Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon - Y Bumed Senedd

Health, Social Care and Sport Committee - Fifth Senedd

07/10/2020

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Andrew R.T. Davies
Dai Lloyd Cadeirydd y Pwyllgor
Committee Chair
David Rees
Lynne Neagle
Rhun ap Iorwerth

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alun Thomas Hafal
Hafal
Dr Clementine Maddock Coleg Brenhinol y Seiciatryddion
Royal College of Psychiatrists
Dr Jenny Nam Cymdeithas Seicolegol Prydain
British Psychological Society
Ewan Hilton Platfform
Platfform
Sara Moseley Mind Cymru
Mind Cymru

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Ail Glerc
Second Clerk
Lowri Jones Dirprwy Glerc
Deputy Clerk
Philippa Watkins Ymchwilydd
Researcher
Sarah Beasley Clerc
Clerk

Cofnodir y trafodion yn yr iaith y llefarwyd hwy ynddi yn y pwyllgor. Yn ogystal, cynhwysir trawsgrifiad o’r cyfieithu ar y pryd. Lle mae cyfranwyr wedi darparu cywiriadau i’w tystiolaeth, nodir y rheini yn y trawsgrifiad.

The proceedings are reported in the language in which they were spoken in the committee. In addition, a transcription of the simultaneous interpretation is included. Where contributors have supplied corrections to their evidence, these are noted in the transcript.

Cyfarfu'r pwyllgor drwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:30.

The committee met by video-conference.

The meeting began at 09:30. 

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau
1. Introductions, apologies, substitutions and declarations of interest

Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma'n rhithiol, Senedd Cymru. O dan eitem 1, cyflwyniadau, ymddiheuriadau, dirprwyon a datgan buddiannau, a allaf i groesawu fy nghyd-Aelodau o'r pwyllgor? Rydyn ni wedi derbyn ymddiheuriadau oddi wrth Jayne Bryant y bore yma, ac nid oes dirprwy. Yn naturiol, cyfarfod rhithwir ydy hwn, gyda’r Aelodau a'r tystion yn cymryd rhan drwy fideo-gynadledda o achos y cyfyngiadau COVID.

Bydd pawb yn ymwybodol bod hwn yn gyfarfod dwyieithog. Mae gwasanaeth cyfieithu ar y pryd ar gael o'r Gymraeg i'r Saesneg. Mi fydd yna ychydig bach o oedi ar ôl i rywun fod yn siarad yn Gymraeg, felly, ychydig bach o amynedd wedyn, nes bydd y sain yn dod yn ôl yn llawn. Mae'r meics yn cael eu rheoli'n ganolog, tu ôl y llenni, a byddwch yn derbyn neges fach i ddad-dawelu ar yr amser priodol, cyn ichi allu siarad. Mae hynny i’r tystion a’r Aelodau.

Os bydd yna ryw anhawster efo fy rhyngrwyd i a fy mod yn diflannu o’ch sgriniau, rydyn ni wedi cytuno fel pwyllgor cyn rŵan y bydd Rhun ap Iorwerth yn cymryd drosodd dros dro fel Cadeirydd y pwyllgor nes y byddaf i wedi dod nôl, gan obeithio fod ei ryngrwyd ef yn Ynys Môn yn gadarnach na’r un sydd yma yn Abertawe.

A allaf i ofyn a oes yna unrhyw fuddiannau i'w datgan gan Aelodau? Nac oes. Diolch yn fawr.

Welcome, everyone, to this latest meeting of the Health, Social Care and Sport Committee of the Senedd, here in a virtual capacity. Under item 1, we have introductions, apologies, substitutions and declarations of interest. May I welcome my fellow members of the committee? We have received apologies from Jayne Bryant this morning, and there are no substitutions. Now, this is a virtual meeting, of course, with Members and witnesses participating via video-conference due to the COVID restrictions.

Everyone will be aware that this is a bilingual meeting and an interpretation service is available from Welsh to English. There will be a slight delay after a contribution in Welsh, so do please be patient until the full sound resumes. The microphones are being controlled centrally, behind the scenes as it were, and you may receive a prompt on your screens to unmute your microphone at the appropriate time before you are able to contribute. That is applicable to witnesses and Members.

If there should be some difficulties with my internet connection, if I were to disappear from your screens, we have agreed as a committee that Rhun ap Iorwerth will step into the breach temporarily as Chair of the meeting until I am able to rejoin, in the hope that his internet connection on Anglesey is slightly more robust than the one that I have here in Swansea.

May I ask if there are any declarations of interest from Members? I see that there are none. 

2. COVID-19: Sesiwn dystiolaeth gyda Hafal, Mind Cymru a Platfform
2. Covid-19: Evidence session with Hafal, Mind Cymru and Platfform

Reit, rydyn ni'n symud ymlaen i eitem 2 ar yr agenda y bore yma: sesiwn dystiolaeth gyda Hafal, Mind Cymru a Platfform. Mi fydd pawb yn ymwybodol ein bod ni'n craffu ar berfformiad y Llywodraeth a byrddau iechyd ac ati ynglŷn â'r ymateb i'r pandemig. Rydyn ni'n canolbwyntio heddiw efo sesiynau penodol ar yr effaith ar iechyd meddwl a'r pandemig. Ac felly, i'r perwyl yna, yn y sesiwn gyntaf dros yr awr nesaf dwi'n falch iawn i groesawu Alun Thomas, prif weithredwr Hafal; Ewan Hilton, prif weithredwr Platfform; a hefyd Sara Moseley, cyfarwyddwr Mind Cymru. Croeso i'r tri ohonoch chi. Rydyn ni wedi derbyn tystiolaeth ysgrifenedig ac, yn ôl ein harfer, awn ni'n syth i mewn i gwestiynu, yn y bôn, achos awr sydd gennym ni. Felly, cwestiynau cryno ac, wrth gwrs, atebion cryno hefyd, os ydyw hi'n bosib. Diolch yn fawr. Ac mae'r cwestiynau agoriadol gan Rhun ap Iorwerth. Rhun.

We move on to item 2 on the agenda this morning, and this is an evidence session with Hafal, Mind Cymru and Platfform. Everyone will be aware that we are scrutinising the Government's performance and that of the health boards in response to the pandemic. We're focusing today in this specific session on the impact on mental health and the pandemic. To that end, in this first session, over the next hour, I'm very pleased to welcome Alun Thomas, chief executive of Hafal; Ewan Hilton, chief executive of Platfform; and also Sara Moseley, director of Mind Cymru. A very warm welcome to the three of you. We have received written evidence and, as is customary, we will go straight into questions, because we only have an hour. So, succinct questions and succinct answers, please, if possible. Thank you very much. And the first questions are from Rhun ap Iorwerth. Rhun.

Diolch yn fawr iawn, Cadeirydd, a bore da, pawb. Allaf i ddechrau drwy ofyn ychydig o gwestiynau ynglŷn ag effaith gyffredinol, os liciwch chi, y pandemig a'r cyfyngiadau ar iechyd meddwl? Alun Thomas, os caf i droi atoch chi yn gyntaf, mi wnaeth cadeirydd Hafal ysgrifennu at y Gweinidog Iechyd a Gwasanaethau Cymdeithasol nôl ar 2 Ebrill yn codi pryderon dwys iawn am impact y pandemig ar bobl a'r gofal iechyd meddwl oedd yn gallu cael ei gynnig. A fuasech chi'n licio ein diweddaru ni ar safbwynt Hafal, gan ddiolch ichi am eich papur tystiolaeth ymlaen llaw? Ydy'r pryderon yr un mor ddwys heddiw?

Thank you very much, Chair, and good morning, everyone. May I begin by asking a few questions with regard to the general impact, if you will, of the pandemic and the restrictions in terms of mental health? Alun Thomas, if I can turn to you first, the chair of Hafal wrote to the Minister for Health and Social Services on 2 April voicing deep concerns about the impact of the pandemic on people and on mental health care that could be provided. Could you give us an update on Hafal's stance now, thanking you also for the written evidence you submitted? Are the concerns still as deep-seated? 

Thank you. Unfortunately, some of them still are. We are hearing quite regularly from people who are struggling to access particularly the specialist talking therapies. We're finding that individuals who have been on a waiting list perhaps for 12 months for talking therapies are now being told, 'Well, you're going to be another so many months on that.' We're also finding that accessing services is still very difficult—

Can I stop you there? We're going to come onto accessing services. Maybe I should have asked my question more clearly. Is the impact as deep on people as you feared it was, and what is the nature of the impact of the pandemic and the restrictions on people?

I think that the issue here is that many of the people that we work with, with the serious, the complex and enduring mental illnesses, are not seeking the help, necessarily, that they would be seeking when they need to, whether that's through self-stigma, that they actually don't feel that they're important enough to be asking for help. But also, I think, we're starting to see an agitation and an anger in the general public, which I think is potentially damaging to those convalescing with enduring mental health problems, because they'll be potentially subject to greater stigma as we go forward.

I think what we're seeing is a great deal of anxiety and stress for people in the uncertainty that's out there. I know my colleagues will be able to give more detail on that. You're looking at where our staff team—. About 70 per cent of our staff team are people with lived experience or carers, and the agitation of not knowing what the world has got for them tomorrow—. I think many of our staff are fortunate in that, the social care field, we're going to need far more staff in the longer term than fewer staff, but the financial implications, the family members losing jobs, the uncertainty about their children, the uncertainty about the schools—it's making it just a very, very difficult time to live. 

09:35

Os gallaf ofyn cwestiwn tebyg i'r ddau dyst arall—Sara Moseley yn gyntaf, o bosib: lle ydych chi'n meddwl ac ym mha ffyrdd mae'r pandemig a'r cyfyngiadau rydym ni'n byw odanyn nhw yn effeithio drymaf ar bobl? 

If I could ask a similar question to the other two witnesses—Sara Moseley first, perhaps: where and in what ways do you believe that the pandemic and the restrictions are impacting on people?

Wel, roedden ni'n teimlo bod yna agendor o ran gwybodaeth ynglŷn â beth yn union sydd wedi bod yn digwydd i bobl tu cefn i ddrysau caeedig. Felly, beth rydym ni wedi bod yn ei wneud ydy gofyn iddyn nhw, achos dwi'n credu mai dyna'r unig ffordd, mewn cyfnod fel hyn, pan ydym ni'n gallu gweld yn iawn beth sy'n digwydd i bobl. Felly, buom ni'n siarad efo 17,000 o bobl ar draws Cymru a Lloegr yn y chwech i wyth wythnos gyntaf y pandemig yma, a beth roedden ni'n ei weld oedd bod y mwyafrif o oedolion yn dweud bod eu hiechyd meddwl nhw wedi gwaethygu, a tri chwarter o blant a phobl ifanc yn dweud yr un peth. Mi oedd hynny yn arbennig o wael ar gyfer rhai grwpiau arbennig, ac fe allaf i fynd fewn i hynny; dwi'n gwybod bod hynny yn gwestiwn arall sydd gennych chi.

