2Implementation
15.We made clear in our interim report that the fundamental issue with the Government’s updated 2012 suicide prevention strategy is its implementation. As we observed in that report, “over the past four years, there has been a failure to translate the suicide prevention strategy into actual improvements” and “implementation, which is largely the responsibility of local authorities and local health services, has been highly variable and subject to insufficient oversight”.16
16.We asked witnesses in our evidence session after the publication of the Government’s progress report whether that report met their expectations. Ruth Sutherland, Chief Executive of Samaritans, responded:
No. I think it is the same as when we opened last time on implementation, resource, accountability and leadership at national and local levels. While the refreshed strategy contains a lot of good things, it is still light on the how. It is not telling us how the 10% target [the Five Year Forward View for Mental Health set the target that by 2020–21 the number of people taking their own lives will be reduced by 10%] is to be achieved, how the implementation is to be resourced, where the leadership lies and how we will know whether we are getting there and what the progress is.17
Hamish Elvidge, a bereaved father and Chair of the Matthew Elvidge Trust (a trust aiming to tackle the issue of depression in young people) and the Support after Suicide Partnership, concurred:
There is a lot of good intent in the Government’s work, but not a lot of clarity around how it is to be delivered.18
17.We agree. We welcome the Government’s progress report and the measures contained in it but it is extremely concerning that there is still no clear implementation strategy. We welcome the Secretary of State’s promise that the Government “will put in place a more robust implementation programme to deliver the aims of the National Strategy as recommended by the HSC [Health Select Committee]”19 and we urge him to publish details of the implementation programme as soon as possible.
18.The lack of detail about implementation in the report does not leave us confident that the steps set out in the report will be realised. Without effective implementation, these measures cannot contribute to a reduction in deaths by suicide.
Quality of local authorities’ plans
19.The Secretary of State, in his ministerial foreword to the progress report, states that he is “delighted that 95 per cent of local authorities now have plans in place or in development”.20 We are also pleased to hear of this improvement since the All Party Parliamentary Group on Suicide and Self-Harm Prevention’s 2014 survey, which found that 30% of local authorities in England did not have a plan.21
20.However, while it is commendable that “95 per cent of local authorities now have [suicide prevention] plans in place or in development”,22 we do not know anything either about the quality of the plans themselves or about how well the plans are being implemented. As PAPYRUS (a charity dedicated to the prevention of suicide in young people, whose Chief Executive we met on our visit to Merseyside) notes in written evidence, “the presence of a document in a local authority is no proof of activity” and “there needs to be proper and effective accountability in delivering on local suicide prevention plans”.23
21.We welcome the fact that 95 per cent of local authorities have a suicide prevention plan in place or in development. However we are concerned that there is currently no detail about the quality of those plans. It is not enough simply to count the number of local authorities which report that they have a plan in place.
22.It is essential that there is a strong and clear quality assurance process to ensure that local authorities’ plans meet quality standards. This will also enable more support to be provided to local authorities where it is needed. In its response to this report, the Government should set out how the quality assurance process will work; who will be responsible for it; how it will report; how often it will be carried out; and when it will start.
23.We recommend that Public Health England’s suicide prevention planning guidance for local authorities should be developed into quality standards against which local authorities’ suicide prevention plans should be assessed.
Ensuring effective implementation
24.It is important that suicide prevention plans meet the quality standards: this is a far better measure than simply whether there is a plan in existence. However, even the best suicide prevention plan will fail if it is not properly implemented. As Samaritans told us, “it is critical to look at what action is actually being taken and whether the plan is being implemented”.24
25.There must be overall national leadership to ensure that local suicide prevention plans are being implemented. We recognise concerns from witnesses that this might reduce or remove local accountability25—this is not our intention. However we consider that national oversight as to whether the strategies are working is essential to ensure that the target for reducing suicide by 10 per cent can be met.
26.There is a role for local scrutiny of implementation of suicide prevention plans in the first instance. We suggest this could be a role for health overview and scrutiny committees within local authorities. However this does not diminish the need for national oversight, which will be better placed to take a broad perspective of where plans are working (and therefore what best practice can be shared), which plans are not being implemented effectively, and which local authorities may need more support.
