 Good morning, and welcome to the 19th meeting of the Health and Sport Committee in 2018. Can I ask everyone in the room to ensure that their mobile phones are switched off or to silent, while it is acceptable to use mobile devices for social media purposes? Please do not record or film any of the proceedings, as we have people who do that for us. I can start by saying that members of the committee greatly appreciated the informal engagement that we have had with people with experience of suicide in their lives, and that is much appreciated and will certainly inform our views at the end of this session. However, our main evidence session this morning in a formal sense is also on the Scottish Government's Suicide Prevention Action Plan. I am delighted to welcome to the committee Dan Proverbs, the founder of Brothers in Arms, James Joplin, the executive director of Samaritans in Scotland, Craig Smith, a public affairs officer from Sam H, Tony Giuliano, who is the policy and public affairs manager for Mental Health Foundation Scotland, and Scott Walker, chief executive officer of National Farmers Union in Scotland. We look forward to hearing what you have to say, questions and answers, as always, through the chair, and we will endeavour to cover the territory in what is a very substantial area of policy. Can I ask to get us started, each of the witnesses, for your view, on the extent to which you consider that the Scottish Government's Suicide Prevention Action Plan addresses the recommendations that were made in the Suicide Prevention Strategy report? Who would like to kick off on that one? We were quoted publicly as saying that we were very disappointed with the first draft that was produced by the Scottish Government, given that we had waited over two years for a new national plan, given that suicide takes 728 lives in Scotland in the last year that we have data for, and given that the impacts across communities and families in Scotland, we felt that the plan needed to do more, it needed to show more ambition, more investment in the kind of resources to support those in crisis care, both before, during and after suicide, and more effort to address the stigma that can often be deep-seated in communities and families about the issue of suicide. We are getting better undoubtedly about addressing some of the issues around mental health and talking and listening more, but there's far more we can do, and we need to address that because Scotland has a higher suicide rate than other countries in the UK, and for men particularly, and that's not business that's been completed, it's not work that's been given the attention it has. We absolutely acknowledge the impact of work done in the early 2000s, and the fact that we've seen that suicide rate decline over time, but our worry is with the increase last year that we might begin to see a return to where that rate starts to increase, and so that's why a plan at this point is so critical. Thank you very much. Other witnesses want to add on that general point. Yes, please, Craig. So similar to James, when the original draft was published, Sam H has taken a kind of hopeful and helpful view on that. We were disappointed with the scope of some of the proposed actions. We are happy to see some progress made, so I know that the Government announced in the recent debate in Parliament that the final plan will have provisions for reviews of all deaths by suicide, and that's something that Sam H has been calling for for our first significant periods of time, and increased bereavement support, so there are welcome moves in the right direction. What's really key for us is that the plan is ambitious, so as James said, we saw an increase in deaths by suicide in 2016. While we have to be really cautious about looking at any year's deaths and pay in mind the context of an overall reduction in suicides over the long term, we don't want to see that becoming a trend, so it needs to be a really key focus for Government at the national and at the local level going forward. What we'd really like to see is a plan that has clear, transparent funding, that really restates that link between the national and the local and provides national leadership and infrastructure to implement local suicide prevention activities to build on that reduction of suicide over the last decade. We are concerned that there has appeared to be a lack of reduction focus on suicide prevention activities in the recent years, but, as I said, we are happy with some of the movements that Government has made recently in the further iterations of the plan, but we need to see that go forward. We really need to have a clear understanding of how the plan is going to be resourced and transparently resourced in the way forward. I welcome and agree everything that has been said so far. The Mental Health Foundation has taken a very clear view about the structures of suicide prevention in Scotland. We think that we need to see a new organisation, a new body set up going forward to drive forward suicide prevention work in Scotland. I think that it is fair to say that suicide prevention work has been eroded locally in terms of funding, transparency and not having a clear view and understanding of what work is going on, primarily because there is no single organisation that can give us that information, given the diverse degree of work that is happening locally and no oversight at all at any level nationally of what work is going on. We have been very clear that we need to instill some new ambition, leadership, drive at a national level. The way to do that is to create a new body that can pursue that, that can work with local organisations on the ground, but also a new body that can be created in conjunction with the third sector. Our organisations that have expertise in suicide prevention are also, from a trust point of view, ensuring that the public can trust the organisations that are involved in that suicide prevention strategy. The reality of the matter is that choose life has been perceived as a marketing tool, as a marketing brand, but not an organisation that you would turn to for help. I think that part of what we need to create is a trusted body that can put new leadership, new drive, new ambition into suicide prevention in Scotland and that can work with organisations on the ground. That is why we have been very clear to minister in our meetings that that is what we want to see going forward. Another area or area of priority that I think that we will hopefully explore at a later stage is, and you have already touched on it, bereavement. Families bereaved by suicide, and I hope that we will be able to touch on that in greater detail later on. Being somebody that is fairly new on the block, I think that for me it is fairly simple. It is the recognition of male suicide. There seems to be a lack. It is almost the elephant in the room when it comes to me in Scotland recognising that 75 per cent of all suicide in the UK is male. The fact that we, as a charity, are the only one at the moment that is trying to reduce male suicide, I think, says something. Saying that, I think that the fact that the same age of funding into research for male suicide in Scotland is an absolute positive step forward, and it would be amazing to see what we learn from that. However, I think that we need to start looking at the fact that men are at risk from taking their own lives in Scotland, especially in the more rural parts of Scotland. Thank you very much, Scott. I agree with everything that has been said so far. Tell from our area, it is that engagement in rural areas. How do we have a multi-strand approach that engages with rural areas? Particularly, the feedback that I get is about adding the myth. It is hugely important, which goes back to the issue that has been touched on a couple of times so far this morning about the stigma of suicide and the stigma of mental health. Not just for, unfortunately, the people who die from suicide but also the families and the support that is needed to engage with those families going forward. When we look at the strategy going forward, it is looking at not only how do we prevent suicide but how do we support the families who, unfortunately, are too much affected by suicide? We will get to the situation where everyone can hopefully talk about it and we can hopefully prevent people before they get to that issue of crisis. Thank you very much. I was struck by some of the evidence that we have seen around the focus of the change in levels of activity around suicide prevention at a local level. My recollection of the early years of the Choose Life Network was that it was dynamic and that it had a co-ordinator for Choose Life in every local council area. I wonder if witnesses would comment on that and on what has changed and why it has changed if, indeed, that dynamism has been lost. We, through our FOI Freedom of Information requests, have seen a number of local authorities reducing their funding for suicide prevention. There is no longer strong ministerial guidance to local authorities like there once used to be on directing money towards suicide prevention. I think that that has undoubtedly resulted in some local authorities not prioritising the agenda. Again, some of the FOI information shows that there are great disparities across the country in terms of plans. The vast majority of areas do not have updated plans. Most of them are not strategic plans. There is not a great deal of information about the exact level of work, the detail of work that is happening on the ground. We have been very clear that we need to use the data. We need to look at the data. What is the data locally telling us about suicide and are those action plans mirroring what the data is telling us? It is very difficult to know what is happening on the ground, particularly in rural areas. We need to make sure that that data is mirroring those action plans. We need more clarity on what is being done exactly on the ground. Government cannot have that clarity unless we have updated plans. In terms of posts and positions, there are some areas that have coordinators that are employed for a handful of hours a week to deal with that. There are great disparities right across the country. We need to have local dimensions, but at the same time, there needs to be some national leadership. If we have a national body that can provide best practice and that can provide that leadership, funding is a huge issue as well. Areas are able to bid for funding from a central pot of money to ensure that funding is not being eroded. If that is purely in the hands of local authorities, we certainly do not have the confidence that, in future years, local authorities will continue to prioritise suicide prevention funding, which is why we believe that it should not be purely and fully in the hands of local authorities. That is why we need to have a kind of innovation fund that can be managed by this national body working in tandem with local areas to ensure that local suicide prevention work is happening on the ground. Where we are now is lacking accountability, ownership and evaluation of local plans. That is different to where things started in 2002. I have been to two local groups or local structures in the last week, one in Glasgow and one in Highland. Very different people each, one led by someone from the third sector, one led by someone from the