Ond mae yna dystiolaeth fwy diweddar hefyd gan Iechyd Cyhoeddus Cymru. Felly, maen nhw wedi bod yn rhedeg arolwg, 'How are we feeling?', ac mae 24 y cant o bobl wedi bod yn dweud eu bod nhw'n teimlo'n eithriadol o orbryderus, a dros un mewn pump yn dweud bod nhw'n poeni'n ddirfawr ynglŷn ag iechyd meddwl. Mae yna dros hanner o rieni yn poeni ynglŷn ag iechyd meddwl eu plant. Felly, rydym ni'n credu bod impact beth sy'n digwydd ar iechyd meddwl cynddrwg a chymaint ag impact ar iechyd corfforol, ac rydym ni'n poeni ynglŷn â'r gagendor rhwng beth mae'r gwasanaeth iechyd yn ei weld ac yn ei glywed a beth sy'n digwydd.

Beth rydym ni'n dechrau ei weld rŵan ydy bod pobl efallai oedd yn teimlo na ddylen nhw fod yn gofyn am help oherwydd stigma nawr yn cyrraedd y pwynt lle maen nhw'n gorfod gofyn am help, ac mae beth rydym ni'n ei weld fel elusen, o ran y bobl sy'n dod ymlaen i'n gweld ni, maen nhw'n fwy sâl efallai nag oedden nhw cyn y pandemig, ac mae beth sy'n digwydd iddyn nhw efallai yn fwy cymhleth ac angen mwy o amser i'w ddatrys. Felly, mae'n rhy gynnar inni fod yn dweud yn union beth fydd yr effaith, ond mi ydym ni yn poeni'n fawr ynglŷn â'r effaith.

Well, we felt that there was a lacuna in terms of information in terms of what exactly has been happening to people behind closed doors. So, what we've been doing is asking those people, because I think that's the only way, in a time like this, when we can see exactly what's happening to people. So, we spoke to 17,000 people across England and Wales in the first six to eight weeks of the pandemic, and what we saw was that there was a majority of adults saying that their mental health had deteriorated, and three quarters of children and young people said the same thing. That was particularly exacerbated for some specific groups, and I can go into detail on that; I know that's another question that you have.

But there is recent evidence from Public Health Wales. They have been running a survey, 'How are we feeling?', and 24 per cent of people have been reporting that they've been particularly concerned, and over one in five say that they are very concerned about their mental health, and over half of parents are concerned about the mental health of their children. So, we believe that the impact of what is happening in terms of mental health is as serious as that on physical health, and we are concerned about the gap between what the health service is seeing and hearing and what is happening. 

What we're starting to see now is that people who perhaps felt that they shouldn't be asking for help because of stigma are now reaching the point where they do have to ask for help, and what we're seeing as a charity, in terms of people who present to us, is that they are more poorly than they were before the pandemic, and what is happening to them now is more complex and needs more time to solve. So, it's too early for us to say exactly what the impact will be, but we are very concerned about the impact.

A chithau, Ewan Hilton—eich argraffiadau cyffredinol chi am sut mae'r impact yn cael ei deimlo gan bobl.

And you, Ewan Hilton—what are your general impressions about how this impact is being felt?

So, for us, the people who are—. Obviously, the impact of long-term uncertainty increases people's anxiety, so people living with pre-existing conditions—increased thoughts of suicide, increased intrusive thoughts, increased anxiety, increased depression and not knowing where to go for help; so, kind of repeating what my colleagues have said. And for me, there are people who are in the mental health service or who have been in and are trying to get back in, and then there's the general population who are also experiencing long-term impacts of trauma and uncertainty. I think what we have to start to think about is what's the long-term impact of this collective trauma on the whole population of Wales. 

That's a very interesting point, and it's one that's been discussed I think in the Children, Young People and Education Committee as well. Is there a danger that because we are all, every single one of us, feeling a level of anxiety through it all that there is an over-medicalisation, even, of that?

That's the risk, and I would urge us really strongly against that. Let's not pathologise people's pain. I think there are people who need to be in mental health services and supported, but I think the understanding of the impact of trauma and the impact of this virus needs to be understood across the whole of our public sector and across the whole of public sector policy making. So, we're talking about the work that the ACEs hub, for example, have been doing in Public Health Wales on the impact of adverse childhood experiences. We need to be applying that to us as adults. We need to acknowledge that people living in poverty, people already having a tough time, are being impacted harder, and we need to think about how we become a trauma-aware nation across all areas of our public policy making, and not medicalise what is a perfectly normal, really, response to a traumatic event. 

09:40

Yes, and we'll come on to access to services for people with mental health issues who need mental health care in the more traditional way, but do we, Alun Thomas, need to think of new ways of dealing with this more widespread anxiety within society as a whole?

Yes, and I support the way Ewan has just discussed this as well. We've done this for a long time in mental health services. We patholog—pathola—you know what I mean—

—the challenges of life. Grief is a normal reaction, but instead of recognising that grief, when it becomes debilitating and is something that then perhaps needs support from mental health services, we classify it as a mental health problem quite early. A lot of work that we did with 'Making Sense of Mental Health' with children and young people—. We use the language of stress, anxiety, depression, where children are worried about things, children are happy, children are sad, children are angry. If we stop using that sort of medicalised language, and start saying to people, 'It is normal for you to feel like this at this point, but here are some of the things that you can do to help yourself; here are some of the things that, actually, Government as a whole—.'

Forgive me, I appreciate the committee is having a focus on mental health, but I think that's part of the problem here. This isn't a case of focusing on mental health; this should be focusing on the whole gamut of Government. And I know you have to do that as a committee, but when we're looking at increasing poverty, when we're looking at the impact of job losses, when we're looking at the impact of people struggling in the families—. We know that we picked up quite early that women in particular were suffering more through this pandemic because they were having to play the role of the carers, and, quite often, they were the key workers. We had some conversations with colleagues and with staff, because partners who perhaps were being put on furlough from non-key worker roles weren't necessarily stepping up to the mark, and the women were the ones who were still left with the childcare, the caring responsibilities for older relatives, and having to be the key workers. 

So, I think it's—. Yes, we are here, obviously, predominantly, on a mental health basis, but I think that's a little bit of a red herring on the whole population side. 

I'll just unmute myself. I think that's really important. By the time people hit the system, we've failed. There are people already in the system, but our policy is dripping with early intervention and prevention, and that means real person-centred work in communities where people are living, and that's the bit that we're missing. So, I think we need to be—. I was reading quickly through Jeremy's, sorry, the Counsel General's—I've forgotten his title off the top of my head—document yesterday. And I haven't read it in detail, but what's missing for me is being explicit about the long-term impact on the whole nation's mental health and well-being in that document. It isn't a mental health pandemic, but I think we need to be a lot braver and a lot more specific about the impact on this and that it is a whole system response that we need, which is why we're talking about having a trauma-informed approach through the whole of Government, the whole of public policy. Otherwise, we're only dealing with a small part of the issue. 

Can I ask a question? You mentioned suicidal thoughts, and I'm certainly hearing from people in the medical profession, in my constituency, anecdotal evidence, suggestions, that there is an increase in self-harm or suicide. I'm reading, as part of research for this meeting this morning, other research that suggests there is no clear evidence of increase in suicide, self-harm or suicidal behaviour. Do you have access to the data that you need? Do we really know what's going on, Sara Moseley?

I think there's a time lag between what's actually happening and when that can be confirmed of at least a year. So, we do have to be really cautious about that, and I know that Professor Ann John is looking into ways of speeding up that updating of knowledge. But one thing we do know is that young people are reporting to us more self-harm as a way of coping with what's happening now. And we also know that there's an increase in using things like controlling your eating or drinking too much or—you know, those indicators that should be flashing some real red lights for us. And I think, particularly with young people and the evidence that's coming through in terms of self-harm, there's a real, real urgency in terms of doing something to help support young people's mental health now. Because we know that, if you start to have lots of these experiences, it can become very difficult for you, because they are extremely traumatic. And unless you have support around dealing with that trauma, you are carrying that through. So, we do have evidence around that, but we have to be cautious about the suicide figures themselves.

09:45

Just very briefly, there's already work going on that I think we can model, and it's speaking to the transformation projects that are under way in Wales and, when we're talking about young people, particularly the stuff that's going on in Gwent, which is using an iceberg model, which is to kind of keep young people out of the system and deal with this stuff really, really early on. So, I think there are models that are being developed in Wales that are in the middle of being evaluated—and I know we've talked to Lynne a lot about this—that we really need to be paying close attention to and really looking to see if we can scale. There are already some really good initiatives working with young people really early in their lives, in terms of their lives of distress, that could make all the difference right now.

I think there are models, but the problem is there's overwhelming evidence now that young people are not well served by what is going on. We know that child and adolescent mental health services is not the right place for most children and young people, and they can't get anywhere near it anyway, unless they're extremely ill, and that there's a yawning gap in the middle—there's this kind of missing middle for young people whose needs can't be contained within the family and school, but absolutely need support and help through this, and a hopeful path into adulthood. And there are initiatives, but they're really patchy, they're short term, and there is overwhelming evidence, I think, that children and young people are not well served.

Thank you. I think there are a couple of points there, from what Sara was saying. One is that children and young people contributed to the report by the children's commissioner quite early in this, highlighting that they didn't necessarily want to have mental health specialists in schools. So, the Welsh Government response was to throw money at mental health specialists into the school environment—you know, counselling in schools. Well, the kids weren't actually in school, so there's an issue there. But some of this—. We look at that cycle of, going back to it, this is the huge gap of not having youth workers. As organisations, yes, it gives organisational growth, it gives us another arm to what we do, but, actually, we shouldn't be doing this sort of work—this should be done by youth services, by people who are working with children and young people to see how they develop. Because some of this is normal development; some of this is development that's been held up, because of some trauma. It's where the youth services are then not able to deal with some of those things; that is where we would be able to assist and support. If they can stop people coming into mental health services, that's the greatest thing we could do to this generation.

Thank you. I know Lynne's got more questions on the access to services to come, but I think I'll leave it there, Chair.

Diolch yn fawr, Rhun. Rydym ni'n symud ymlaen nawr at yr adran nesaf o gwestiynu, ac mae hynny o dan ofal David Rees. David.

