, which include:

• Staff recruitment, and ongoing development and support.
• Providing support to people bereaved by suicide.
• Developing local referral pathways.
• Local networking, awareness raising and promotion.
• Developing internal policies.
• Local team meetings.

Service leads reported being confident that the hub and spoke model, with defined central and local functions, would support the rollout of the service into other areas. Each new area would represent an additional spoke, benefitting from the centralised functions carried out by the hub.

4.2 The service delivery model and meeting practical and emotional support needs

A consistent delivery model has been implemented across both pilot areas. The delivery model is underpinned by the following core components:

• Rapid response to referrals/self-referrals received (24-hour target for initial contact from receipt of the referral).
• Provision of person-centred emotional and practical support aligned to individual needs.
• Person-led approach to providing support which accommodates and responds to individual preferences in relation to the format, frequency, timings and duration of support sessions.

The components listed above mirror the original service specification for the pilot. These aspects were identified as being critical by people with lived experience of suicide bereavement who were engaged in consultation to inform the development of the service specification.

4.3 Reflections on the delivery of support

Service staff described the delivery model as fully embedded and underpinned by a person-centred and person-led approach, with the provision of support tailored to individual needs and preferences.

As described in the Year 2 annual report, a wide range of practical support has been provided to people who have accessed the service. However, over the duration of the pilot, service staff reported that practical support needs are expressed less frequently than emotional support needs. They observed that people receiving support do not often express their practical needs, and staff must be vigilant to pick up indications that someone has a practical support need, then discuss it further and explore how to address it.

Through the support they have provided, service staff have generated extensive learning about the emotional support needs of those bereaved by suicide and the various factors that can influence this. This includes:

• Immediate emotional needs following a bereavement by suicide relate to the impact of the trauma people have experienced.
• Everyone is at a different point in their bereavement journey and has specific needs, which are influenced by circumstances and wider life events.
• There will often be fluctuations in the intensity, frequency and types of support people need at any given time, and it is important that people understand that these variations can be accommodated.
• Service staff need to have a range of tools, approaches, and models at their disposal to meet the emotional needs of the people they support.
• Beyond the early stages of support, there is often a shift to focusing on supporting people to identify and take steps towards their new routine, returning to work, starting to socialise more, and resuming other day-to-day activities.
• It is important to help people recognise and acknowledge how far they have come and the progress they have made.

Reflecting this learning in their approach, service staff provide a range of emotional support at different points in each person’s journey, and which is responsive and tailored to their changing needs.

4.4 Caseload and capacity

At the last reporting point in March 2023, 90 people were receiving support from the service. This has increased by almost 50%, with a current caseload of 132 people being supported across both areas.

Individual caseloads vary, with most service staff reporting that they are approaching capacity. Reflective of findings in previous evaluation reports, a staff member’s capacity is not defined by a specific number in a caseload but rather by the mix of different frequencies in support sessions, differing lengths of support sessions and the varied needs of the people being supported that make up any individual staff member’s caseload. The number of people accessing face-to-face support and the additional time commitment this requires differs across practitioner staff, and this is also considered when assessing capacity.

All practitioner staff reported having a mix of people in their caseload that require weekly, fortnightly, monthly or even six-weekly support sessions. However, that mix is different for each member of staff. Furthermore, there are instances where the frequency of support staff provide can increase following a period where it has decreased.

While service staff reported being close to capacity, they also felt that there was an emerging pattern of flow through the service that enables new referrals to be accommodated. For example, changes in session frequency, service exits or planning for exits provides capacity for new referrals. Referral rates have been unpredictable throughout the pilot, so it is unclear whether this flow pattern through the service will continue to accommodate the current higher levels of referral.

In Highland, a staff member has left post, and capacity was maintained by increasing the working hours of the remaining staff. Had that not been possible, it would likely have impacted the extent to which the needs and preferences of those receiving support could have been met.

While telephone-based support remains the preferred option for most people engaging with the service, staff in both service areas reported an increase in people opting for face-to-face support sessions during the evaluation extension period. Potential options for face-to-face sessions are explored during the initial conversation a staff member has with a new referral to the service, including logistics, locations and potential meeting places. The preferences for how each person accessing the service would like to receive support will also influence which practitioner is allocated to provide support.