mental health division, different organisations around the table, some first responders, some not. In Highland, at the moment, there is no choose life coordinator. The structures worked for when they were introduced in 2002, but what we have lost sight of, as Tony has highlighted, is that sense of, is there a reasonable plan addressing the highest risk groups in a local area? Are we investing in programmes to support those individuals? How can we evaluate what has worked? When our efforts started in the 2000s and the reduction that we saw in suicide, other colleagues of mine from Samaritans looked to Scotland as the model. The inquiry last year by the Westminster Government through their health committee identified that 95 per cent of local areas had local plans in place, and there is also a commitment to evaluate those plans. Neither of those things are the case in Scotland, and that is why we need to make up ground. On from being ahead to being behind, I think. It feels that way. Much of what I was going to say is covered by James and Tony, so just to reiterate some points and the key link of funding. What we saw was a change from a transparency of funding back in the early 2000s, and that stronger national choose life infrastructure to support development or delivery of local plans when that was lost when local funding arrangements changed. We have completely lost that transparency of funding, so, like mental health foundations, SamH has done FOIs to local authorities asking, if they had a choose life coordinator and how many hours that person worked and what dedicated funding they used for suicide prevention, and less than half of local authorities could give us the answer to those questions. We know that there is a huge disparity of activities across the country, so we managed the choose life coordinator. SamH manages the north-east choose life coordinator who covers Aberdeen and Aberdeenshire. There is some excellent local work. We have the development of the choose life app, the award-winning app in Aberdeen and Aberdeenshire, which allows people to anonymously access information about suicide prevention and get linked into support, but we do not know what has been replicated across the country, and that is a huge issue. What we would like to see is that national infrastructure to help local partners to develop plans, to share good practice, to have a transparency of funding. We would be keen for the national leadership group to be a budget holding organisation that can fund local areas directly, either through an innovation fund type arrangement or we have learning there in England. James was saying that we know that 95 per cent of local areas in England have a suicide prevention plan or are actively developing one, and they are developing arrangements for evaluation of those plans, but also in England there is dedicated suicide prevention funding, £25 million over the next three years, and part of that funding is dispersed directly to clinical commissioning bodies against the local action plans, so you have that linkage between activity and funding, which we have really lost in Scotland. Having that or a similar model in Scotland, where you can track the funding against activity and having that activity evaluated robustly, would make a huge difference to making Scotland a leader again in suicide prevention. It is very sad that much of the early choose life activities that were pioneered in Scotland are being taken up by England, Wales and other parts of the United Kingdom, but have appeared to have been lost in Scotland. Talking from the sharp end, we deal with the many members of the public who have experienced suicide, or they would not know who choose life is. There is no visibility, and that in itself would tell you something. I am aware that, in Dumfries and Galloway, the National Farmers Union, DNG and NHS Dumfries and Galloway have a wee pilot programme to work collaboratively to look at isolation, as well as mental health issues, so the rural mental health forum. Scott Walker, if you could just say a few words about that, because I am assuming that that programme will feed up as a pilot to see how people are working together to address rural isolation and suicide. Starting off with the negative first, I am not sure how it will feed up. It is one of the projects on the ground that is very visible and well received, and it is hugely important in terms of prevention before people get to a crisis stage. However, I am not aware of how that good practice that is happening down in Dumfries and Galloway will feed into change and influence what happens elsewhere in Scotland. We also have initiatives up in Aberdeenshire, which is working with NHS up in Aberdeenshire, which is a soft engagement with rural communities. Going into rural communities and dealing with issues that could be as simple as starting a conversation of somebody who has a back problem that leads into a whole set of other engagement with them, but getting that early engagement wherever possible. You have highlighted what is a very good scheme down in Dumfries and Galloway and one of the many different schemes that we have down in that neck of woods. However, it is disconnected from what could be a national project. A quick point on that, and the shared learning is so important. I think that there are some models in Scotland that could be adopted that work very well. We have the children and young persons collaborative work in Scotland and the Scottish patient safety programme, both which pioneer local innovations and then bring people together to disperse that learning nationally. I think that the national leadership group for suicide, which has been prepared, could be a key body in facilitating that shared learning. There is definitely potential there for that to be built into it. Good morning to the panel. Thank you very much for coming to see us today. Before we convene this morning, the committee met a group of witnesses in private who were families and individuals affected by suicide. I want to put on record my thanks for their candor and the very moving stories that we heard. One of the consistent themes that came out of that was the lack of access to talking therapies. Capacity is such that many times you might visit a GP and the first recourse to action will be medication, because there is no talking psychological therapy intervention available. The first question that I have is how do we increase that? Where is it working well and how do we replicate that? The second point is that when we do have access to talking therapies, there is no continuity of care. We have heard one horrific case of an individual who became unwell and in the five months they were unwell before their suicide saw five different psychiatrists. You would not see five different cancer surgeons, so why do not we have that continuity of care and how do we change that? That is a big question, or two big questions indeed. Who would like to start talking therapies, psychological therapies and continuity of care? I think that the first thing to say is that psychological therapies, talking therapies play a crucial role, an absolutely important role in mental health on a wider level, and you touched on medication as well. I would like to say on the record that it is important to remember that we should never stigmatise people who are on medication for mental health purposes for whatever reason. I think that medication has an important place. It is safe. It works for a lot of people. It is not for everyone, and in many cases, GP's health professionals will have to have a trial and error experience whereby you have to see what works for that individual. I think that patient choice has to be absolutely at the heart of this. Professionals and patients need to come to an agreement together as to what the best course of action is for each individual. The problem—the Mental Health Foundation has said this in the past—is that when medication is given, when there is essentially no alternative. That is an issue that we need to be honest about. Is this happening? If it is happening, we need to address it. We have said before that we would like to see an independent review, not just in Scotland but across the UK, of what is happening with regards to the way that the different options—whether it is psychological therapies, social prescribing, which is very effective for many people, whether it is medication—are reviewed to determine exactly how that decision is made and whether resourcing comes into it. If we are in a situation where psychological therapies are not the first port of call and the nice guidelines are very clear, especially with regard to young people, children and young people, that medication is not the first port of call in most—I mean, they are guidelines, but in most circumstances, medication is not the first port of call and it should be talking therapies. We would like to see a review of how we arrive at the decision as to whether it is talking therapies or whether it is social prescribing and what impact lack of resources is having. However, I completely take the point that Alex Cole-Hamilton makes about continuity. It is unacceptable that anyone should have to see five different psychiatrists. You would not accept that for physical health conditions. Quite frankly, it is not acceptable that anyone should have to undergo that process for mental health. Greg Scott. On both aspects of the question, on the talking therapy, we have to be honest, there just is not enough talking therapy. We saw the stats from ISD published this week last week and I think it was only one or two health boards that met the 18-week target for talking therapies and that has been a long-term trend. I think that was there, Sharon Arran, that met the target. There is a huge issue around resourcing for talking therapies. Talking therapies are a really important part of an overall suite of mental health treatments. As Tony has said, medication plays a really important role and can be absolutely crucial for some people. There needs to be a range of social prescribing, activity-based therapies and talking therapies is crucial in that suite and there needs to be focus on how we bring those waiting times down and how we increase resources going to talking therapies. I think that the other aspect of the question that is really important is that crisis care support, continuity of care and it is absolutely unacceptable that someone has to keep asking for help from different places to different people and not getting that help and being pushed further and further into crisis. We need much better crisis care pathways. There is some work down in England that that mind and the Government and NHS in England have pioneered around crisis care corridors. That is something that Sam H is called for in Scotland. That is where you have national crisis care standards of what should be expected if you are presenting to anyone in crisis or any statutory or non-statutory service. There are local guidelines, local care pathways that are shared by the statutory sectors, so by A&E, by GPs, by the third sector, and someone is placed on that pathway and can get rooted into care as quickly as possible. What is crucial when someone is crisis is that they get an empathetic, humane response as quickly as possible. There is no additional barriers put up, be that in A&E or wherever. Getting that crisis