Thank you very much, Rhun. We'll move on to the next section of questions, and they are from David Rees. David.

Diolch, Cadeirydd. Morning, all. Ewan, I think you've mentioned it, and I've heard a little bit in a sense from the others, in the sense that there were wider determinants, social issues, that have an impact as a consequence of this pandemic. And you've talked about how we need to address trauma as a major factor going ahead. Is the Welsh Government getting that message? And it's not the short term—. You mentioned Jeremy Miles, who is the Counsel General and Minister for European Transition, and his paper yesterday, saying that you didn't see much there, but is it only in that or should the Welsh Government actually be taking a far longer approach to this rather than just a short-term one, which that report relies on?

09:50

The short answer is 'no', the Welsh Government isn't paying enough attention. There is movement in the mental health directorate and we're hearing good noises. Trauma pathways are being developed and a more non-pathologising understanding of people's distress is starting to move within the mental health system. It's not sticking fast enough and it is not getting to be cross-Government, which is where I think it needs to be.

And then when we start to talk about the other determinants that impact on people and prevent people from moving on—poverty and inequality—we have a punitive benefits system that makes people sick, for example. So, if we were talking about other brave, long-term action, we would be wanting to talk about what we can do with exploring further devolution of benefits in Wales, exploring things like pilots of universal basic income and taking away—. So, when we talk to the people we support, it's that financial fear of not having any money. We spend a lot of time delivering food parcels because people's money had stopped and they had absolutely no way to get any money—these fundamentals that we wake up with of having some security over every day that so many people in Wales don't have. So, yes, trauma needs to work its way across Government, and poverty and inequality and addressing that seriously in Wales needs to be a priority.

Yes, I would agree. One of the things that this pandemic has really done is heighten inequalities and it's really shone a light on inequalities. That's particularly true in terms of mental health. So, Alun has talked about the effects on people who are already unwell, and that's one group of people who have been disproportionately affected—particularly things like eating disorders, post-traumatic stress disorder and anxiety-related disorders. If you think about it, this has been the kind of situation that has really amplified some of the things that break the things that support people who experience those. 

And the second group of people who've really been disproportionately affected are people who are economically insecure and in economic distress. We've seen that. For instance, our helplines, whenever there's a change in the benefits or people have to engage with the benefits system for the first time, we see a spike in people coming to the helpline and they are absolutely incredulous about what they have to do to navigate the benefits system and get help and support in order to survive.

And then I think the other, third group of people who have been disproportionately affected are people in black and minority ethnic communities. Talking to them and from our research with them, the reason for that is because they tend to be in groups that are in more insecure housing, more insecure employment and are experiencing discrimination anyway. So, it's not that there is something intrinsic about the mental health of people from black and minority ethnic communities; it's that they are more disadvantaged generally and more locked out of access to services, which do not feel safe and welcoming and open to them. So, I think the overwhelming message from this pandemic is that, in terms of mental health, it's not equal.

Thank you. Yes, in terms of the money side of it, Lloyds Banking Group plc gave us a 50 per cent increase for our mental health and money advice service—quite a specialist advice service. We're drowning with it; we cannot manage all of the calls that we're taking on this. And these are people who are now getting to the point where they're going to start losing homes and they're going to be—. So, we've dealt with the street homelessness issue by making sure that everyone had a roof over their head, but we're going to start seeing a whole new raft of people coming into those problems. 

The short-termism is the challenge here. Welsh Government have put money into this, but you get three or four weeks to write a bid, you then get notification that the money is there, you've got to spend it by 31 March. I do wonder if there's an understanding that we might have cupboards that we open up and get staff out of to deliver these short-term projects. One of my concerns is that if we want a long-term fix for this—. We know that in society we're going to have industries now that are going to be badly damaged—we're going to have the hospitality industry, we're going to have a lot of people who need to be finding alternative employment. We're going to have this increased need not for mental health services, but for community, for youth support, for the sort of things that people need to rebuild. What are we doing, as far as a longer term plan, to retrain, to support, to educate, to develop that new forward thinking workforce?

One of my big concerns on the money is that Wales has had a ring fence for mental health money for some time. Everything at the moment is being pushed towards, 'This mental health issue', 'This mental health issue', 'This mental health issue.' Is that ring fence going to go up, then? Because, if, all of a sudden, everyone is seeing that there's this huge problem in mental health—. We know that that money wasn't enough to start with. We're looking at lots of short-term pots instead of finding a way to say, 'We need to be saying mental health money is for those people who have specific mental health challenges', and we need to be looking more at society and the issues that are out there, and stopping those individuals getting into mental health services, where they could be supported at a much earlier stage. 

09:55

Just very quickly on that, if we believe that that is what we need, then, health is not the solution; local authorities and third sector are. So, I think we need to be thinking about long-term, strategic funds that focus themselves at youth work, community development work, employment work, skills work in communities with people. So, health is not the answer to the whole of this if we believe that working with communities in a preventative way is. 

I absolutely agree with that, but I would say that there's a balance to be struck here, because what lots of our beneficiaries are telling us is that they do need specialist help and support in certain circumstances as well, and we do know that people have difficulty—there aren't enough talking therapy services, there aren't enough really specialist services. So, I completely agree that the focus needs to be early intervention, early help and support, but I also think that has to be balanced with, if you need specialist health services, then you should be able to get hold of them quickly. And all of this is about dealing with things as quickly as possible, because we do know—we've got lots of evidence now—that the longer you wait, the longer somebody holds back because they're stigmatised or they're afraid and, then, the longer it takes to get them to the right place, the more that this tends to accumulate.

Mental health problems, issues, anxieties, trauma—they don't usually go away by themselves. Even if it's just accessing really good information that helps you understand what's going on and support yourself—. So, I think, to come back to a phrase that's been used by all my colleagues, it is about whole systems and being there where the person is. 

Alun, I know, had his hand up, before I go back to the Chair for a second. 

Thank you, yes. I think some of this—. The Welsh Government has been particularly good on the policy and the vision. Prudent healthcare is clearly a way through this, but there are some conversations that are not taking place. Some of these conversations need to be the courageous conversations about what is it that services are able to provide. What is it that you can expect from services? Our biggest concern throughout this is that of all the plans that the health boards gave the Minister, which reassured him that there was nothing going wrong out there—yes, okay, that was a red herring—none of those actually really involved discussing and working with patients and families to actually work out what it was that people needed. If there are things that we cannot provide, then we need to be honest, we need to have those conversations with the public and the public will accept that there are things that are impacted. But what we can't have is the treating of patients and people in Wales like mushrooms, where we're kept in the dark. We must see a way where people are involved—co-produced services—where we have those conversations, and not simply, 'This is what we can offer you.' but, 'What do you need? How can we best work that out? Do you realise that this is something we could do differently?' And we have those discussions.

I agree with Sara that specialist mental health services are needed, and that's one of the key things that we think this will help with—that we get people out of specialist mental health services that don't need to be there and shouldn't have ever been there in the first place, to make sure those resources are targeted at the people with those specific needs. We then need to have a system that stops people getting in there. A very famous psychiatrist, Thomas Szasz, in the States, whose comment was, when somebody asked him, 'Who is mentally ill?' he would say, 'The person who sees a psychiatrist.' Actually, mental health services are not the place to be for a lot of people. It's only when they actually get to that point that they need those specialist services.

10:00

Okay. We've got a supplementary from Andrew R.T. Davies, and we'll come back to you then, David. Andrew R.T.

Thank you, Dai. Just back to Sara, you made the point, Sara, that there aren't enough talking therapies out there, and Alun was touching on the point that the health service isn't necessarily the place for people with mental health conditions to be in. I couldn't agree more with you—you need more talking therapy sessions and support out there, without a shadow of a doubt. But I was hearing that 10 years ago. So, from your position as advocates for mental health provision, what's the obstacle? Why isn't the talking therapy capacity being commissioned, either by the health boards or by the councils? I don't hear any dissent from that, but, in 10 years, I've seen very little progress in that field.

I think there's a lack of a joined-up, long-term plan for how you build the skills and the capacity for talking therapy services, and how you make sure that people are, as my colleagues have said, getting what they need and that people are working to their level. You can deal with the need for, if you like, talking therapy services that are at the lower levels, in the right place, and not necessarily within the NHS even. So, we've had a really interesting experience over the past six months. The Wales Council for Voluntary Action and Welsh Government have supported us to roll out an emergency talking therapy service, and, usually, that would be going through GPs, but because of the disruption around GP practices, we have been inviting people to come directly to us and using things like Facebook and so on. And in the first six weeks, we saw 1,600 people come to us, and we could see that their level of mental health need was pretty significant, and by just doing that directly, the people who were coming (a) really needed it and (b) were really benefiting from it. So, I think that you're right—if you're banging your head against a brick wall and nothing is happening, then stop doing that and try doing something different. So, let's have a really constructive, open, creative discussion about how we might change this, and let's not just have it within the health service—let's have it much more widely and put together in a way where people can get good information, get good self-help, then get really good access to universal talking therapies, if they need it. And then we're sure that we are using our resources very wisely and we're helping a maximum number of people, and we're empowering people to help themselves.

Could I just ask whether you would believe a national register for accredited counsellors would be beneficial? So, if you do turn up—the example you gave of going to a GP practice—the GP behind the desk there could, obviously, signpost you to an accredited counsellor for a talking therapy session. At the moment, as I'm led to believe, there is no national register, so the GP doesn't have that ability to access that information and, therefore, that surely should be the starting point.

I think what is absolutely vital is that the organisation that's planning the training and development of health and social care professionals in Wales needs to spend more time looking at how this applies to mental health and how it applies to individuals and professions outside the NHS, because at the moment that kind of holistic view of, 'How do we know that we're accessing something that has got a certain kind of quality?', 'How do we use the same ways of measuring what's going on?', all of that needs to be brought into play and at the moment it isn't. And it also links into the core data set, so we need to be able to know, 'What are we all measuring?', 'What are we all looking at here and how does that make sense across different sectors?' So, it's actually focused on the individual, not whether you're being seen by the third sector, the NHS or a GP service—wherever you might be, it's about the individual.

10:05

Just to support Sara, really: we often have the life commissioned out of us, or our ability to respond to what we really need to do commissioned out of us, and actually what's been brilliant about some of this new money is, 'Here's the money; go where you are needed and do what needs to be done', and that's what the third sector used to do. So, I think there are questions about system change and some of the things that are changing in the system are happening already, but I think there are some more lessons to be learned around trusting organisations to know what needs to be done. Get out there and do it and be less worried about measuring it all. So, yes, just to make that point.