27.We consider that oversight of nationwide implementation could usefully be carried out by an implementation board, as recommended by Samaritans and Hamish Elvidge (Chair of the Matthew Elvidge Trust (a trust aiming to tackle the issue of depression in young people) and the Support after Suicide Partnership). As well as ensuring implementation of local authorities’ plans, the implementation board should have responsibility for overseeing the implementation of the other aspects of the Government’s suicide prevention strategy.
28.We recommend that health overview and scrutiny committees should also be involved in ensuring effective implementation of local authorities’ plans. This should be established as a key role of these committees. Effective local scrutiny of a local authority’s suicide prevention plan should reduce or eliminate the need for intervention by the national implementation board.
29.We heard different views on whether the responsibility for the quality assurance process should rest with the implementation board or with a separate body.26 There appear to be advantages and disadvantages of both options, but we have not heard sufficient evidence on this particular point to make a specific recommendation about whether the implementation board should be responsible for the quality assurance process.
30.The Government should consult the National Suicide Prevention Strategy Advisory Group on whether the implementation board should also be responsible for the quality assurance process of local authorities’ plans, or whether that responsibility should rest with another body.
Zero suicide approach
31.We welcome the “zero suicide” approach pilots being carried out in three NHS trusts. This approach is underpinned by the belief that suicide is preventable and that it is not inevitable for people in crisis and we commend that attitude. We observe that many of the methods that were suggested when these pilots were announced (including joining up of services, good follow up care post discharge from inpatient care and training for front line staff27) are ones that we have recommended during the course of our inquiry, both in our interim report and in this report.
32.We recognise that the early outcomes of these pilots have not yet been fully evaluated. We also note that the zero suicide approach appears not to be fully integrated with the wider suicide prevention strategy in all areas: there is no mention of it in the Government’s 2012 strategy nor in the third progress report. Rather than making recommendations on further implementation at this point, we await the evaluation of the pilots. We also reiterate that we commend and encourage any approach which acknowledges that suicide is not inevitable and seeks to prevent all suicide.
Funding
33.We remain concerned that the funding for suicide prevention will not be sufficient to ensure the implementation of the interventions required. As Samaritans note:
The provision of funding by NHS England for suicide prevention from 2018/19–2020/21 is of course a welcome development although we question whether this will be anywhere near enough to cover the wide range of interventions required across the whole country. The £5m allocated for 2018/19 represents an average of just under £33,000 for each of the 152 upper-tier local authority areas and the £10m allocated for each of the following two years represents an average of just under £66,000. We should also bear in mind that this coincides with a period where the overall ring-fenced public health grants to local authorities have been cut quite significantly with a £200m in-year cut in 2015/16 followed by an average real terms cut of 3.9% in each year to 2020/21.28
34.Witnesses have told us that there are “major steps which [ … ] can still be taken if the Government is to be truly ambitious”,29 particularly in the areas such as liaison psychiatry and self-harm. However while “many of these steps are referred to in the strategy”, RCPsych state that “it is unclear how possible implementation of the strategy will be without significant additional resources and policy changes”.30 Dr Peter Aitken told us in oral evidence that
The general sense is that the level of uplift required in mental health spend to meet the ambition and the strategy is not available.31
He went on to give specific examples:
While it is welcome that liaison psychiatry services are being rolled out across the five year forward view and there is investment in improving access to psychological therapies for children, and in maternal health and so on, if you look at the detail of the 10 recommendations of the national confidential inquiry as to what ought to happen, it is hard to see where the help is to get crisis and home treatment teams 24 hours a day; it is difficult to see how we protect and build on community treatment for people who do not want to come for care. There are some real concerns around the core elements of mental health delivery that are not met in the five year forward view piece.32