care aspect is right and that is going to be a key aspect of the suicide prevention strategy going forward, is that support for crisis services and crisis pathways. Definitely, it is unacceptable that people and we hear it often from people using our services. In terms of Sam H, we have done over 500 assist interventions since 2014, so suicide prevention is an absolute key priority for us on the ground working with people who come asking us for help, but also our own service users. Time and time again, we hear that that experience of crisis support is not up to standard. For some people it is and it works really well, and there are some great crisis services, but other people are still facing a stigmatised response when they are asking for help, be it with self-harm or suicidal ideation, and that is going to be really key going forward. Again, it is another priority that the national suicide prevention group needs to tackle and support local areas in developing a good crisis response. We did some research last year with people who have experienced suicidal thoughts or lost relative suicide in the Highlands because there is a disproportionately high suicide rate there, just very briefly verbatim quote as part of that research. Services are terrible, almost on the verge of non-existent. Theoretically, I am supposed to see a psychiatrist every three months, but we have not had a permanent psychiatrist in post for seven or eight years now. We have a series of locums and I must have seen eight or nine different locums in the last few years because they don't stay. They stay a couple of months, they move on, there is no continuity of care at the moment. This backlog of appointments for psychiatry is enormous, that someone is on the Isle of Skye. It is just quite a new spoke to people from the central belt today, so it is a very common theme, as others have said. Another thing that we have looked at recently is people knowing that first place to go. What is admirable, and Samaritans is on this work, is that lots of other organisations are encouraging people to talk and listen and mean it when they do so, and we can all do that. The question is what happens after that? If you go to an app or an online resource and your sign posted to somewhere where you might get help, what happens after that? When we asked a sample of the Scottish population back in April, if someone close to them was experiencing distress or trauma or was in crisis, would they know where to turn to to help them? 40 per cent of people in Scotland did not know where to turn. Now, if it was a physical injury, you would hazard a guess, people could plump for 999 if nothing else, but when it is not that, those first stages are not in place and then after that, where is that continuity into resources, because crisis in this kind of situation might be something that someone goes in and out of over a period of months and years, so we can be there as Samaritans sometimes in that emergency situation, but what happens after that? I was going to say, as somebody with a lived experience, I use medication and I have used talking therapies, so I appreciate that it is out there, but especially for the talking therapy, there can be a waiting list. Of course, if you are not in a position to self-manage, then that can be really difficult. Something that I think should be part of your strategy is actually a digital strategy, where we use digital technology, as has just been mentioned, in the form of apps and other uses of digital technology to support people waiting in those waiting lists, waiting to see the GP or waiting for the talking therapy. We have launched our own and we have had 1,500 downloads in 90 days and we are reaching everywhere from Stornoway to all parts of Scotland. They are not an answer, but they are part of the support, and I think that it is a very easy way, especially for men who do not want to talk about their stuff, where they can download something in private and in confidence. I think that digital strategy needs to be part of your suicide prevention plan. Thank you very much, Emma Harper. I will go on with the targets. Yes, thank you, convener. It is just a really quick question. In the SAMH submission, it says that there needs to be new national targets for reducing deaths by suicide, so I am interested to know if you think that there is merit in developing a national target to reduce deaths by suicide. Short answers are allowed on this one, just because of Time Creek. Yes, so SAMH believes that there is definitely value in having a national target. We reflect back to Choose Life, where there was a 20 per cent target and there was a significant reduction. I know that there is a debate around targets in healthcare. I reflect on the Harry Burns review, which SAMH took part in and which did find value for healthcare targets. Suicide prevention, we feel, would benefit from a target because it would provide ambition and drive and focus at a national level. However, there are some caveats around that. While we very much support a national target, it would not be for us to decide. We are very clear that any target needs to be evidence-based, robust and ambitious. We would see that as an early action for the national leadership group to come together to bring experts together, academics, stakeholders, particularly those of lived experience, to devise an ambitious target for Scotland, which can push resource and ambition in Scotland. A target is certainly not the BO and end all, but we think that that can help frame. It does not need to just be a simple target. While we would like to see a reduction target, that could be multi-layered, looking at inequalities, the issue of deprivation and inequality between the deprived and least deprived areas. So, yes, while we do strongly believe that a target has its use, it is not the BO and end all, but what is important is that it is evidence-based and robust. Let's mind it about a specific target. I think that if the ambition is right and it has got compassion and we aim to make sure that no one facing suicide is alone, then we can deliver against an ambition, which I think we can get locally and nationally behind. I think that there are so many factors involved in driving suicide rates that won't be on the success or failure of the plan to be judged only on that. Of course, we want to see fewer suicides, absolutely, but I'm less sure that setting an absolute target is the way to do that. I am sure that expressing an ambition, which we're beginning to see the green shoots of since the first draft came out, is the right way to go. Tony? Probably the only issue where we, or some each mental health foundation, may not entirely share a view on today's issue of targets. We've made it clear to ministers that we would not be in favour of a target. We are not interested in an arbitrary target that may turn into a political football on this issue. What we need is focus on prevention and evaluation. We've not had evaluation in suicide prevention in Scotland, but very few countries in the world have evaluated suicide prevention programmes. It's tough, it's complex, it's difficult, but it's not impossible. There are countries that have very, very few countries—I believe that New Zealand is one of the very few that have evaluated suicide prevention programmes—but very few have. That doesn't mean to say that we shouldn't. Unless we evaluate what works and what doesn't, we will never fully understand which programmes work and which programmes don't. We know, for example, that low mood and depression, the identification of low mood and the management and treatment of depression are effective ways of preventing suicide. The evidence is clear on that. We don't have evidence on many other programmes, and that's why it's time to evaluate those. For us, the focus is very much on evaluation of what works and what doesn't. It's taking a preventive approach but a public health approach, so not purely about what's going to be happening in this suicide prevention strategy, but what's happening in our schools, what's happening in our workplaces. That public health perspective to suicide prevention is what will drive—is what will reduce, we hope, the number of suicides in Scotland. For me, we already have something that is 75 per cent of all suicide in the UK's mail. For me, that is something that we should be looking at and working towards. How do we reduce that? That's where we are when it comes to men and how we cope with our emotions. What we tend to do is take our own lives. No specific view on the national target, that's it. I suppose just very, very briefly. A target can be a very blunt instrument, and people become focused purely on that headline figure, whereas listening to the evidence that's been given so far, it does become down to those local action plans, best practice, and target evidence seems hugely important. That would be the way to go forward, rather than just focusing on a single figure and a single target to achieve. Can I raise the important issue of inequality? Almost irrespective of the type of inquiry our committee does inequality is such a strong issue. The Samaritans have pointed out that suicide rates are three times higher in disadvantaged areas. Does the draft strategy adequately deal with the issue of inequality? Perhaps I could start with Samaritans. In addition to the figure that you just quoted, we know that the poorest men in the poorest communities in Scotland have a 10 times increased risk of suicide than wealthiest men in the wealthiest communities. Inequality is inextricably linked with increased suicide risk. We did a report recently to look at some of the reasons why that's the case. It's one of the reasons that any approach to suicide needs to be embedded in other key government functions both nationally and locally, so that we understand that connection. Not every suicide prevention project has it plastered above the door. Projects that are about increasing employability, supporting people who have been out of work for considerable periods of time, supporting those who are in a period of uncertainty around employment—those are all periods at which we know that suicide risk can be increased and supporting people at those times needs to be addressed. It's why it's so important that this plan stretches into those other areas of government and speaks, honestly, about suicide being part of the risks associated with inequality. We think that it's critical. We don't see it enough and consistently enough across local plans in how that's addressed, and it's something that certainly we would expect to see and be accounted for in any future plan. I suppose that picking up on the point that was said there, that yes, inequality is certainly a part of the problem. If I look at rural areas, yes, it's inequality, but it's isolation, and it's also going through that period of change. If I look at farming just now, we're going to go through a significant period of change. For people involved in farming community, it's not just a job to be involved in the farm, it's an entire way of life. It's how people view themselves just now. With Brexit, with car changes, a whole period of change is going to be involved there. I think that it's important for my Government's point of view that whenever they're looking at policies and how that's impacting upon people, people is the key bit. How is that