Thank you, Chair. Can I go on to the disproportionate approach of this to people? Now, it's been mentioned already this morning that people in poverty and the BAME community are probably most disproportionately affected. It happens to be similar groups as the most impacted upon by the virus itself physically. But I think Sara also mentioned women as a group of people who actually also have additional pressures as a consequence. Is it the same—? Are the same groups—other than the women, in a sense, because that covers a wider age range—are they the same groups that are physically being impacted upon that are also suffering the greatest disproportion mentally, and are their voices being heard on the mental agendas, because we hear an awful lot about them on the physical agenda, but we don't hear an awful lot about it on the mental agenda? Sara.

I think that the really big group that is more affected psychologically than physically is young people. So, yes, there's a big overlap in those other areas that you mentioned, but young people are being disproportionately affected psychologically, I would say, and that is really, really clear now. 

Okay. Ewan, do you agree with that? And then I'll go to Alun. Alun—Ewan's just nodding.

Yes, thank you. I think there's also got to be the recognition that within mental health services BAME groups are disproportionately affected anyway. We've got the current review of the Mental Health Act 1983, which is due to produce a new White Paper, where we're seeing a far greater proportion of people from BAME groups who are detained in hospital.

And if I can just pick up on one of the points that was raised on the talking therapies, one of the greatest challenges is that we have got people who are having to be detained in hospital in incredibly expensive placements while they wait for specialist talking therapies. Welsh Government under-resourced a programme a few years back, the Matrics Cymru programme, which was looking to develop this across Wales as a whole system. I can remember going to meetings where this was building up to something that was going to be a pathfinder, to find that the individual who was commissioned to do the work, 'My contract ends on 31 March and there's nobody to pick it up after that.' I know more work has been done on this, but, again, counselling isn't counselling for this group, counselling for that: counselling and support is a whole population thing. And I think we need to be recognising that the people who are most disproportionately affected are those then, again: BAME groups in mental health hospitals who are there detained and have their liberty taken away. We're looking at those individuals from that socioeconomically disadvantaged group who, again, are more likely to be in mental health services already, who are more likely then to be experiencing all the challenges of life. So, I think this is just the perfect storm for that group of already very vulnerable individuals.

Okay. And Sara, you've mentioned—finally from me now—young people and we've seen a lot of young people go back to university in the last month who are now facing some challenging times. Is it actually having a more detrimental impact upon that group as well?

10:10

It's too early to say, really, because it's still early days in terms of going back to university. But what we do know is that young people are telling us that they're finding it harder than adults to know where to go for help and support; there is less help and support that is suitable for them; there are increased levels of self-harm and anxiety and the effects of trauma; and there are really quite high levels of loneliness and isolation amongst young people as well. Because just thinking back, quite a long time, to when I was that age, your peer groups and your rites of passage through life are just incredibly important and meaningful to you in terms of shaping your whole life, and that has been very disrupted. So, while we might think that people who are most prone to the effects of loneliness and isolation are people living on their own, for instance, or older people, that's not the evidence that we are seeing. We are seeing that happening very much amongst young people.

Gwnawn ni symud ymlaen nawr i adran arall o gwestiynu sydd, wel, ychydig bach o sôn eisoes, ond mae Lynne Neagle yn mynd i arwain ar y cwestiynau yma. Lynne.

We'll move on now to another section of questions that have already partly been covered, but Lynne Neagle's going to lead on these questions. Lynne.

Thank you, Chair. As you say, some of this has been touched on already, and I very much agree with Sara, because we're not in an ideal position where we have that community infrastructure, the youth workers, so people have to access services. We've been told as a committee over and over by Welsh Government that they gave an instruction that mental health services would continue through the pandemic. The committee has its own views on that. I'd like to get your perspective. And when I'm talking about services, I'm talking about the full spectrum, from primary mental health services right up to the most specialist end.

Okay. Ewan to kick off, then, and we'll go along.

I think Mind will have lots of data from their survey; our experience was a massive disconnect. We had a really good response from Welsh Government. We met regularly and we were assured that pathways were open across the service, whilst it was disrupted, so no-one expected things to be normal. People who we support were getting answer phones, were being turned away, were being bounced around services. We've had people in accident and emergency for three days. So, there were some really awful experiences. So, yes, absolutely, what Welsh Government was saying was happening was not happening on the ground.

Yes, I think it was very much a curate's egg. So, from the people that we spoke to, around about 16—I'm going to give you some figures now—16 per cent of adults and 30 per cent of young people tried to access mental health services; one in six adults couldn't and 40 per cent of children and young people couldn't. Half the young people told us that not being able to get hold of services had made their mental health worse. Some of the barriers there, especially, were: not feeling comfortable or not able to access services remotely and using digital technology. And, again, we know there's an overlap with some of the—I mean, Ewan has talked about some of that. But, also, some of our local Minds, like Ystradgynlais, was going out and buying data for people to put on their phones so they could get hold of their mental health workers. Difficulty in getting hold of the GP or a community mental health team, that was another big factor, and having appointments cancelled, and I think Alun may have some very specific examples of some of that happening. So, those were the difficulties in terms of access.

But I think the other thing that came out was that just knowing where to go, how to get there, was quite a big issue for lots of people. That was compounded by all the changes that were going on and, perhaps, a lack of clarity around that. But, also, people were coming who needed help for the first time because of the circumstances they were in; they just had no idea where to go, really.

If I can just mention that, obviously, there are some very specific things I think we'd like to see around this, so we'd like really clear published information about where you go and what help and support is available. In Part 1 of the Measure—. Because we know that people are supposed to go to their GPs, we had a good look at the schemes under Part 1, and the schemes are the things that list what services should be available, and some of them hadn't been updated ever and some of them just weren't very accessible or clear. So, as well as knowledge and access for you and me, there's also knowledge and access actually for primary care, and those links between primary care and secondary care, I think, are really important and need to be strengthened.

10:15

Thanks for that. Our chair, Mair Elliott, said that she'd forgive me if I swore when this question came up. [Laughter.] It's across that whole system. I know in early days, 60-odd per cent of our clients struggled to get hold of the GPs. We know that Welsh Government did put together a mental health incident group, which we found very helpful in trying to deal with problems once they occurred, but I think our biggest concern was that we were telling people within Welsh Government—we were telling the Minister—that these things were happening and we were getting patted on the head, when you look at the letters coming back from the Minister saying, 'No, don't worry about it. I've been assured; I've been told that these things are all sorted.'

Betsi Cadwaladr—I think you've got to ask the question. A health board that has been in special measures for five years, we've raised concerns about people being turned away from service and services being cut. The Minister was prepared to accept the word of that health board without checking it out, and then all of a sudden we see 1,700 patients discharged from services. Where's the accountability for that? This is a letter from the Minister saying that he was assured that everything was right. So, I think he's got to actually answer what he is going to do to make sure this doesn't happen next time, because as we get into this again, we cannot have those assurances just being thrown out.

What we have got is a system-wide issue, as well, for people accessing. As Sara said, where do I go and what do I do? If I'm coming into services new, how do I access them? We've had a number of experiences with children and young people through this. I don't think any parent, unless they've been involved in the system, will know where to go for that first step. They were asking for help, GPs weren't available to see them face to face. They were then getting referred to primary care CAMHS, primary care CAMHS weren't doing face to face. Ultimately, somebody would get some medication prescribed, they'd be put onto medication, the child would start self-harming, they'd then be told they were too ill for primary care CAMHS and needed specialist CAMHS, specialist CAMHS were saying, 'You don't meet the threshold,' to the point where we were asked to give examples, and the families refused to let us put their names forward, because, yes, the NHS and the individuals in the NHS have worked very, very hard through this and been through some trying times, but there's a fear that people will be victimised for complaining about services as well. I think there needs to be some accountability through this period. Simply being told that, 'COVID is not letting us do this,' isn't a good enough answer.

Okay. You'd better go and have a lie down there, Alun. I've got a supplementary from Andrew R.T.; I'll come back to you then, Lynne, all right? Andrew R.T.

Yes, just two things if I may, Alun introduced in an earlier part of the evidence—I just want to see if Ewan and Sara agree with this—that the plans that are being submitted by the local health boards just aren't being challenged by Welsh Government, and it's almost as if, 'Everything's all right here, move on, there's nothing to see.' I think that's an important thing that we as a committee need to understand: how much challenge is put by the officials before they hand advice to the Minister on plans that are submitted by the health boards in their areas. Because if that challenge isn't there then it's no wonder that, obviously, services are in such a state.

I'd also like to understand: do you identify with the point that Alun made, because it is a very strong point, that people won't step forward because they're fearful of being victimised if they hand over hard evidence to say, 'Look, the service just isn't working for us'? Because if people are being cowed into silence because of that victimisation, that, again, is a critical component of any report that we would be submitting on our findings, and I'd like to see whether there is endorsement of that from all three panel members.

Sara gyntaf.

Sara first.

Ewan, then. Sorry, we'll have Sara then—.

Okay. So, is there challenge? I think Alun has said we've been having regular meetings with NHS Wales and Welsh Government, which have been very welcome, as Wales Alliance for Mental Health. I think there's been a bit of a journey. So, obviously, when the 1,700 cases came to light, that was a bit of a revelation, so one would hope that, following that, there would be more challenge and scrutiny. Obviously, we're not in a position to know, because we don't necessarily know what those conversations are, and that's me being honest, but obviously that did happen in Betsi, and you would think that that would be a bit of a wake-up call.

In terms of the victimisation, I think this is a really, really tricky one, because I think people who are really desperate for mental health support and services are already in a power situation that disadvantages them. There's a huge amount of stigma over mental health and your own position in terms of that, and how you feel, and the way you feel within that dynamic. So, there's already a lot of self-stigma and self-censoring going on when you are in that position, where you might not feel that this is an equal relationship, and I think that kind of support and empowerment and feeling of self-worth and agency for individuals who are unwell and the people who are caring for them is an essential component of what we're talking about here.

Alun has got quite a lot of specific information and knowledge from the people that he supports and cares for who are severely unwell, and their families. I personally don't have that knowledge, but I do know that that kind of stigma and that sense of self-worth and your place in the system—. I mean, just look at care and treatment plans and whether they are real, living documents that are co-produced and used. There are lots of indicators in the system around what happens. But that's all I can say on that, really.

10:20

I would just say very quickly, performance management and accountability isn't a new issue through COVID. As far as I'm concerned, it's always been an issue, and it's just been highlighted again now, and that's not just health—I would say across local authorities too. I have not heard stories of victimisation, but I have heard many, many stories of people just not getting what they need, and being left in terrible, terrible circumstances. But Alun's referring to specific cases.

I would agree with Ewan.