Feedback from service staff suggests that people understand the need to ensure face-to-face sessions are feasible and logistically practical, and to date there have not been any situations where a request for face-to-face support has not been accommodated. In some instances, a combination of face-to-face and telephone formats has been agreed to reduce the frequency of travel required for in-person sessions, with one example given of a supported person who travels three hours by public transport to meet face-to-face.

Changing personal circumstances, such as returning to work, has also influenced the preferred format of support, with face-to-face no longer being convenient for a few people being supported, and moves to telephone-based sessions were arranged to accommodate this. Aligned to this, one service staff member explained that several of the people they were supporting had returned to work, which led them to require support sessions from the service at the end of their working day and into early evening. A shift in frequency to fortnightly calls for those people made this change in timing and format easier to accommodate.

Setting boundaries for face-to-face support sessions

One staff member described a challenging situation with a person they support through face-to-face sessions. The supported person demonstrated aggression and anger with the circumstances surrounding their bereavement, and made accusations while mentioning names, which is not appropriate for a public space. While the staff member understands they are distressed, they have had to explain to the person that their behaviour is unacceptable.

Supporting young people

One staff member shared their experience of supporting a young person who was 12-years old. The staff member supported the child’s mother, who had referred her daughter and consented to the support. This has been provided through home visits by the member of staff, who has taken a play-based approach to exploring emotions, thoughts and feelings to support the child in navigating their grief. The staff member feels that this has been an effective approach and explained that they also have a role outside of the SBSS, providing support to young people in a local school. Furthermore, they have participated in training focussed on supporting young people with grief using creative approaches. The staff member explained that supporting young people required a different approach to supporting adults and that additional training and experience were essential.

4.4 Exiting the service

The Year 2 evaluation report described two ways in which service staff experienced people exiting the service:

• The supported person stops attending sessions and does not respond to contact from the service. In these instances, an exit protocol is implemented, which involves a series of weekly and monthly contacts followed by a final written letter explaining that they can re-access the service if needed.
• A managed exit whereby exiting the service is agreed upon following discussion with the person receiving support. This discussion is generally broached following a period where the frequency and intensity of support have reduced, and there are conversational cues which signal that a person’s support needs have also reduced.

Service staff told us that these two routes to exiting the service are still evident. A small number of staff described how they had become more responsive to cues and opportunities to have discussions with people about exiting the service. The regular caseload review sessions in the service were also seen by staff as helpful in identifying cases where exploratory discussions about possible changes to support frequency and transitions towards exiting the service could take place.

During discussions with people who had been receiving support from the service for over 12 months, we explored the frequency of support sessions and their thoughts about what would indicate to them that they would no longer need the service.

Among those we spoke with, the frequency of support sessions included weekly, fortnightly, monthly and every six weeks. Those receiving monthly or six weekly support sessions generally recognised that their needs had reduced and felt a lower reliance on the service to cope and get by day to day. They had re-engaged with activities they participated in prior to their bereavement and, in some instances, started new hobbies and social activities. However, they still valued the safety net and reassurance of having support sessions available to them while at the same time recognising the reduced frequency was a way of testing how they managed between each session.

In a few instances, people receiving support from the service commented that they had a specific event they were looking to get past before considering ceasing support. This included anniversaries and the conclusion of reviews into the death of their loved one, such as those carried out by statutory services when someone is known to have been in contact with mental health services prior to their death. They recognised that these could be difficult times and gauging how they managed during those periods would give them a strong indication of how ready they were to exit support.

People supported by the service reflected on the strategies and techniques that have helped them move forward and cope day to day, but a few also commented that things could happen in their lives that took them by surprise. Family get-togethers, a glance at a photo, a question asked by a friend – were all given as examples of instances that had triggered an emotional response that the person had not expected. This and other similar instances had made them realise that they were not quite ready to stop receiving support. Two people also explained that they supported others in their family who were unwilling or did not feel ready to engage with outside support. This was an additional emotional pressure on them, but they felt that their support from the service enabled them to support their loved ones.