going to impact on people and how do you provide those networks, how do you provide the support mechanisms that actually outreach to individuals? If I look at, again, particularly the rural community in isolation, Government is one of those areas through agriculture and rural inspectors. There's a lot of Government individuals who connect with farmers, and possibly the only connection on a regular basis with farmers that can be used as a signposting mechanism. I look at it slightly different than straight inequality, but that access in that rural isolation. Even though I agree with the inequality raising of that, we've also got to put into what I call the brothers hiding in plain sight. I think that sometimes we forget that because of men and how we hide our feelings, we put on a suit of armour, we tend to forget that it's everyday manner as well that can be affected by this. Somebody that can be, to all intents and purposes, be the life and soul of the party and is successful and has good status, but they will still take the same path if they cannot find a way of dealing with their mental health. There's simply no escaping from the fact that people in the most deprived areas are about three times more likely to die by suicide than people in the wealthiest communities in Scotland. There's no escaping from the fact that inequalities are more likely to lead to mental health problems in general, in particular depression. People who experience suicidal ideation are people who, generally speaking, will have experienced some form of loss, so it could be loss of income, it could be loss of a job, it could be loss of a relationship, it could be loss of friendship, it could be loss of pride, self-esteem. That's why, in our submission, we've been very clear that we shouldn't just be looking at, and maybe we'll get into the issue of training. We shouldn't purely be looking at the health service and GPs, but we need to look at job centres, ensuring that there is training available in job centres for staff there. Places like citizens advice, because debt is a huge issue, and we know that financial burdens have a big impact on our mental health. Lawyers, because of break-ups and divorce. There's a whole host of places that we have suggested in our submission that look at training for key staff, not just clinical staff in our hospitals and GPs, which should be core training, but a wide range of staff. The Mental Health Foundation is also called, in its recent report published on mental health awareness week, we've called for the UK Government to conduct an impact assessment on its austerity agenda. We've called on the UK Government to look very closely at the impact of welfare reform and the impact that that is having on our mental health, particularly people with mental health problems. Again, there is clear evidence that the austerity agenda, as well as welfare reform, has had a huge impact on people's mental health, particularly around employment. Employment is a significant area. If you look at the stats, around 70 per cent of people in Scotland who took their own lives were in employment. It is also about looking at in-work poverty. It is looking at things like job security. We could go on for hours talking about zero-hour contracts, for example, and the impact that zero-hour contracts have on people who are forced to take those kinds of contracts because they have no other choice. The economic and welfare impact on mental health is significant. The wider picture is that we understand the social determinants of poverty and inequality, and that our policy on suicide prevention should be embedded in all policies that Governments engender. We can record that everybody agreed with our proposition. That's probably the first time in my life that everyone's agreed with that. Thank you very much. Sandra White Thank you very much, convener. Good morning, everyone. More has been heard from the panel, hospital and GP, healthcare and national leadership. I want to talk about who whole community approach issues in that respect. Over the mental health foundation and their submission, I had mentioned that criminal justice system workplaces, I think that Tony mentioned it there, and various other places, schools, colleges, etc. I certainly think that it's really important that some of the evidence that you've been given has. What role do you actually see for the suicide strategy and mental health as a whole in schools and workplaces and the criminal justice system, obviously? What role do you see it playing, and should it be—perhaps I'll throw this in because we heard evidence of it—as I mentioned before, hospital and GP's health service, but should the money that is put forward for the strategy and mental health perhaps be given to either public health or education and that type of thing as well? I know that there are a couple of questions in there, so I'll throw it open to whoever wants to answer first. James McCrack Just on your last point there, what we know is true in Scotland is that of the people who take their own life in Scotland, 25 per cent of them have been to A&E within the three months before their death, and of those, 40 per cent were in the week before. So while suicide is a relatively rare occurrence across the whole of our society, there are key opportunities when dealing with people compassionately and ensuring that they receive support. Not only at their point of contact with health services, but out with that and afterwards are critical in playing a role in suicide prevention. So absolutely, we need to look at those touch points during someone's life when there might have been an opportunity to change that direction and change that focus, and so it's critical those people know how best to respond in those situations. But wider than that, I think our ability to support, for want of better word, peer-to-peer support is critical. Samaritans for over 25 years has run a programme where we train prisoners to be Samaritans and support other prisoners right across the country, right across the UK, because those people understand best the stresses and strains of other prisoners. I think we can take that model and those basic skills that we're quick prisoners with and ensure that others and communities are too, because some of the best people to understand the stresses and strains you might be facing are people alongside you, and some of the people you might trust to have those conversations might be the people alongside you. So I completely agree, I think this needs to sit four square within the approach of the new public health agency in Scotland, and that needs to be embedded in an approach which looks at resilience and looks at developing compassion in all the engagements we have, both individually and in those more formal settings. Yes, and to kind of build on that particular last point on public health, so we kind of strongly believe that that should be the kind of locus for suicide prevention. Suicide prevention, as has been said, covers all policy areas and has to, and needs to be a focus in education, in health, in justice, in housing, in welfare. Institutionally, we see it should be kind of located in the public health environment because of that role public health plays in health inequalities. We much rather see suicide prevention at a local level as well in that kind of public health space, which is developing with the reforms of public health, rather than solely sitting with local authorities or IJBs. We think that public health is the best place to get all those different actors around the table and to develop targeted responses. In the wider point about a whole community approach, definitely, we need a multifaceted approach to suicide prevention with strong national leadership and national priorities, but very much informed by local need. You mentioned schools and education, we know suicide is one of the leading causes of death still for people under 25. Schools, colleges and universities have a key role both in having awareness around suicide prevention and having adequate training and having staff that are skilled to support people, identifying risks of suicide, which is a very challenging thing to do, and support people in crisis. We need to see that in the context of wider mental health provisions such as school-based counselling, university counselling, but suicide prevention needs to be key in that, and key is what Tony was saying, and to build on that is training as well. The new social security agency, for example, would like to see all staff members trained in suicide intervention training, the wider job centre and the wider welfare service. We know that there is an issue still in primary care with GPs having a lack of understanding of mental health and not having any formal mental health training across our nature. We see suicide prevention needs to be key in that, and key in the role of link workers and the GPs to help to root people into support. It is a multi-faceted approach that is needed, and it always comes back to that balance between a whole population and a targeted approach. That is why we need that balance to make a really clear national well-resourced infrastructure to support national priorities, because we know suicide impacts everyone, but we are definitely taking a targeted view as well. We know men in the middle years, particularly men in the middle years in deprived areas, as has been said, suffered disproportionately from suicide. We know some of the things that work, and we know peers. That is all right. I am unfulful. I do not mean to interrupt, but the last point that I made was to put money into the mental health strategy and the health service. Should schools and colleges be able to get money from that budget? Rather than just being in the health budget? Yes, definitely. It needs to be funded across the board. How that happens could be up to debate, so you could have, as we have proposed, a national suicide leadership group holding a budget and could do some funding. We know that there is path funding for schools at the moment, but we need a more long-term, robust funding for mental health provision in schools. If that comes from the existing mental health budget or not, that is up for debate. However, my last point, just to make why I was on a full roll, was that we know there is target, there is population who are at risk, such as men in deprived communities. We know those things that work, so we know peer support has been said. Sam H runs a Movember funded changing room project in Edinburgh, where we bring people who are burning football supporters together, particularly that group at risk, men in the middle years, to discuss mental health and get mental health awareness and do shared projects. We know some things like activity-based projects, horticultural projects, sports and physical activities have a key role. It is about having a really wide vision on what is needed to tackle suicide prevention, and that being national priorities, but local informed needs as well. Much before Scott Walker answers, and I know he is keen to answer, I bring in a link question from Kate Forbes, which perhaps you can address them both together. It is to do with the point around targeted areas or the whole population. There are two populations in particular. I would like to know your views on how we use the whole community approach to reach them. The first is rural