And I think there are cases where we had—. I don't want to name names, but it's somebody who's actually blogged about it, who complained that they weren't able to get face-to-face counselling and then had a telephone call from their therapist to give them a wigging. It's something that—. It's going out there—. I think the perception that it's going to happen is probably greater than the amount of it that's happening—the fear that it's going to happen. But I think just, to go back to your point as far as the civil servants actually scrutinising the documents, we did FOIs for these plans and one health board refused to give us their plan at all, on the basis that it was secret. So, what sort of scrutiny is going to be there? The Minister did actually instruct them, then, to provide us with copies, but is that an open and transparent NHS?

I'd like to try and get, really, to the bottom of why there is this clear disconnect, really, between what Welsh Government is being told and what yourselves and certainly I think is happening on the ground. I was told in the Senedd, in Plenary—I raised the Mind figures—that there was a COVID mental health monitoring group and that every week Welsh Government officials were looking at the data on what is happening in mental health. Have any of you seen the data? Do you know what the process is in terms of handling the data? I'd really like to get a handle on why there is this massive disconnect, because going into the winter, a much longer period, there is a real concern.

10:25

A couple of things. I think probably the disconnect is because the information that's supplied by the health boards is from professionals within the health service, around who is coming forward to them. It's not asking people what their experience is and what their needs are. So, it's not identifying what's going on for individuals and families, which is where we come from, because that's our ethos and we are constantly talking to beneficiaries.

The other thing on data is that, obviously, they've suspended the monitoring data, the official monitoring data, but we do know that local health boards have been collecting it. So, I think this whole issue of data—we would want them to publish that so that we have at least that information, and we would want them to really accelerate the development and delivery of the core mental health data set, because I think, as you say, we're obviously in a new world here, so if you're going to learn, you need to know what's actually going on first. The intelligence, the information and the data is the absolute basis for what you're going to do next, because we all understand that this was an unprecedented situation, and we all understand there are lots of people working incredibly hard and making a massive effort. That is an absolute given, but you need to know where you are before you can get to where you want to get to. 

Can I ask about the money, then, please? As you know—Sara and Ewan know that I've been making a fuss about the £7 million that was taken out of the mental health budget, and seems to have gone in and out like the hokey cokey. And we now know that, apparently, health boards have been asked to spend half of that money, £3.5 million—I'm not sure still what's become of the other £3.5 million. Has there been any attempt by health boards to involve third sector organisations in how to spend that money locally?

We've had a couple of health boards that have talk to us about whether we could put in joint bids with them, could we work with them. One of the things that appears to be gaining some traction is a role that we developed in partnership with Mental Health UK and Johnson & Johnson, which we've now rolled out, which is a social navigator. It's aiming to help guide people around the system, because I think part of the challenge is that people don't know where to go and, sometimes, if you can actually help the individuals navigate the system, you find that they don't end up in mental health services because they're able to get that assistance elsewhere. 

One of the things we're looking at, going forward, is: could we actually do something similar to that for key workers, for their own support? But it's only the odd health board that is talking to us. Quite a lot of the time we're seeing that, 'We've received this money, this is what we're going to do', but it's quite similar to the way the Welsh Government did it themselves with the money for schools counselling at the beginning of this: 'Look, we've had a great idea, we're going to do this.'  And if you want to get on to great ideas, the £500 for key workers—again, who came up with that one, because that's been a disaster.

Just to say patchy as well. Where we're actually part of transformation projects, we have been involved, but it's felt a bit more like competing to see which bits of that transformation project are going to survive—the clawing back of the money, rather than a bigger strategic conversation about really bedding this in and making sure it works. So, very patchy. 

Okay. Can I just ask finally, then, about people who don't feel able to access services digitally? And there will have been people in distress who it just wasn't going to work for, doing this on Zoom. As far as you're aware, have they been able to access face-to-face services when they really needed them? 

Unfortunately, most of them not. We've been providing face-to-face services throughout, which has meant that we've got rooms full of PPE, which, again, was one of the key issues. We've had some quite interesting conversations with Jo Jordan and Shane Mills from the mental health incident group, where I think they have got a way forward for this. There needs to be a deal with patients and families. We're not going to be able to go back to the point where everyone can have a face-to-face contact every time they need to see somebody, but there needs to be a way so that people don't get told, 'You can't have one at all.' It is a case of managing that. It is a case of using organisations like ourselves, like Platfform, like Mind, where we can support people to use the technology because some of this isn't about people not being comfortable about the technology; some people don't have the technology, some people don't know how to use it. But also, they need almost that translation service on the technologies themselves: 'What do they mean? What do I do know? How do I go forward?' I think there has been, 'Oh, this is an opportunity for us now to throw everything out and we'll go to a technology-based approach, and look at this—this is going to be so much better.' Again, I think there needs to be a lot more thinking about that. 

10:30

If I can just quickly say on the money, I don't think there's a joined-up view on where we are in terms of the money and what we need to do to meet this massive challenge that we've got coming down the road. We have been told that there's a review of mental health funding, but it looks as though that's just been done within the NHS. On behalf of WAMH, I have written and asked for details around what that means and what it is. As it stands at the moment, I don't know. You may well know more than I do, but there isn't that joined-up view. So, Alun and Ewan have talked about this initiative here and that initiative there, but what does the whole of it look like and what does it mean in terms of the rest of what's going on? 

Thank you. I think everything else has been covered. 

Diolch, Lynne. Symudwn i adran olaf y cwestiynau, ac mae yna gwpwl o gwestiynau nawr gan Andrew R.T. Davies i orffen y sesiwn. Andrew.

Thank you very much, Lynne. Moving on to the final set of questions, and they come from Andrew R.T. Davies. Andrew. 

Thank you, panel, for the evidence you've given so far, and I appreciate this is the final set of questions so some of these points might have been touched on in previous questions, so don't feel the need to go over the ground again. Sara, I think you touched on it just now when you were responding to Lynne about the massive untapped demand that's out there, and building through the crisis. And it's important that we as a committee, compiling our report, hear from people working in the field how they think that, going forward, we can put some solutions in place to address this demand that's been building and building, but we knew was there before the pandemic as well. 

So, from all three members I'd like to hear, if possible, any suggestions you might have that could be incorporated into the report to assist the Government in meeting that demand that is in mental health. And in particular in the field of bereavement, because whilst people have focused on the deaths through COVID, for understandable reasons, right the way through the crisis, many people have had a very traumatic experience of losing a loved one where they haven't been able to be with them at the last moment. That is something that they will carry for the rest of their lives, and for some people it would be enough to push them into that mental health category of support and assistance that's required. 

Ocê, pwy sydd eisiau dechrau? Sara.

Who wants to start? Sara.

The bereavement thing, Andrew, I think is a very important one, and I think, again, it's avoiding that being seen as a mental illness issue, and, again, being one of a support matter. I lost my mum through the COVID period to a non-COVID-related condition, and not being able to go and visit her, not being able to spend time with her in the care home, you then need family around you. But, again, you couldn't have family around you because of the issues that accompany that. Fortunately, we've been able to deal with it as a family, but, you don't know, these things can affect you at different points. 

I think one of the messages to Welsh Government from this going forward, because we work pan-disability as well, is that we've been delivering a huge amount of domiciliary care to very vulnerable individuals across huge areas of Wales throughout this on a face-to-face basis. So, why do mental health services have to stop delivering face-to-face services? We've got staff who are working 10 hours a day in full FFP3 masks, suits, because they're working with children on ventilators. If we said we're not going to do face-to-face, what's going to happen to those children? We have people who need to be washed, fed, supported, helped to get up, helped to go to bed. They had face-to-face throughout this. Have we discriminated against people with mental health problems through this period by simply saying, 'They're the easiest ones for us to say we're not going to provide a face-to-face service to'? And I think the Welsh Government has to commit to providing face-to-face services and not having such a knee-jerk reaction in health boards and local authorities as they did this time.

I think that, when you look at the third sector, the third sector generally took the lead in this. I remember conversations with Ewan at the beginning where I was getting a bit grumpy, and Ewan said, 'Look, there's no point getting grumpy; it's just up to us to get on with it and drive forward', which was quite correct. 

10:35

Okay. So, what can we do about it? Well, first of all, this needs to be seen as a priority, and it needs to be dealt with with the same level of urgency and leadership and focus as the physical impact and the economic impact of COVID, because if we don't also support the psychological and emotional impact of COVID that's going to have a knock-on effect as to what services we're able to provide for staff in those services, and how we get businesses back up and running and how communities work. 

Secondly, I think people need to be able to not feel ashamed or afraid or discriminated against when they feel the psychological effects of this. It's traumatic, it's wide-ranging, and you should be able to say, 'This is really tough. I'm not coping very well; I need some help.' And then you should be able to get really good information about what's happening psychologically in terms of the impact and generally and move quickly into the kind of support that you need, and to be able to access that really quickly and be trusted to know when you need that, not having to go through loads of different kinds of assessments before that happens. And then, when you are facing a situation where you have really quite severe needs and issues and problems, it needs to be really clear where you go and how you get that support. 

And, underlying that, I think we need to pull together the evidence. We need to have some research into a funding model for mental health services that looks at future demand and makes those services sustainable and around the individual where they are. And we need to really start thinking, because 'Together for Mental Health' is in its kind of dying days now really, and some of the additions that are being made to it around COVID—well, we'll see what they are, but it is very much in its dying days, and we need a really fresh approach and a proper strategic review that encompasses what is happening to people in Wales in their homes, in their workplaces, and to incorporate those things.

Alun, you've never described me as right about anything, so thank you for that, first of all. 

I think there's an opportunity here to grab some of the system change stuff that is happening. So, I'm not putting a rosy glow on this at all, but we are seeing boundaries come down between organisations that used to fight. We are seeing people at the front end actually look at what needs to be done and do it together. So, there's a lot more collaboration; there's a lot less contract management and holding everyone to the detail of what it is they should be doing, and more letting people get on with what they're doing.

We ran a big conversation—over 250 people, I think, across the sector in Wales—just looking at the system and what is happening, and I think we're missing something about organisational culture here and leadership and how we look after the workforce. It was no surprise, really, that where people felt cared for, nurtured, looked after and trusted, really great things were happening on the ground in terms of service delivery. Where there was a less trusting structure, the hierarchy kicked in, the rigidity kicked in, and the drawbridge went up. So, I think there's a real opportunity to keep looking at what is happening and put the leadership challenge out to us in the third sector, and the public sector, that we need to change the culture of our whole system if we are really going to grab hold of the change we need to see. 