People receiving weekly and fortnightly support sessions were the least certain about when or what would indicate to them that they were ready to exit support. However, they did acknowledge that the next step for them was to begin reducing the frequency of their support sessions, and in most cases, this was starting to be explored with the member of service staff providing their support.

4.5 Referral pathways and the wider ecosystem of support

Self-referral and Police Scotland referrals were the two official pathways into the service when it was launched in August 2021. This was a deliberate strategy to enable the service to manage and understand potential demand for the service, while allowing the delivery model to be tested and become embedded. The Police Scotland referral pathway was chosen due to the role of police where there has been a suspected suicide, and the contact Police Scotland then has with those that could potentially benefit from the service.

Work to increase awareness of the service and expand referral routes commenced after the initial few months of the service launching, and when a full staffing complement was in place. The creation of new referral pathways was focused on the various touch points that someone bereaved by suicide was likely to have with different organisations and services. This area of service development was an ongoing aspect and involved various activities requiring the input of all service staff to both create new pathways, and also to maintain and embed those that had already been established.

The most common referral pathways

Throughout the pilot, levels of self-referral have fluctuated, though it has been one of the most common routes into the service in both pilot areas. The most recent service referral data shows that 30% of all referrals in Ayrshire and Arran and 34% in Highland have come via self-referral.

In Highland, referrals from Police Scotland have also fluctuated during the pilot while remaining one of the most common routes into the service, accounting for 38% of all referrals received. This contrasts with Ayrshire and Arran, where the level of referrals from Police Scotland has constantly declined throughout the pilot and now accounts for only 13% of the total referrals received.

Recent discussions with representatives of Police Scotland in each of the service areas confirmed that they are aware of the referral levels into the service, with one Police Scotland representative in Ayrshire and Arran explaining that they were disappointed with the level of referrals that had been made. In both areas, good relationships and communication between service staff and the police were reported, and discussions about increasing referral rates regularly took place. Both divisions of Police Scotland also described internal processes to monitor referrals being made to the service by officers that had attended a suicide, and how follow-up procedures were in place where a referral had not been immediately discussed and offered. Why referral rates differ across the two service areas is unknown. However, the Police Scotland divisions in both areas are equally committed to working with the service to maximise the effectiveness of this route into the service.

While there has been a drop off in referral rates from Police Scotland in Ayrshire and Arran, there has been a steady increase in the level of referrals being received from health services (e.g. GP, Medical practice, community mental health), which now account for roughly a third of all referrals that have been received.

Perceptions of referral organisations

Throughout this evaluation, the feedback from those who have referred people to the SBSS has been positive, both in terms of the referral process and their perceptions of the service. The key themes in feedback are summarised below:

• The referral process is seen as straightforward, and communication from the service was reported to be effective. Referrers appreciated being updated that referrals had been received and that action had been taken to contact the person they referred. This is not always the case with other services they refer people to for various support needs.
• Most of those who have referred people to the service have made only a few referrals throughout the pilot period. However, they value having the service as an option to discuss with those whose needs related to a bereavement by suicide. A small number of referrers working in community mental health reported that presentation of these needs was more common (e.g. at least weekly occurrence), though often not as the highest priority need. In these instances, other mental health or substance abuse support was a priority before considering something like the SBSS.
• Several referrers spoke about the unique needs of those bereaved by suicide and some recognised and understood that tailored support is needed rather than generalised bereavement support or emotional and mental wellbeing support.
• There was mixed awareness of other support and services available for people bereaved by suicide in the pilot areas. This included more general bereavement support or support for emotional and mental wellbeing, as well as support specifically for those affected by suicide. However, differences in accessibility, availability, type and nature of support were identified as setting the SBSS apart from other services and was the preferred support option for those making referrals.
• Change Mental Health and Penumbra have good reputations locally and are known for other services they provide, which increased the credibility of the SBSS among referrers.
• A few referrers explained that they have had follow-up contact with the person or people they have referred to the service and received positive feedback. This is reassuring for referrers and adds to their confidence in the service.