35.Samaritans also outlined the importance of ensuring that the funding is allocated in the right place. They explained that while the current understanding is that the additional funding will be allocated to CCGs, the funding is required for public health interventions (for which the local authority is responsible) as well as for clinical services:
It is important to note that many of the interventions required from a local suicide prevention plan are not NHS-based and so it is essential that this money is used appropriately to cover activities involving public health and other services in addition to NHS-based initiatives.33
36.Ruth Sutherland expanded on this in oral evidence, explaining that it is unclear where the money is and how it is to be distributed:
If it is to be through the health route and go to CCGs, it is only £33,000 per CCG; it is a tiny amount of money within their much larger budget, with all the other pressures and things they have. If it went to the local authority and it were ring-fenced, it would be likely to have more impact. It is still too small but, if you have a small amount of money, put it in the right place and use it to the greatest effect. [ … ] If it went to the local authority and was ring-fenced for the purpose, it could be tied. There are good examples of local authorities joining together and pooling their resources and making the most of them. It could be incentivised in that way, so that you get more money if you can work collaboratively with others. There is a very complicated picture locally in terms of STP plans and health and wellbeing boards. We want some clarity about where the responsibility lies and who is going to oversee it. Health and wellbeing boards [ … ] would be a place for it. The directors of public health are there; they have the lead in suicide prevention, and if the money were ring-fenced within those budgets perhaps it would make more impact.34
37.Sustainability and transformation plans are likely to be the appropriate means by which collaborative suicide prevention planning between public health teams and CCGs takes place. Dr Aitken told us that his priority for progress with implementation is
To see sustainability and transformation plans explaining transparently how they are going to deliver the mental healthcare necessary in the suicide prevention strategy and being very clear about how that is going to be managed and monitored.35
38.We welcome the provision of funding for suicide prevention guaranteed for 2018/19–2020/21. However, unless it is supported by other funding already committed by the Government to mental health, and unless that funding actually reaches the front line, we are concerned that it will not be sufficient to fund the suicide prevention activity required both to meet the Government’s target of a 10 per cent reduction in suicides and to implement the strategy.
39.We note that there are currently important steps which could be taken to reduce suicide but which cannot be acted upon due to the lack of significant additional resource. The Government should make a clear commitment to assuring the funding for every action outlined in the suicide prevention strategy. In order to demonstrate this commitment, the Government should make an estimate of the cost of each activity referred to in the strategy, and indicate what funding is currently allocated to each. This will allow the funding gaps to be identified and addressed.
40.The Government must make clear who has overall responsibility in each area (whether that is the CCG, the director of public health, or another body) to ensure that the money is allocated in the right places within the area to fund both NHS initiatives and public health activity. The Government should set out how the additional funding will be distributed and accounted for so that local authorities and CCGs can plan their suicide prevention work effectively. If there is insufficient funding, the Government should be realistic about what is achievable on existing resources and set out the evidence on prioritising resources.
16 Fourth Report of Session 2016–17, Suicide prevention: interim report, HC 300, paragraph 8
17 Q396 [Ruth Sutherland, Chief Executive, Samaritans]
18 Q400 [Hamish Elvidge, Chair, The Matthew Elvidge Trust, and Chair, Support after Suicide Partnership]
19 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, Ministerial foreword
20 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, Ministerial foreword
21 All-Party Parliamentary Group on Suicide and Self Harm Prevention, Inquiry into Local Suicide Prevention Plans in England
22 Preventing suicide in England: Third progress report of the cross-government outcomes strategy to save lives, Ministerial foreword
23 PAPYRUS (SPR0167)
24 Samaritans (SPR0173), paragraph 4
25 Q401 [Councillor Richard Kemp]
26 Q408 [Hamish Elvidge]; Q409 [Ruth Sutherland]
27 “Nick Clegg calls for new ambition for zero suicides across the NHS”, Government press release, 9 January 2015
28 Samaritans (SPR0173), paragraph 11
29 Royal College of Psychiatrists (SPR0174)
30 Royal College of Psychiatrists (SPR0174)
31 Q397 [Dr Peter Aitken]
32 Q397 [Dr Peter Aitken]
33 Samaritans (SPR0173)
34 Q398–399 [Ruth Sutherland]
35 Q415 [Dr Peter Aitken]
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