In 2021, the number of people who died from suicide in Scotland fell to its lowest level since 2017, with 753 probable suicides registered. This follows a year-on-year decrease from 2019 (833 registered) and 2020 (805 registered). People who are bereaved by the suicide of a close friend or family member are estimated to be 65% more likely to attempt suicide than if the deceased had died by natural causes.
The National Suicide Prevention Leadership Group (NSPLG) was established in 2018 to support the implementation of the Scottish Government’s Suicide Prevention Action Plan ‘Every Life Matters’. In 2019, the NSPLG’s Annual Report included a recommendation that the Scottish Government should fund a pilot to test a new model of suicide bereavement support. In response to this recommendation, a pilot support service for families bereaved by suicide - the Suicide Bereavement Support Service (SBSS) - was funded by the Scottish Government.
Following a competitive tendering exercise, Penumbra and Change Mental Health (formerly named Support in Mind Scotland), working in partnership, were commissioned to manage and deliver the pilot, with Change Mental Health delivering the service in NHS Highland and Penumbra in NHS Ayrshire and Arran.
The Scottish Government commissioned The Lines Between to deliver an independent evaluation to run alongside the SBSS pilot. The main aims of the pilot were to capture learning generated from the implementation and delivery of the pilot to inform any future rollout of the service and to explore the experiences of people receiving support from the service and evidence any outcomes achieved.
Overview of service activity
The SBSS received 155 referrals over 19 months of delivery, an average of eight referrals per month. This has been reducing over time, with an average of five referrals per month over the preceding six months of service delivery. Self-referral and referrals from Police Scotland account for just under two-thirds (61%) of all referrals received by the SBSS. However, over the previous six months, these referral pathways have been less active. The service has carried out activities to raise awareness and establish new pathways, which has resulted in a wider variety of referral sources, though not resulting in an overall increase in referral rate.
At the end of February 2023, a total of 90 people were receiving support from the service. A total of 1,950 support sessions, and 1,452 hours of support, have been provided, which equates to an average of 12.5 sessions per person being supported, each lasting an average of 44 minutes. The service has supported a higher proportion of females (72%) than males (28%), with an average age of 44 across the people being supported. Most people accessing the service for support are direct family members of the deceased.
The consistency and completeness of monitoring and activity data collected by the service has improved over time as processes have become embedded. There are still some slight inconsistencies in how some data is categorised and recorded, but service leads and managers are aware and working to address this.
Service structure and delivery model
The service is structured around a hub and spoke model, where the hub is responsible for centralised functions that support and influence local delivery. This includes aspects such as quality assurance, receiving and allocating referrals, and staff training and development. Local delivery is carried out collaboratively across the two partner organisations, with each area representing a spoke in the hub and spoke model. Service leads are confident that this model would enable easy expansion of the service into other areas.
The delivery model in both areas is underpinned by a person-centred approach that is compassionate and responsive to people’s needs and circumstances. The service provides practical and emotional support for as long as people want and need it. The following components underpin the delivery model:
- Rapid response to referrals/self-referrals received (24hr target).
- Provision of person-centred emotional and practical support aligned with needs.
- Format, frequency, and duration of support sessions are led by the person being supported.
Overall, the service delivery model has been implemented and embedded as planned, and the evidence gathered during the evaluation period to date enables us to conclude that the service is providing a rapid response and liaison service for bereaved families.
The service launched in August 2020 when COVID-19 restrictions were still in place, meaning support could only be provided via telephone or video calls. Face-to-face support sessions have since been introduced though most people still opt for telephone or video calls. Some practical and logistical challenges have emerged, with the additional travel time for support workers being highlighted. Service staff acknowledged potential difficulties if more people start choosing face-to-face support.
While service staff provide practical and emotional support, practical support needs were found to be less common, with most support focussed on meeting emotional needs. When the service is supporting more than one person from a family unit or connected through the same bereavement, most people choose to have one-to-one support sessions rather than shared support sessions. Learning gained by staff about people’s needs and providing effective support to meet those needs include:
- The immediate emotional needs of those who have been recently bereaved relate to the impact of the trauma they have experienced.
- It can be more difficult to engage people in support when they have been referred to the service in the days immediately after their bereavement. Engagement is more effective with those who are referred a few weeks or months after their bereavement.
- Everyone is at a different point in their bereavement journey and has their own specific needs, which are influenced by circumstances and wider life events.
- There may be fluctuations in the intensity, frequency, and types of support that people need at any given time, and it is essential that people being supported understand that they can increase the frequency of support again if they have previously chosen to reduce it.
- Over time support can be focussed more on helping people to identify and take the steps towards their new routine, returning to work, starting to socialise more and resuming other day-to-day activities.
- SBSS staff must be vigilant to pick up cues that signal that someone has a practical support need, as fewer people tend to proactively seek practical support.
- It is important to help people see how far they have come and reflect on the progress they have made.
Some people disengage from support through non-attendance of support sessions and ceasing to return contact from the service, which service staff can find unsettling. There is a robust protocol that staff follow in these instances that gives people the opportunity to re-engage while not being overly intrusive. Others end their involvement through a managed exit, which is agreed following a discussion between service staff and the person being supported. This typically follows a period where the frequency and intensity of support have reduced, and there are conversational cues, such as the topics, that signal the support is becoming less necessary.
The core components of the service delivery model were reported to be working well, though whether the degree of flexibility and responsiveness can be maintained when the service is operating closer to capacity remains to be seen.
Supporting service staff
Throughout this evaluation, practitioners have consistently reported that mechanisms are in place to ensure they have all the support they need. There are several formal support structures in place for practitioners, which includes regular supervision, de-briefs, daily check-ins, and reflective practice sessions.
Over and above the more formalised support mechanisms, peer support within and across the service areas is highly valued by staff and seen as essential. Service staff also described working in an environment that encouraged and supported ongoing learning and development, which is essential in ensuring they are equipped to respond to the many new situations and different support needs of the people they support.
Experience and outcomes for people supported by the service
People are either referred to the service by another organisation or service or self-refer by contacting the service directly. Visibility and awareness of the service were highlighted as an area for improvement among those that had self-referred, with a few also describing a hesitancy or difficulty in taking the first step to establishing contact. The right time for accessing support is different for different people. However, several did feel that they would have benefitted from earlier engagement with the service. Following a referral/self-referral being made, people supported by the service reported that they received a rapid response.
People supported by the service explained that they led decisions about the frequency, duration, and scheduling of support sessions. They also described the importance of quickly establishing a relationship with the staff member supporting them, which made them feel comfortable opening up and sharing their thoughts, feelings and emotions.
The emotional support provided by the service was described as invaluable, helping people to explore, understand, process and cope with a wide range of emotions, including sadness, anger, blame, guilt, and shame. While practical support needs are not as common as emotional support needs, people valued this support as they often did not have the capacity to act for themselves or invest the energy that was needed.
People reported that being able to talk openly, share, explore and understand their feelings and emotions with someone who listens and responds in a compassionate and non-judgemental way was critical to the improvements they experienced in their mental and emotional wellbeing. Feedback also suggests that the service is having a positive impact on people’s ability to cope with daily life and get back to doing day-to-day activities.
Overall, people have a positive experience and receive responsive person-centred support that is delivered with sensitivity and compassion. They are receiving support that is led by them and provides the flexibility required to respond to their changing needs. The support has a positive impact on the emotional and mental well-being of the people they support, as well as the extent to which they feel they can cope and return to day-to-day life and activities.
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