areas. The point was made about ensuring that people who best understand those at risk can reach out to them. How can we do that better in rural areas? The second is about minorities. Minority groups where there might be language barriers and cultural barriers might not use services in the same way. Rural populations and minorities. Scott, I feel free to answer Sandra's point. There is a huge consensus breaking out across here. Public health professionals are very important, so that goes without saying. For me, it is looking at the at-risk groups. Who are the key at-risk groups? What are the touch-points? How do you engage with those at-risk groups? Who speaks their language? Who can engage with them and pull them back for crisis? Show them the support that they can receive. For agriculture and rural areas, one of the successful groups, I believe, is RSAPI, which reached out in the past, was in essence a benevolent institution to help farm workers who had fallen on harder time, but it has evolved over the course of time. I was dealing with not just farm workers but farmers and farmers families who have difficulty. They are an organisation that can engage and signpost people to elsewhere. Also, if we are looking at rural areas and how to engage, we have to look at people who have the trust in those rural areas. I am looking from farming and going into wider rural areas, looking at the inspectors from the agricultural department who engage on farms. They can see where people have changing behaviour. I can signpost them and help them in the system. You have to help to skill those individuals. Here, it is key to becoming embedded. We talk a lot about resilience in farming, but we are not really talking all the time about the resilience of the individual. How do you build that resilience within the individual? We know challenging times come ahead. You have networks here around the table. You have innovative ways of working. How do they bring their skills and engage that with local community groups? There is a whole network of very strong local community groups. Whether you go to Shetland, Orkney, Westernau, Dumfries and Galloway or Aberdeenshire, you need to tailor it slightly differently in each of those areas. It is giving them the access to the funding, but another important theme that we have touched on today is access to best practice. Who can go and support local groups to train them in a way that they can deliver what is needed on the ground? Brian Whittle I thank you for coming in. Even in my short time in this place, the changing attitude towards mental health has been quite remarkable. There is a long way to go in de-stigmatising mental health, but it has already moved a huge distance. In some of the evidence that we heard this morning, Sandra White and I heard some quite traumatic and compelling evidence last week, as we did. It is very obvious and it is touched on by Tony already that there is a huge diversity approach in that first instance when we are asking for help. A huge diversity in our healthcare professionals, how they are treated at school, how the justice system deals with poor mental health, how the police deal with poor mental health. I wonder, and I am already touched as well on social security staff needing training and lawyers needing training, where are we in that time frame? It seems to me that the time of healthcare professional or a teach whatever gains qualification, we are already out of debt. How do we approach that? How do we deal with that? In terms of training, we have called for modularising training. We have called for training to be streamlined and brought together, because there is a whole host of different types of mental health training and suicide prevention training. Frankly, schools and workplaces are very confused about what is what and what is suitable for them. We have said that this is something that the new body should look at. Let us bring the training together, modularise it and, depending on the staff member's level of engagement with the public, that will determine the level of training that they would get. However, what we are saying is that, as a minimum, each organisation should be trained on mental health first aid and suicide prevention, as well as physical health training. We want to make sure that we bring mental health training and first aid training to the four, in the same way that physical health already is. To answer your question, we are really nowhere near that at the moment. Health Scotland, in its initial paper—the Scottish Government, rather, the consultation paper stated that, according to NHS Health Scotland, 92,521 people have been trained in mental health or suicide prevention training across Scotland. That is all very well, but a lot of this is historical data, and a lot of those people would need to be retrained. For physical health training, you would need to go through training again after a three-year period, so we would need the same again for mental health. Anyone who is undertaken this training, the likelihood is that they will need further training, as you would have with physical health. It is important that that process happens. I want to stress that, going back to Sandra's point of the targeted approach, transport workers, lecturers, prison officers, victim support, lawyers and job centres are the targeted places that we need to make sure, in addition to health services, that we have interventions that we have trained individuals that can perform interventions if and when necessary. We are not there at all, and that is something that should be looked at by the new body, whatever it is going to be called, and whatever function it should have, it should definitely have the function of bringing the training together, modularising it and ensuring that organisations and making it easy for workplaces, incentivise workplaces to take out training for their staff, particularly line managers. Line managers are absolutely critical with regard to providing, to creating the working environment, the working space for people to thrive, and, as a minimum, we need to ensure that workplaces start looking at mental health in the same way that they do physical health. Funny enough, we have been involved in a pilot project with a major retailer, which is doing mental health awareness training with line managers, because they have the direct link with their team. The idea is to look at their team from a performance issue. If they dip, they will take them down a certain performance-managing situation. Now, what they are trying to say is that if there is a dip, could there be other things out with that and to give them that awareness of saying, well, maybe there is something mental health or something at home. For a major retailer to start looking at that, it tells you that that is a really good way forward. Just one point on training. We have a slight concern with the draft action as it currently is. In terms of suicide prevention training, what is really key for us and what we know works from being an assist trainer ourselves and undertaking over 500 assist interventions supporting people in crisis. Since 2014, we really do not want to see that intervention aspect of suicide prevention training lost. What is really key and effective is giving individuals that skills to support someone who is thinking about suicide, who may have a plan around suicide, to support that person to access help and to develop a safe plan. We would like to see that it is assist retained. We know that there are issues around financing for assist, but we also know that it evaluates excellently. There are numerous international evaluations of assist training, which shows that it is a good programme. The Scottish Government did an evaluation in 2008 of assist, which found that it was a very effective programme. We would like to see that it is retained, particularly for that interventionist aspect. If it is to go, we would reassurance that suicide prevention training in a new training model would not just be around awareness raising. Awareness raising is key—absolutely key—and there is a huge amount to do around tackling stigma around suicide. While that should be an aspect of it, what is really key is that the training provides the skills to intervene and provide that crisis support. As Brian was hinted at in his question, stigma is still a huge issue, and that needs to be tackled—a whole population and, again, a targeted response. We know that suicide was brought up by people with lived experiences in the engagement piece of work prior to the publication of the draft strategy. We are somewhat disappointed that stigma has not featured very highly in the drafts that we have seen of the Government strategy. We hope that it is implicit in all the work that is planned going forward in suicide prevention, but we know that, while there has been significant progress around mental health stigma and mental health stigma, it still exists. That same progress that we do not feel has been made around suicide prevention. There are particular issues around suicide that are hugely challenging in the stigma terms for people who have attempted suicide and their families. Just briefly, one point to pick up from your question, Brian, is that there has been a welcome investment by the Scottish Government in a programme of distressed brief interventions. Across four different locations, looking to bring together those agencies who most commonly encounter those people with distress and trauma, and making sure that those agencies are equipped in how to have that first conversation and do that compassionately, and also that they can refer people on to an immediate programme of support for a couple of weeks to try and help that person to deal better with future crises, prevent re-admissions or reoccurrences of the same concern. In Great Glasgow and Clyde, they look at a multi-agency distress collaborative, which is a very long title for trying to make the same agencies work together and do it in a more coherent and cohesive fashion. The kind of gaps that you might have been experiencing and the differences that we can reduce. The important thing is that we learn from those programmes and try to embed that learning in a Scotland-wide approach once we run them for a little bit longer. It seems to me that as part of the issue around how we are managing to bring mental health much more to the fore and trying to bring parity with physical health is that we are encouraging more people in this situation to come forward and we do not have the capacity to deal with that. The issue that I have is that I know that Sammy has produced some really good literature around accessing physical activity in the mental health foundation. I have got some really good literature around the importance of nutrition. What Sandra White and I discussed last week with the group, they know this. Those people who are in this situation know that if they are physically active or they have better nutrition, it will improve their mental health, but they still are not in a position to be able to do that. In terms of training, social prescription is not enough to say if you are physically active, if you have somebody to talk to, could you improve your nutrition? It is not enough. How do we make that link? To me, that seems to be the most important thing because the surprising thing for me was that those in that situation