Da iawn. Ac ar amser hefyd, felly bendigedig i bawb. Diolch yn fawr iawn i'r tri ohonoch chi am eich tystiolaeth y bore yma ac am ateb y cwestiynau mewn ffordd mor raenus. Diolch yn fawr iawn i'r tri ohonoch chi. Ac, fel rydych chi'n gwybod—rydych chi wedi hen arfer bod o flaen y pwyllgor yma rŵan—mi fyddwch chi yn derbyn trawsgrifiad o'r sesiwn yma er mwyn i chi allu gwirio ei fod e'n ffeithiol gywir. Ond, gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi; dyna ddiwedd y sesiwn yna. 

Ac i'm cyd-Aelodau, fe wnawn ni gymryd toriad nawr tan 11 o'r gloch nes bydd y sesiwn nesaf efo'r tystion nesaf yn dechrau. Felly, dyna ddiwedd y cyfarfod cyhoeddus. Diolch yn fawr. 

Excellent. And on time too, so well done everyone. Thank you very much to the three of you for your evidence this morning and for answering the questions in such an excellent way. Thank you very much to the three of you. And, as you'll know—you are used to appearing before the committee now—you will be receiving a copy of the transcript of this session so that you can check it for factual accuracy. But, with those few words, thank you very much to you. And that brings us to the end of that particular session.

To my fellow Members, we'll take a short break now until 11 o'clock, before the next session with the next set of witnesses. So, that brings us to the end of that part of the public meeting. Thank you. 

10:40

Gohiriwyd y cyfarfod rhwng 10:40 ac 11:00.

The meeting adjourned between 10:40 and 11:00.

11:00
3. COVID-19: Sesiwn dystiolaeth gyda Choleg Brenhinol y Seiciatryddion yng Nghymru a Chymdeithas Seicolegol Prydain
3. Covid-19: Evidence session with the Royal College of Psychiatrists Wales and the British Psychological Society

Felly, croeso nôl i bawb i ail sesiwn y bore yma o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma fesul fideo-gynadledda o achos cyfyngiadau COVID. Rydym ni wedi cyrraedd eitem 3 ar yr agenda rŵan, a pharhad efo'n hymchwiliad i mewn i, wrth gwrs, sgil-effeithiau y pandemig COVID-19. Rydym ni wedi cyrraedd rŵan y sesiwn dystiolaeth gyda Choleg Brenhinol y Seiciatryddion yng Nghymru a Chymdeithas Seicolegol Prydain. Ac i'r perwyl yna, dwi'n falch iawn o groesawu—wel, bron i mi ddweud 'i'r bwrdd', ond croesawu i'n sgriniau—Dr Jenny Nam, cadeirydd yr adran seicoleg cwnsela yng Nghymru, Cymdeithas Seicolegol Prydain—croeso—a hefyd Dr Clementine Maddock, is-gadeirydd Coleg Brenhinol y Seiciatryddion yma yng Nghymru. Croeso i'r ddwy ohonoch chi. Diolch am bob tystiolaeth rydych chi wedi ei chyflwyno ymlaen llaw. Gan fod amser ychydig bach yn dynn, mae yna res o gwestiynau gyda ni i'w gofyn, felly awn ni'n syth i mewn i gwestiynu, yn ôl traddodiad ar y pwyllgor yma. Ac felly, i agor, mae Rhun ap Iorwerth. Rhun.

So, welcome back, everyone, to this second session of the morning of the Health, Social Care and Sport Committee, here via videoconference, due to the COVID restrictions. We've reached item 3 on the agenda now, and the continuation of our inquiry into the impacts of the COVID-19 pandemic. We've reached the evidence session with the Royal College of Psychiatrists Wales and the British Psychological Society. And to that end, I'm very pleased to welcome—I almost said 'to the table', but welcome to our screens, rather—Dr Jenny Nam, chair of the division of counselling psychology in Wales at the British Psychological Society—welcome to you—and also to Dr Clementine Maddock, vice-chair of the Royal College of Psychiatrists Wales. A very warm welcome to both of you. Thank you for all of the evidence that you've submitted ahead of time. As time is slightly tight, we have a long list of questions to ask, so we'll go straight into those questions, as is customary for this committee. And to begin, we have Rhun ap Iorwerth. Rhun.

Bore da i chi, a chroeso atom ni. Allaf i ofyn ychydig o gwestiynau cyffredinol yn gyntaf? Sut fyddech chi yn asesu, erbyn hyn, yr impact mae'r pandemig, a'r cyfyngiadau sydd yn cael eu cyflwyno yn sgil y pandemig, yn eu cael ar bobl? Pwy sydd am fynd yn gyntaf?

Good morning to you, and welcome to the meeting. A few general questions first of all. How would you assess the impact that the pandemic, and the restrictions that have been put in place as a result of the pandemic, have had on people? Who wants to start?

Diolch yn fawr iawn am y cyfle i siarad â chi heddiw, ond mae'n well i fi siarad yn Saesneg achos dwi ddim yn rhugl yn y Gymraeg eto—gobeithio yn y dyfodol.

Thank you very much for the opportunity to speak to you today, but it's best that I contribute in English because I'm not fluent in Welsh yet—hopefully in future.

I think the main impact is yet to come, in many respects. I think what we have created is a perfect storm of mental illness. We know that there are three very, very well-known risk factors for both depression and suicide, and, unfortunately, COVID, and the restrictions that have been associated with them, and the outcome of those, have increased those risk factors. So, I think the three main areas that are both risk factors and factors that, potentially, the Welsh Government has the ability to mitigate in the future, are social isolation, economic hardship and untreated physical illness. We know very well from a lot of evidence-based research that social isolation is a massive risk factor for depression and suicide. Colleagues have reported to me that they've been seeing an increase in suicide attempts and self-harm, both in young people and older adults. I'm aware from colleagues working in a general hospital that one particularly distressing situation was an elderly lady who'd been on her own in lockdown for a couple of months, and she'd set fire to herself. So, the side-effects of the pandemic are really quite horrific.

The other area in which I've been informed that people have really been suffering is those with alcohol dependence issues. So, they're not having the support that they would have done—of course, things like Alcoholics Anonymous meetings, which we know can be a really, really important factor, aren't happening, or people aren't having the support that they need from their family and friends. And I think particularly in Wales—. So, from my work on the Mental Health Act 1983 review, which covered both England and Wales, what's really striking—and having worked both in London and back home in Wales—is that the family network in Wales is so strong, and, even if people don't have a family, they have neighbours or friends they can call on. And I call this the Christmas dinner test; when I was working in the community in Gorseinon, every single person had somewhere to go for Christmas Day. And I think that's reflected in the fact that, in Wales, we have a very, very low rate of admissions to hospital under section of the Mental Health Act 1983—figures are between 15 per cent and 20 per cent. Whereas, in England, it's between 50 per cent and 60 per cent. And the one factor I've noticed quite considerably is the impact of having social support—people who are able to go with you to hospital at 3 a.m. in the morning if you're in a crisis.

So, I think social isolation and minimising the effects of the restrictions to reduce social isolation is really one very, very key factor where we can perhaps balance the risks of the virus, which is horrific. My hospital went through an outbreak. We had some very, very severely unwell people—and a massive thanks to the intensive treatment unit at the University Hospital of Wales, who, basically, did incredible work. So, those are the three areas that I think are potential mitigating factors for the future.

11:05

Diolch yn fawr iawn am hynna—ateb cynhwysfawr iawn, iawn. Byddaf eisiau pigo i fyny ar ambell i elfen ohono fo, ond, Dr Nam, o ran eich argraffiadau cyffredinol chithau.

Thank you very much for that—it was a very comprehensive response. I will want to pick up on some aspects of it, but, Dr Nam, in terms of your general impressions of the impact of COVID.

Yes, I think, naturally, we've seen that COVID has impacted everyone—every single person—one way or another. And then you've got—. On the one hand, you've got—. Some people who had experienced mental health difficulties prior to lockdown actually saw a decrease in their distress when the first lockdown happened. There was almost a sense of, 'I'm not alone; everyone is in a similar situation to us—everyone is finding things difficult.' So, initially, lockdown for them—actually, we saw a decline in people accessing mental health services. So, the people who were already on the caseloads within mental health services, it kind of dipped. And I guess it's also because there was also that connection—you know, not so alone, but also there was that decrease, I guess, in the social expectations of people. Certainly, children, I think, saw a decrease in their mental health issues, because they weren't then exposed to school and all of those worries.

But then you've also got, on the other hand, those other cohorts of people who struggled in that lockdown because their whole lives then just reduced dramatically. So, certainly for carers—a reduction in their respite services—and people who were trapped in abusive relationships or abusive situations.

So, yes, the initial lockdown, there was this spectrum, then. But then also, as lockdown eased, it almost—that turned it on its head, so the people who initially felt quite comforted then started seeing an increase in their anxieties of, 'What should we do? What shouldn't we do? What can I do? What can't I do?' and that uncertainty then started increasing for them. Then, on the other hand, you've got that people who were very isolated and lonely then had access to the things that they previously hadn't got access to. 

But then we've got to think about the people who were shielding and I guess the huge impact on those people. So, again, maybe initially for those people, they felt protected and safe in being told to shield and having those restrictions, then, as lockdown eased, seeing how other people were able to increase their support network and they were very limited.

Psychologically, the effect of COVID is massive. There are a range of emotions going around relating to COVID itself, with people concerned about catching it, passing it on to loved ones and things like that. And then we talk about, I guess, the overarching issues on the wider world, on work and healthcare, and all of those things are going to start impacting people's well-being. 

I guess early on in the pandemic there was much anxiety about catching and passing it on. So, it was felt that there was insufficient and poor guidance at the start around the use of personal protective equipment, and obviously we've commonly heard about what can be categorised as 'moral injury', I guess, where we feel that we're not able to provide the level of care and support that we would normally do because of the restrictions of PPE—naturally, it's needed, but it also impacts, I guess, the service that we're able to offer. I guess—

Is there a danger—? You've referred there to the range of emotions that every single one of us felt, anxieties that you would perhaps expect to arise at a time like this, although we couldn't have envisaged it. Is there a danger that for a cohort, not for ones with serious mental health issues—? Is there a danger that for a cohort—a significant cohort—there's an overmedicalising of what is just a general human response?

11:10

Yes. Yes, indeed. I guess one thing that we in psychology are really keen to ensure is—yes, these range of emotions—to not overmedicalise and pathologise that. We are human beings. We are going to experience this range of emotions, which are normal emotions to an abnormal situation. That's what we've got to remember: the situation is abnormal, not our reactions to it. So, yes, it is about ensuring that we don't overmedicalise that, but, at the same time, we also want to ensure that by doing that it's not leaving people feeling, 'But, I'm struggling' and not getting the sense of, 'Well, it's normal, so I should be able to cope with it'. It's still being able to access services to say, 'Actually, yes, you are struggling, that's normal to struggle, but there are also services there to help you to find different ways of coping with that'.