Local priorities and the wider support landscape

The evaluation engaged with service stakeholders with a role in local suicide prevention planning and activity in each pilot area. During these discussions we explored the perceived importance of the SBSS in terms of its contribution to local suicide prevention priorities and where the service sat in the wider provision and support landscape.

Stakeholders in both pilot areas reported that the SBSS had filled a significant gap in the support available for people affected by bereavement by suicide. While there was acknowledgement of various support and services already in place, it was also reported that these did not or could not provide the same accessibility, availability, responsiveness, type or intensity of support offered by the SBSS. Feedback suggests that the SBSS has been able to meet the needs of people bereaved by suicide that other types of provision would not be equipped to meet.

The value attributed to SBSS was not framed in a way that dismissed or devalued the support provided by other services and provision, with stakeholders acknowledging that different people needed different types of support and services to meet their needs, and therefore a range of different support and services were required. In both pilot areas, stakeholders identified a need to better understand and map the different pathways into, through and across the different support and services that could help to meet the needs of people affected by suicide, to help develop an understanding of what, if any, gaps remained.

There is a strong desire among stakeholders to see the SBSS continue in the pilot areas. The service was viewed as a key component in achieving local aims and aspirations in relation to suicide prevention and without the service there would be significant gaps in being able to meet the varied needs of people bereaved by suicide. Some stakeholders also reflected on the knowledge, learning and intelligence that the SBSS has developed as having great potential to inform and contribute to wider suicide prevention planning and activity.

The contribution of the service beyond the support it provides to people bereaved by suicide was also highlighted by stakeholders. SBSS leads and managers attend various working and sub-groups involved in local suicide prevention planning and activity, and their contribution to these groups is highly valued.

Some stakeholders also reported that the level of demand and need for the service was still to be fully understood. They argued that the need for the service is evidenced by those who have been referred or sought out and accessed the service. However, stakeholders also reflected the need for greater awareness about the service across the pilot areas. In these discussions, stakeholders explained that their comments on service visibility was not a criticism and acknowledged the breadth of activity undertaken by service staff to raise awareness and develop referral routes. Stakeholders also recognised that it can take a long time to achieve awareness and understanding of a new service across an existing service landscape and among the public more widely, and the period the pilot has been operating is relatively short.

Related to the above, one stakeholder highlighted the time it can take to achieve an awareness and an understanding of who a service is for. They shared an example of a local service that has been in operation for many years which is perceived by the public as a service for younger people, but is in fact, open to all ages.

4.6 Critical elements of the service delivery model

We explored with service staff and people supported by the service which elements of service delivery were critical for providing a positive experience and generating outcomes. Several features were consistently cited:

• Independence of staff and a compassionate person-centred approach: Having someone outside the immediate circle of friends and family to talk openly with, and for that person to demonstrate empathy, sensitivity and compassion while being responsive to the emotional and practical needs of the supported person.
• Flexible and person-led support: Session frequency, format and duration is led by the supported person. Furthermore, being able to test longer gaps between support sessions was highly valued by people, especially because they were confident that if they needed to increase the frequency again, the service would be accommodating and responsive to that need.
• Consistency in support: The opportunity to develop a trust-based relationship, rapport, and understanding is important for the person being supported as well as the member of service staff and is seen to be one of the most important aspects of providing effective and responsive support. However, it is also important to acknowledge that staff changes in the service have resulted in instances where there have been changes in the person providing support for some people, and this is perceived to have been managed well with minimal impact on the effectiveness of support provided.
• Initial response and access: A rapid response following initial referral and commencement of support sessions at the earliest opportunity helps ensure people receive support when needed.
• No time limit on the support provided: There is no set maximum duration that a person can receive support, and this is perceived by staff and supported people to acknowledge the complexity and impact of bereavement by suicide. It removes any pressure or concerns for the person being supported that they will not lose support they still feel they need.
• Support for service staff: Service staff have continually praised the level, different formats and effectiveness of support they receive in their role and see it as critical in enabling them to carry out their role effectively.
• Encouraging and enabling continuous development: An environment that encourages and enables staff to prioritise their development and access opportunities that allow them to continually build on their skills, knowledge and competence was highly valued and seen as essential for frontline practitioners.