actually are aware of what could make them better, but somehow or other that switch is not being switched. James, do you want to briefly? What we understand about people when they are at a point of considering suicide is about worthlessness and purposelessness. Whilst you can be equipped with all the knowledge in the world about the ways out of the situation that you might be in, that does not necessarily mean that you are able to, in that moment of crisis, to understand and take the actions that you are talking about, and it is during the calls that people make to Samaritans for minutes, for hours, sometimes over a period of time where it is about listening. Many of you know that we do not provide advice. It is about listening to someone and helping them find what is the way out of the situation that they might be in and being alongside them during that real challenge. That requires time more than anything else and that requires the ability to be compassionate and listen. There are many ways out of the situations that people might find themselves in and many options available. We have talked about some of them here, but we need to understand that at that point of crisis it might be that it is very difficult for someone to see that those are the solutions that might best help them. I will come in at this point to talk about crisis, because we have not really touched on that. It is important that people receive a compassionate and empathetic response when they are in a state of crisis. From what people tell us, it is not uncommon for people to be in a state of crisis to go to present to A&E, to wait for four hours and be told to visit the GP the next day. That is not because we have staff that are not empathetic, it is because of resourcing. We do not have enough mental health staff in our A&E units and I am delighted that there is a commitment in the mental health strategy to bring forward 800 workers and some of those mental health workers and some of those will go to A&E. However, we need to make sure that if people present to A&E in crisis and the vast majority of people, whether it is for physical health or mental health in a crisis, will go to A&E, some will argue that A&E is not the best place for people in a crisis, in a mental health crisis. We certainly would argue that we need to have a situation where NHS 24, for example, if you phone NHS 24, that you are automatically then passed on to staff who can help, who can give you immediate help, or that they will come to you, or that you will be seen in a community setting, but depending on the local arrangement of the health board and because there is no national framework, but the point here is that people need to receive a compassionate and empathetic response because if their experience of the NHS is a negative one, they may not go back for help a second time. It is absolutely crucial that every time that someone is seen, and one of the main challenges is that mental health teams in some situations will not assess someone if they are not in suicidal ideation. If they are not suicidal, they will simply tell them to go home. That is not good enough. It is not good enough because any mental health crisis, whether the person, whether the individual is feeling suicidal or not, needs to be addressed. That is what DBI was brought in to do. DBI, by the looks of things, we look forward to the evaluation of DBI, but unfortunately that is quite some time away. There are parts of the country that do not have a system such as DBI, and the Glasgow system, the NHS Greater and Clyde community triage service works very well as a system. We would like to see that rolled out in terms of an out-of-hours system as well. We need to make sure that we have crisis systems across the country that provide a fast response and empathetic response and reach people, even if they are known to the system. That is one of the main challenges. Either people who are not suicidal, who are potentially maybe next time, and people who are already known to the system are the two biggest challenges. Mental health staff sometimes will say that this individual is known to us. Perhaps, in some situations, they are not given the consideration and the care that they should. I think that the only thing that I was going to say is going back to what was talked about in the community, but also in education. Education has to be at the forefront. You have to start getting into the young children, especially the boys at an early age, boys becoming men, so that they build up a resilience so that they can cope with the knocks that are going to be ahead of them in the future, so that they can overcome those situations, so that they do not reach crisis. That is what we should be doing, is not waiting until they reach crisis before any action is taken. That has to start with education. I spoke well about crisis and what needs to be done in that crisis situation. It is even more difficult to achieve that sort of framework in the rural areas. It is in the central belt of Scotland, but I then also looked at the report by SRUC, which I think picks up very well on the point that you talked about. It talks about people wanting to connect, but at the same time, they cannot for many different personal reasons. That is where early intervention is. The likes of the Scots Association of Young Farmers Clubs have done a very good, successful multimedia campaign out to their members, which is about raising awareness of mental health issues and getting individuals to talk about it. It has been talked about there. The Scots Association of Young Farmers Clubs is a pretty even split between male and female members, but there has been a big focus on getting the male members to open up and talk about it, because they are more reticent. There is a greater hurdle and barrier for them to overcome those challenges. For me, yes, we have to deal with the crisis. We absolutely have to have the right systems in place to deal with the crisis, but if we are going to get the strategy right, it is that early intervention. We are trying to get as many people away as possible from ever reaching that point of crisis. I want to develop that point further, because, in their evidence to the committee, the Royal College of Psychiatrists said that there must be absolute clarity across Scotland about where people in mental health crisis can go for help at any time. From the conversations that we have had this morning and as a committee from the evidence that we have taken, it is quite clear that, at weekends, so many people have failed or are told on a Friday wait to see your GP on a Monday. I wanted to know, in terms of the draft strategy, as it currently stands, where do you think that that can seriously be improved and what needs to change in that context? We have heard, as Tony outlined, what could be done, but it is quite clear that it needs to be a cross-portfolio approach, especially around trauma training for emergency services. Anyone else want to follow up on that? I think that we have covered quite a lot of the crisis issue in the answers to the last questions. One of the things that we have welcomed since that first draft came out, and it was attached to the debate in Parliament about the mental health services in Tayside, was a commitment around delivering more constant crisis support for people who have lost a loved one and those affected by suicide. The test of that will be what more constant means, for exactly the reasons that you have highlighted. As I mentioned earlier about our survey, which indicated that many people do not know where to turn, either themselves or for those that they are supporting. In the country the size we are, that should not be impossible to do. If you look at things like online resources and where you can direct people from there, it should be possible that, even if the resources you end up using are local to you, that there is a way to establish your way into that complex system. Just to add to the crisis stuff, as I said before, in England we have a crisis care concordat with local crisis pathways agreed between all partners, statutory and non-statutory. We think that that would definitely be a way to learn from that in the Scottish context. There are significant issues around out-of-hour support. Back to the stigma issue, we know that, while the majority of people when they attend A&E or other emergency services in a mental health crisis will receive a good response, we know that all too often we are still hearing around people, particularly around issues around self-harm or people who are reprieved presenties with suicidal ideation not getting a proper response or a compassionate response. That is key and needs to change. Like Tony, we have called very strongly for the community triage projects in Scotland, so in Great Glasgow and Clyde but also in Lovian, where you had a mental health professional working directly with the police to support emergency services and dealing with people or supporting people who were in mental health crisis. We think that that should be rolled out nationally. They have evaluated well. We do not see there should be delay in a roll-out with them. However, those care pathways are missing at the moment and they need to be improved at a local but also at a national level. There needs to be an infrastructure for shared learning around that and resource in place for that as well. Talking about out-of-hours and online resources, I was dealing with somebody, the mother of a 17-year-old boy who attempted to take his own life because his best friend had taken his own life. Luckily, there was an intervention, but what came out of that, and he was most frightened of and really opened my eyes, is that they found his laptop and every window that they opened was a search for how to take my own life. For me, 17, you can be younger than that. In fact, I know that I have had emails from mothers of 12-year-olds and nine-year-olds and the fact that they have access to that material, yet there is nothing online as a resource that balances that out or combats that. I think that that is something that we need to be looking at. Samaritans in evidence have said that there is no longer an effective structure of suicide prevention leadership or delivery in Scotland. I note the point that there is no longer, so you obviously feel that at some point there has been. I would like to understand what has changed and what you think that leadership should look like. Obviously, for the first time, we have a minister for mental health. I am just wondering what difference you feel that has made. What would you like to see change given that suicide is preventable, but we are still talking about the biggest single killer of men under 50 and young people aged 25 to 34? Something that I discovered recently, which struck me along that similar vein, is that if you look at all deaths from all cancers in those under 29 in Scotland, that is a lesser number than all deaths by suicide under the same age. That is a measure of how seriously we need to make sure that we are taking this issue. We have touched on some of the elements that have changed over time earlier in the discussion. In 2002, when Choose Life was first instigated, there was a dedicated national team at NHS Health Scotland that were tasked solely to look at suicide prevention, develop national plan strategies and support and guidance, and