So perhaps there needs to be a new tier of help available for that kind of level of anxiety and uncertainty, but that has to, of course, run alongside what would be more traditional mental health treatments. Does that make sense? Are we, in any way, developing that kind of new response? Dr Maddock.  

I think that it is very important to distinguish between normal anxiety, which will abate and get better, and some serious and enduring mental health problems. So, I would advise, based on the fact that we have so many risk factors now for severe and enduring mental health problems, that we shouldn't overmedicalise normal anxiety, but that we do have the resources in place for the increased risk of more severe and enduring mental health problems, which we know we have now got the risk factors for, and this is where I think psychiatry obviously can take a lead. We have a Choose Psychiatry campaign at the Royal College of Psychiatrists, which is aiming to recruit more medical students into psychiatry. Because we have had a historical lack of people going into psychiatry, and I think that is also related to the lack of parity of esteem between mental and physical health problems. So, while you've seen a massive increase in the number of consultants in all the physical health sectors, there's been a tiny increase in the consultant vacancies in mental health. I think what we're really worried about, as psychiatrists and as a college, is that we know, in Wales, it can be incredibly difficult to recruit already to many mental health posts, and I think we are going to get an increase in severely unwell people. So, psychiatry, as a secondary care sector, deals with severe and enduring mental illness—the most severely unwell people. We can expect an increase, but we already have overstretched services, so I think it would be really important for the Welsh Government to support increased posts for severe and enduring mental illness, and that runs alongside our college's Choose Psychiatry campaign. 

You've both given a pretty solid qualitative analysis of what's going on. Are we able to quantify yet the extent to which these problems are taking hold? Do we have the kind of data that we need about the extent of the problems that we face, including—and this is something I raised in the Senedd yesterday with the First Minister—suicide, for example, where anecdotal evidence seems pretty strong that there's something going on, but we have other studies that suggest, maybe quantitatively, that doesn't add up?  

There's a massive lag in suicide reporting, because it can take between one year and two years—. Generally, it will be about two years, often one to two years later, before a suicide or a suspected suicide gets to the coroner's court and is reported as a suicide. Then, nationally, there is the national inquiry into death by suicide and homicide by people with mental illness, and I would get those reports about two years later, once it had got to the coroner. So, I think that there will be a lag. Probably some of the best evidence we have so far is from the Centre for Mental Health, which looked at figures for England. They did an analysis that was published last week, and they suggest that almost 20 per cent of the population in England would require either new or additional mental health support as a direct consequence of the crisis. And in England—bearing in mind England has a much larger population—about 1.5 million of those will be under 18. So, they did a quantitative analysis. But I really have to say that these are forecasts at the moment, and the numbers are a bit of a lag.

11:15

Do we need, then—given that, perhaps, there's something urgently going on—to be able to gather and turn around data in a quicker and more usable way, even if it's only to raise the level of the alarm?

I think so. Just on a very basic level, it would be really helpful to see numbers of patients presenting with self-harm at accident and emergency. The problem is that you haven't got the pre-COVID levels, so it could be horrific numbers. If we start collecting them now, that's great, but we won't be able to know, necessarily, if there's an increase. But it would tell us the extent of the problem. Because many, particularly young people, who come to A&E with deliberate self-harm—they may never get secondary mental health services. They will be managed by their GP. But we do know that a cohort of those young people—many will recover with no further intervention, but there will be a cohort who will go on to have recurring self-harm or long-term mental illness.   

I don't have any data to hand, but I think you're right in terms of that being an essential guide to finding out what services are needed. The services pre COVID were already overstretched, so we know that, as lockdown happened, they actually reduced in size. A lot of psychology colleagues were being redeployed and leaving just a core cohort to deal with urgent mental health cases. So, of course, there's a backlog of that happening, and then we know that we're very likely to get an increased surge of new referrals. As Dr Maddock was saying, there's a bit of a lull, there's going to be bit of a—I can't think of the word, sorry.

Yes. So, I guess, in terms of the Government wanting to set ourselves up to be able to deal with that before that happens—that's going to be hugely beneficial.

Okay. Thank you. Chair, I'll leave it there for now. Diolch yn fawr iawn.

Diolch yn fawr, Rhun. Symud ymlaen nawr i David Rees.

Thank you very much, Rhun. Moving on to David Rees.

Diolch, Gadeirydd. Good morning. You've been talking about the serious impact on people and the challenges they're facing with depression, anxiety and suicidal thoughts. Have you noticed any disproportionate approaches in the way in which society is working? Is one sector more disproportionately affected than another sector, or are you seeing more of a spread across all sectors of society? Dr Nam.

I work in older adult services at the minute, and older adult services, again, prior to COVID, were disproportionately—the referrals of older adults into mental health services were disproportionate to the population. So, there was already, again, a lag in terms of older people, without dementia, accessing psychological therapies. Again, knowing that these are a cohort of people that are at high risk of COVID, it's going to probably increase their resistance to wanting to access psychological therapies. So, I think they're certainly a cohort of people that need to be looked at in terms of accessing mental health services. 

I absolutely agree with Dr Nam that older adults can, particularly, be more severely affected, especially as we have moved towards virtual consultations. So, many older adults are very au fait with the internet, but there is a risk that many, especially older adults who are dealing with memory problems and perhaps have difficulty in new learning, will be disadvantaged because of the lack of ability to use virtual consultations. I think there is a risk as we move towards virtual consultations that people who do not have access to the internet, or, for example, people who have pay-as-you-go devices—the point was made that it can cost £5 or £10 for a video consultation, even for a few minutes. So, there's particularly a digital disadvantage.

As we've moved towards digital, certain groups of mental health patients are also disadvantaged in that they do not have a safe space to undergo the video consultation. So, the Royal College of Psychiatrists had a really interesting presentation, which had patient and carer groups represented, and feedback from some of the patient groups was that one person was in an abusive relationship so couldn't have her psychology session at home, so she was having to go to drive in her car to a car park and do this thing on her mobile device. Another person was within the family home—a young person—and their family weren't fully aware of their mental health problems, because obviously these are very, very difficult issues, and they didn't have a private space to undergo that assessment. So, I think, while there's been—I have to say, I think, in Wales, we've really taken a lead in virtual assessments, they have many, many advantages for many people, but there is that risk. 

I think the other group, potentially—particularly within mental health and our medical workforce—is the black and minority ethnic groups. We have a large number of BAME doctors and healthcare staff who have been disproportionately affected in terms of morbidity and mortality from COVID, and particularly within the psychiatric workforce. So, we have to look after the people who are then helping others as well. I think that's a really important consideration.

11:20

I'll come back to that in a moment. You've identified one thing, which is that the digital divide, in a sense, and the digitalisation of the way in which you are now undertaking some of your consultations, is causing difficulty for people to be able to find that safe space in which they can have those discreet and private conversations with people. I understand that, but are you seeing—? So, physically, we're seeing disproportionate elements of our society. Are you seeing disproportionate elements of society—? Taking away the digitalisation out of it—maybe those in poverty or maybe, as you say, BAME communities, but not just in the health service, or maybe in particular younger people who may not also have that access to it. Are there sections of society that you think, actually, disregarding the digital side of it, are disproportionately being affected by COVID-19 and the increase in need for help with mental health support?

If I may respond, I think I understand what you're asking, but I think our group of patients, mental health patients, over a third—37 per cent—have a co-existing physical health problem, so they are at much higher risk of severe complications from COVID. So, our patients, as a group, are at higher risk of mortality and morbidity from COVID, but I think, in a way, in terms of sections of society, the issue is that we're now creating sections of society who will be at greater risk of mental health problems because of the consequences of the lockdown. And I fully understand how difficult these decisions are, because one is balancing the right to life and trying to minimise the effect of this devastating virus, but we also have so many side-effects in terms of the response to COVID, which will have very long-lasting effects. So, I think we're yet to see the effects on young people whose education has been disrupted, young people in university, young people away from home for the first time who haven't had that same university experience. But as I said, we have created a perfect storm of future mental health problems.

Another cohort of people who have been disproportionately affected are deaf people and those who are hard of hearing. In terms of accessing any services, face masks are being worn and so the fact that people who are hard of hearing are not able to lip read—these cohorts of people generally are already quite vulnerable in terms of going around in society because of their communication difficulties. And obviously, those people can have an increased risk of other physical health difficulties, so I think some people, again, are more anxious about leaving their homes to access services because of this communication difficulty, and I guess that's where it would be really helpful for an increase, I guess, in access to interpreters, and also maybe looking into wearing transparent masks. I think that would go a long way in helping people in being able to access and increase the communication abilities of services and patients to services.

11:25

And obviously, the introduction of local restrictions in certain areas across Wales has now put back into people's minds some of the challenges that you already mentioned—loneliness, isolation—even though we have now the opportunity of single people being able to actually extend their households. But we also have a situation now where we have a large influx of young people into universities, as a consequence of moving out of their homes and into university, into areas that may well be under local restrictions. Do you see that as a serious possible challenge and something we need to be aware of in the months ahead?

Yes. I think, again, there is the potential as young people are going away from home for their first time. One of the things that keeps you going in those first few months is going back home for Sunday dinner after a few weeks away, and taking away that social support from young people is going to be a risk factor for their mental health. We know that for many young people, the first time they'll present with major mental illness is in those first few years, between about the ages of 18 and 21, when they first go away from home. So any support structures that are taken away—the ability to go out and socialise and meet new people—it's making it very, very difficult for young people.

And I think, just going back to the effects of social support, within my hospital we had a very severe outbreak—it was really horrific—but one of the factors that was most heartbreaking was that some of the young—particularly the young support workers—were in tears because they couldn't see their mum or they couldn't see their boyfriend, and they'd normally go out and have a chat with them and have a hug, and all those sorts of things do make a big difference. So, I do think we need to think about how we can safely reduce the risk of transmission, but also allow those really important social contacts to happen. And I know that's a horribly difficult balancing act.

No, I agree with Dr Maddock. Going to university, as you say, is possibly the first time that these people are leaving home and taking that first step into independence, and so they're already in an unfamiliar environment and situation, and having to deal then with this global difficulty and then being, as you say, isolated from their family and close ones is going to add a huge amount of pressure onto them. But, yes, similarly, in terms of them needing that support, and it's kind of finding that balance for them.

A last question from me, for the moment. Dr Maddock, you've already mentioned the staff and the implications for staff, particularly the BAME element of the workforce. What type of support do you think we should put into place to ensure that we can provide the right support for staff—all members of the NHS and the care sector, but we particularly recognise that the BAME communities are disproportionately affected?