there were dedicated resources within each local authority. The landscape has changed undoubtedly, but you do not see that same resource. There is not the same commitment to this specific topic, which is strongly related to mental health, but does not only sit within mental health. We need to make sure that those resources are aligned and that leadership means something, both at local and national level, as in who is responsible for our local plan. Local authority, IJB and some combination of those things are not clear at the moment. The danger is that this is a topic that disappears amongst the good work being done to integrate health and social care. It is one thing that we are very clear and have tasked the minister to show that leadership and make sure that any leadership group that has been discussed has teeth, has the ability to hold the minister to account for what needs to happen in Scotland and that that leadership group has the ability to shape and direct activity locally. Not define what every project is, but using the best knowledge that we have available and targeting those groups of individuals that we know are at high risk, make sure that we are allocating those limited resources appropriately. There is not that line of sight through the minister through to what is happening locally. If we want to hold a minister accountable for where the suicide rate over time goes up or down, we need to make sure that there is greater alignment of those resources to make sure that that happens. Is that a view shared by others? Yes, absolutely. We run the risk of no one having real ownership of suicide. That is not just a problem in Scotland, frankly. It is a problem globally in terms of public mental health and how suicide prevention is tackled across the world. We have seen that in many other places, but it is crucial that we do not, as has been said by Samaritans repeatedly, use that as an opportunity as a turning point to instill that new drive, that new ambition with new leadership. We absolutely can do that, but we need to ensure that we take it out of the current structures. There is no other way of doing it. We need to create a new system, a new body that can drive forward this agenda in partnership with local authorities and local groups and have that public mental health perspective. Thank you. It has been a very interesting discussion this morning. There were a couple of areas that I wanted to touch on. The first is covered to some extent, but I will go into a wee bit more detail. That was running about specific groups. We know that certain groups are disproportionately affected. We have talked about poverty and rural. Men is clearly a huge issue. There is an age issue. We have not talked about the LGBT issue, but that is an issue. Farm is affected by suicide is an area that is disproportionately affected. To what extent should the strategy target actions on specific groups? I suppose that, following on from that, we will get again touched on that as well—trigger events within those groups, so that, to some extent, it is possible to target them as to when the issues can arise. To what extent do you think that it should be focused down in that sense? I think that it is a key task for the leadership group, if it is convened correctly and has the ability to influence and shape resources nationally and locally, that they are leading the way in deciding where priorities should lie. From our perspective, you have covered off where we think that the main areas of attention need to be it in terms of men, people experiencing disadvantage and how inequality plays across the issue of suicide, those bereaved by suicide and those who have survived it, and LGBT individuals who we know are disproportionately at a higher risk of suicide. We need to make sure that efforts that we make nationally and locally are targeted specifically to reach the different discrete needs of those particular populations. There are many other elements that can increase your risk of suicide. The only other thing is that we need to make sure that it gets national attention are those people who are not in contact with health services, who are remote and lost to us and we know from the data that they are not contacting their GP and not on a mental health drug prescription. There is nothing else that tells us that they might be at risk. How can we reach out? How can we use our community insight? How can we develop more compassionate approaches? How can we reduce that stigma, particularly deep-seated in rural and more remote communities, about discussing suicide at all, because until you can do that, the challenge is substantial in terms of breaking down the barriers about talking about this issue. We need to prioritise to make sure that the resources are critically allocated. People will argue about whether they are right or wrong choices, but we need to direct our attention in that kind of focused way. I will focus briefly on one of those areas. People are bereaved by suicide, family members, friends. As things stand, the people that we have spoken to tell us that there is essentially no support available to them in terms of direct support. What we are calling for very specifically is link workers. We believe that there should be link workers available to people who have been bereaved by suicide, who can deal with things like relationship with the coroner, who can deal with asking for emotional help, psychological help from their GP. We should not be waiting for people to go and speak to their GP following a suicide. We should have a system whereby link workers can offer that support, because we know that evidence is very clear that people affected by suicide are at risk themselves of taking their own lives. Therefore, why do we think that it is acceptable that anybody should be on a 12-week waiting list for psychological therapies if their family member or friend has taken their own life and they themselves are vulnerable and at risk? It is completely unacceptable. That is why we have called very specifically for link workers to provide trauma-informed approaches, trauma-informed support, immediately in the aftermath of suicide. I think that, nationally, it is all about awareness and stigma. Across the board is raising that issue about awareness and removing the stigma. You have to focus on the individual groups according to the local action plans. Look at the local action plans, give them the flexibility to identify the groups that are most at risk in their area, and give them the tools to target those groups in the most effective manner. For me, when I look at the rural areas, there is a big difference between a rural area of Scotland and here sitting in Edinburgh. Although the challenges are the same for the individual, how you access the health professionals, your ability to access them are far easier in Edinburgh than it is in rural areas. Everyone knows everyone in rural areas, so you have a greater stigma to come across where you do not want your business known by everyone else. The point that we have talked about before is that the digital ways of connecting with people is hugely important. We will have to get over the connectivity problems that can exist in some rural areas of Scotland, but that is where, for me, it comes back to the local action groups to say, right, how do we trigger and tackle the people who are most in need in those areas? I think that we have to be aware of trigger events. For me, it is about embedding policy within everything that the Scottish Government or the UK Government does. We have talked about welfare reform previously. That should have been highlighted where the risk of that could have been to certain groups and how we are going to tackle it. For me, just now, we are looking at a whole change in the rural support system. That is a trigger event that could cause problems, so how do we prevent that? How do we use the networks that we already have in place? Whether it is the RSABI, the Scottish Association of Young Farmers Club, the NFU Scotland, or the very many touch points that people in rural communities already have? How do we build the capacity within those groups so that they can tackle the problems as they come forward? There are two very specific groups to ask about. Sorry, Adam, did you have a follow-up question? That is a point that I wanted to raise with. I welcome your professional perspective on that. It was something that struck me reading the papers. Every time we talked about suicide, we talked about mental health at the same time. It was just to get your take on whether you think that those two things are inextricably linked or other situations where people will come to the conclusion to take their own lives when they would not say that they were suffering from mental health towards an external factor. If they take the external factor away, then those thoughts go away. There is definitely a strong evidence base for a link between mental health and suicide, but I would definitely reiterate that not everyone who takes their life by suicide has a mental health problem. You are at an increased risk of taking your own life. Basically, for any diagnosable mental health problem, your risk of suicide increases. There are circumstances where people who do not have a diagnosable mental health problem will be in that crisis point due to a whole variety of personal financial employment relationship issues that bring them to a place where they feel that they have no other choice but to take their own life. Although it is important not to minimise the link between mental health and suicide, because a large proportion of people who do end up taking their own life tragically will have the presence of a mental health problem that has contributed to that, it is certainly not the only factor. Specifically for men—you are absolutely right that most of it is linked to mental health, but I think that the high statistics for male suicides is because that is our coping mechanism. It is because we cannot cope with what life is throwing at us. Ultimately, somewhere we will try and do the risky behaviours. We will use coping mechanisms such as alcohol and drugs or gambling, and at some point when we no longer can, those do not work and we no longer can put that behind us, we then take this other path out as a way that we believe is going to solve the problem. However, of course, going back to the bereavement, I just wanted to put that in. I get a lot of contacts from families that we do need a bereavement support service, because very often these families, when a male takes his own life, they had no clue. They had no clue, so for them the shock is just absolutely astronomical because they will say, because as men, we hide this stuff, and I can give you scenarios where two weeks ago a young boy had a family gathering, and then suddenly he takes himself away and tries to take his own life, and the family is like, so I think that is going back to the bereavement support. We have got to put that in place. Thank you very much. I just wanted to come very quickly in on the issue of crisis support. In many cases, the first line of support that somebody who has either suicidal ideation, self-harm, or is actually attempting suicide will be the police. We were instructed here this morning from Families Affected that training on mental health or suicide to first aid is only available to the police, but for those who sign up for it, it is not mandatory. Is that something that we should change and find a way of making mandatory as part of Tolly Allen training? Craig? Yes, absolutely. It should be mandatory for the police, for all emergency services around suicide prevention, and particularly those skills around supporting someone who is in crisis. We know that there is a particular issue around emergency services, and as I have said earlier in the evidence session, around sometimes people receiving a stigmatised response. There is more that can be done around that. That is again why we strongly favour the roll-out of community triage nationally, so you have that mental health support and someone who is maybe not on the seams, someone who can phone for support to provide that advice in that time for front-line staff and front-line police. Another issue around crisis and police is the issue of alcohol and drugs, and we know that not just police but with emergency psychiatric assessments. We know that there is an issue where people have been refused psychiatric assessments because of alcohol or drugs in the system, and that is something that needs to be tackled as well. On the point of training, definitely all police officers and custody staff should have suicide prevention training and on-going suicide prevention training. We were also very concerned about the lack of apparent communication between primary care and the police. First and foremost, police are not always made aware of a mental health situation, and they start to protest somebody through normal criminal justice channels, but also sometimes police officers are left waiting in hospitals for hours and hours and hours because of their continuing duty of care to somebody who has threatened to take their own life. How do we make that communication between those forces better? Craig spoke earlier about crisis care concordat, which I think is critical about bringing those agencies together who deal with people in those crisis situations at a national level and establishing what those pathways should be, and then that being followed up with action. There is a way to do that. There is a model in England that we need to look at and see if it is fit for purpose, but there is an approach that we can take to make sure that that is much more joined up. Thank you very much. We are pressed for time, so I will move on to Emma Harper. That is just a quick question, convener. We have spoke about all the groups that are really at risk, but there is obviously a way that we need to engage children. There has been an adverse childhood experiences cross-party group formed in this Parliament in the first meeting this tomorrow night, so I am one of the members that has chosen to join. I think that that is something that will help to raise awareness, but the suicide prevention plan needs to have some specific issues focusing on children, so I will add just any quick comments on that. I will say that. Our research published for Mental Health Awareness week showed that 33 per cent of young people experienced suicidal thoughts in Scotland, which I think is a shocking figure, and relates back to the whole resilience programme that we need to look at in our schools. There is a lot that can be done at schools and at home, but we need to make sure that the curriculum for excellence, the health and wellbeing strand, is not, as is seen by some, some may argue, as some tokenistic element of the curriculum. We need to make sure that our teachers are able to deliver it. In order for our teachers to deliver it, they need to receive the training to do that, and the reality is that too many teachers still today aren't able to deliver mental health issues in our classroom, be it the big issues that are affecting many of our young people, partly as a result of our digital age, whether it is body image, whether it is a pressure to succeed, whether it is exam stress, comparing them to others. Those are all big themes that came out in our research earlier this year. In order to address them, we need to look at resilience building in schools. To do that, we need to make sure that curriculum for excellence and health and wellbeing is fit for purpose, our teachers are trained and our universities are delivering the mental health training for our teachers in their teacher training curriculums. I would say that, as part of their education, especially for young boys 12, we should be doing it along gender. We have a programme in place called being mankind that we would like to put into schools, but we would sometimes hit obstacles because it is looked at as gender specific. However, we need to start looking at—if it is 75 per cent of society's male—we need to be looking at young males separately and talking to them on their level. I was interested in picking up the aspect around monitoring and evaluation. I know that we have partially covered that already. It seems from what has been said that we are maybe not doing a good enough job on that. Obviously, it is very difficult to know what we should be doing if we are not really sure what we are doing well or what is working. I picked up earlier about the idea about local plans and specifically about them not being evaluated. If we move on to the strategic level, how should we be, longer-term, evaluating the action plan? In your view, what would that look like? We have heard a bit of evidence on that already, but if there is anything that has not been said or any witness who has not commented on evaluation and what we need to do, James. There was no formal evaluation of the last suicide prevention strategy. It leaves us in a challenging place to identify which elements of the programme that we believe underpin that success that we have seen in reducing suicide from 2002 onwards. We need to make sure that, in any discussion about evaluation, it is built in from the outset that we understand clearly what the objectives are of the national leadership group and how they are able to enact them. We can evaluate them against those and the ambition that we set for the programme as a whole. I guess that it does not look exactly how to, but that there is a substantial gap in our understanding of how to address suicide risk in Scotland and that it would be remiss of us to enter into what we hope will be a step change in our efforts to address suicide in Scotland unless that was an essential part of the process. Having me to have an evaluation framework that is built in from the outset, I completely agree with what James has said. I think that if we have whatever new body is established, it is something that they can look at and create a framework for local groups to be able to look at that evaluation, what they need to ensure that they deliver and how that should be evaluated, independently evaluated, but nevertheless a framework for that evaluation process. Finally, the plan in draft, as we have seen it at the moment, has no specific or is very, I think, fair to say. There is no specific commitments in relation to time skills and there is no specific commitments in relation to funding and resources. What do witnesses think about that? Should they be in there as part of the plan or should there be things that develop under the auspices of the plan? Who would like James? The point that you have made most clearly is that if we want to see the step change, which we believe is the ambition of the mental health minister, we need the resources to build the steps. As far as we are aware right now, we have not yet seen evidence of that. You can look at a number of other areas of government policy. Last year, a commitment to £500,000 pot of resources to address social isolation and loneliness at projects that were developed locally through to £50 million identified to address the meeting of homelessness targets. It is not as if there are not other areas of government where we have made clear and specific resource commitments to areas of real concern. Our belief is that the level of suicide that we have experienced and the concerns that we have over that one-year increase—admittedly, it might only be one year and we hope that it is no more—means that we need to see when the plan is published that there are resources behind the leadership group. For them to have the ability to deliver all that we hope and everyone on this panel hopes, they need to be able to direct resources and shape plans effectively and they need resources to do that. Does that mean ring-fenced resources, specified resources? I think that there is plenty of evidence to say that what we have lost since 2002 by losing ring-fencing is losing that ability and a number of my colleagues have spoken to that issue. We need a way to do that. We have seen an example again in England. My £25 million across three years have been identified for local suicide prevention priorities. To make sure that this work is happening, we need resource that is allocated to it. Yes, definitely we need resource and timescales. I would like to see resource and timescales against each action and a pot for the national leadership group to hold, to be able to fund transparently local activities. As James was just saying, that is particularly what we have lost in Scotland. Where we saw the most progress under the original choose life strategy is where we had a clear transparent budget and we had local budgeting that could be tracked and that has lost. I do not have a figure in my head of what the budget should be and partly that is due to such a lack of clarity around what is being spent at the moment on suicide prevention. We need to find out what that is. We need to have not an audit as such but we need more clarity of what is currently being spent and we know locally that we just do not have that details available. Ring-fencing or not ring-fencing but at least strong ministerial guidance on how budget is spent locally. We believe that the best route for that is for the new national body, the leadership group, to be a budget holding organisation that can, either through an innovation fund model or funding directly against local actions, can fund local partners directly and that that money is tracked and the projects are evaluated. Thank you very much. I agree with what the guys have said. I think that it needs to be ring-fenced, but you cannot rely on third sector charities to do that. There has to be funds that are allocated towards that. You cannot just rely on us as a charity trying to raise the funds ourselves to come back to that. So again, in agreement, yes to a budget, yes to a timescale but I would also put in place that it has got to be compulsory delivery across the whole of Scotland. We do not want it to be seen to be targeted at any specific areas or any areas to lose out. This is a challenge that the whole of Scotland faces, so we need to see action across the entire landmass of Scotland. Just to finish on the point that I think we have a real opportunity here to bring suicide prevention back on the political agenda and we can do that. We are able to do that by creating a new national body that can lead that step change, that can bring that leadership. The strategic plan, including funding and timescales. Excellent. Thank you very much, gentlemen. That has been a very thorough evidence session. We will now adjourn for five minutes and then resume in private session. Let's say at 12 at 16 minutes past 12.