This is really from my personal experience of having, in April, been through a hospital that had a COVID outbreak, and the response. I think it's really practical stuff, so it's about giving some clear guidance on what working practices would be acceptable in order to reduce risk. Because we can do risk assessments, but if there are certain working practices that expect face-to-face contact, then that is where the risks are increasing, and what's been interesting is the way that different hospitals have adapted their workforce in response to COVID. So, some have been much more flexible about being able to work from home, work remotely—for patients to be seen remotely. So, even if they're in the same hospital, having maybe a video link to another room, which, obviously, reduces the risk. Because I think what happened in our hospital is that you can isolate patients and cohort patients to wards, but you have staff moving between those wards and acting as a vector of transmission.

I currently work in a forensic service, so all my patients are detained under the Mental Health Act and are subject to some restrictive practices, which require face-to-face reviews. So, as a very simple example, if a patient is secluded from the ward because of their risk to others, they require a face-to-face review every 24 hours, which, for many services, will mean a doctor coming in, who is not on site, to come and speak to the patient face to face. But, actually, they are then increasing their risk of infection or transmitting infection. Could we have—? I realise this is a very small point, but it's a significant point, which I think will help to ensure the workforce feels supported. Are we able to say, 'Actually, we can do a telephone or video consultation'? Because the outcome—I don't think that would be any less problematic.

So, I think, really clear guidelines on when staff can work from home, what is necessary, because there is a lot of margin of managerial discretion at the moment. I think that would be really helpful to support staff, particularly those from BAME groups who we know are at higher risk, to continue their job but not have that face-to-face contact where they are being put at higher risk, and that's for all elements of the health and social care sector.  But, on that point, if I may make a request: within Wales, Mental Health Act assessments have been completed remotely via video link, which has worked very successfully, but it would be really helpful to have some guidance from the Welsh Government as to the legality of that and practical guidance on that, because that, as I said, has worked really well and meant that we haven't needed to request that emergency Mental Health Act legislation be put in place.

11:30

I guess I'm coming from a different kind of point of view, thinking about the psychological well-being of our workforce, and I think that needs real, careful and important consideration. I mean, there is a huge theme of how tired people are. There's obviously an increased workload, there's staff shortages, there's staff dealing with trauma in the workplace, people are burnt out, they're going off sick due to stress and other mental health difficulties. And, you know, I guess they're not—with that tiredness, there's no perceived view of any cavalry around the corner. There are huge staff shortages. There seems to be more funding that has been developed in other nations for the psychology workforce compared to Wales, and, obviously, that's going to disadvantage our workforce because there's going to be a risk of our staff leaving to cross the border where they're, perhaps, perceiving there being more support.

Is there more support in England then than you've seen in Wales? 

They have developed—. NHS England have invested in nine well-being hubs across England led by consultant clinical psychologists, so I guess it's about the Welsh Government looking at trying to bring something like that into the Welsh workforce. And I think that a huge injection needs to be put in to staff and well-being services—psychology-led staff and well-being services—to maintain the mental health and well-being of our staff force. Otherwise, if that keeps getting left where the staff force is just going to leave, services are going to suffer and it's just going to be this huge ball of disruption.

I think you introduced a really important point there, Jenny, in respect of the state of the workforce and the ability of the workforce to rise to the challenge, which I'm sure they are capable of doing, but, obviously, it's been through a traumatic time itself, not just the patients and the citizens of Wales, but the workforce that provides all these services. In our report, how much emphasis do you think we should be placing on the current state of play—and I'll put that question to both of you—of the well-being of the workforce and its sustainability in the short to medium term to continue to function?

11:35

Sorry, I'm trying to remember how much, I guess, as you say, the plan—. I saw it within the plan in terms of mental health services, in terms of injecting more funding in terms of preventative measures for mental health services, and there was some talk about—. The workforce were—. I haven't—and apologies if I've just not seen that, but I guess whether there still needs to be a huge—. I mean, the workforce were already—. The demands already outstretched the supply in mental health services, again prior to COVID. COVID has just increased that and we're going to see that increasing as time goes on. Also, with winter coming about, there's added—there were already those extra demands that were going to be placed on services. We're just seeing a very, very tired workforce and, yes, that really needs to be looked into to help maintain that.

I absolutely agree with what Dr Nam says. We had that initial really difficult period, and I think I felt it calmed down a little bit over the summer, but we're seeing the re-emergence of it again. And I think, as a workforce, you're just anxious about what will happen next and how it will affect your ability to care for your patients. That is the thing that drives us every day. You want to do your best for your patients, and when you know that you can't do that, that in itself is a stressor. 

Much of the proactive approach is how can you reduce that stress. And I think one of the ways of reducing that stress is to make the jobs as doable as possible. So, I think this is where investment in staff, in terms of increasing the staff where possible, is important. Because actually, even in a very, very busy department, if you have enough staff to meet the need, your stress levels will go down. People are stressed when their demands increase their ability to supply the needs for those demands. So, I would focus on making the jobs as doable as possible, making adaptations in this really difficult environment, so that people can do their jobs as well as possible, not to expect people to do the jobs they've always been doing in the same way. Why can't we have some video assessments if that will keep people safer, and perhaps some guidance around that?

But I think looking after our workforce is really key, and I would heartily recommend that that is a major focus. Especially as well because it's a major employer in Wales, so a lot of the citizens of Wales are members of the healthcare workforce and social care.

Can I just add one question onto that? Perhaps Dr Nam might be able to answer it more. We all appreciate the pressures that the workforce has and we all recognise the importance of ensuring that we look after their well-being, but very often the workforce will face those traumas in their work environment and go home to what would be a normal situation. They get normality when they go home. Have you seen an impact of that normality disappearing? Initially in the lockdown, clearly, that normality definitely disappeared. But, we are in local restrictions. What impact is that having on the workforce when they go home, so they don't have that normality to get away from their workplace trauma, in that sense?

Yes, I guess, you know, it's—. Yes, I guess the front-line workers, as you say, not only when they go to work they're having that stress of having to deal with all these different restrictions and the fears and the worries, and then going home and also having to deal with their other family commitments, and then the financial difficulties or whatever of other family members. I guess you've got certainly front-line staff members who perhaps isolated themselves from their families in order to protect them if they had vulnerable people at home. So, there's that cohort of people that have had to move away from what their normality is, so where they would have perhaps got a little bit of a balance. But, I think that's still a long way off. I guess it doesn't balance it nicely; it's still way off. Even if there are some people who do have that bit of normality at home, it's still way off balancing that abnormality in work.

So, it actually adds more stress and more anxiety onto those workforce members.

11:40

Ocê. Diolch yn fawr, David. Amser i symud ymlaen. Mae'r cwestiynau nesaf o dan ofal Lynne Neagle. Lynne.

Okay. Thank you very much, David. Time to move on. The next set of questions come from Lynne Neagle. Lynne.

Thank you, Chair. We've touched on access to services already. Welsh Government has told us that they asked all health boards to make sure that continued delivery of mental health services should be a priority throughout the pandemic. Is that your experience of what's happened across the spectrum of services, from primary mental health services to secondary services?

No, sadly not. I think, in reality, how can that happen when people are being told to stay at home and not go out, and we have to make our workplaces COVID secure? So, for example, in the community mental health team that I used to work in, I'm aware that the office, which would've had about 16 people in it, can only have three people now. So, people aren't based on site; people can't just drop into the community mental health team and see their psychiatric nurse, because their psychiatric nurse will be working offsite or working from home. So, the reality is—and this is not just in mental health, but physical health. So, for example, I was speaking to another colleague who wanted to see a patient, but there was no room that could be booked in to see this patient, because they already had too many patients booked in on that day for her to see them. So, I think the real problem has been physical space. In order to comply with social distancing, you'd need to make your offices 10 or 20 times bigger. So, with the best will in the world, telephone consultations have been taking place, video consultations have been taking place and they're really helpful and they allow the service to continue, but it's in no way a substitute for face-to-face contact. But the reality is— 

Can I just interject there? Can you fill in the gaps for the committee in terms of what people are missing out on by only having that telephone contact? Is it just people checking in or is there actual therapeutic intervention taking place on the telephone or on Skype or whatever?

It's a good substitute, but it's not the same as being in a room with somebody—particularly telephone. I think video consultation is really helpful because you can see the body language, you can see the facial expression, but so much of psychiatry and mental health is what's not said; it's body language, it's a person's ability to engage, it's their facial expression, their self-care. You know, so much is in the non-visual, the non-verbal signs—has this person been looking after themselves? Those are really important factors in terms of the assessment, which you do not get on telephone.

I think the other thing is that people can put on maybe a telephone voice or a happy voice, but actually, when you see them and you see their face or you see that they're perhaps dishevelled or that they've lost weight—those are all the other signs. I think the other problem with telephone consultations or video consultations is that you don't know what's going on in the background. So, again, it's about that safe space to do an assessment. So, I think those are the areas that are missing.

If I can come in and just answer your initial question about services and whether they continued. I think it did vary across each tiered service. And as I said before, I guess, the Government had said that mental health services were still seen as an essential part, but there was also a lot of talk about staff members being redeployed and, as you say, kind of leaving, still, core staff members, but a skeleton, I guess, to deal with the urgent cases. So, some of the less urgent ones were—they weren't left; certainly in my service, they weren't left, they were contacted regularly and had checking-in services. But, I guess, on psychology intervention, as we're talking about, yes, like I said earlier, there is no substitute to being in a room with someone and not having those restrictions of the PPE. Obviously we understand that that is certainly necessary, and, certainly, in my service, with older adults, we're aware that the people who are using and accessing the service are at high risk, so we've really got to take into consideration the risk levels of seeing them versus not seeing them. And, as Dr Maddock said, one of the biggest barriers is actually rooms. You know, if we actually had the ability of having rooms that were large enough, where we could socially distance, well ventilated, then we probably would be able to at least have service pretty much as normal. But, obviously, services are trying to do their best in doing alternatives such as the video for the people who are able to do that, and telephone, but, as you say, it falls far short of what we would normally be able to offer if COVID wasn't around.

11:45

You mentioned redeployment, and the children's committee were told that people like child psychologists had been redeployed, which we were very concerned about. How widespread was that redeployment of mental health staff, and how appropriate do you think that is, to take away psychologists and psychiatrists to deal with a physical health situation?

I guess it's difficult, because when the lockdown first happened, no-one really knew—I guess we were expecting such a surge of need that it was kind of balancing the needs of the service and expecting this overwhelm, and, actually, it didn't happen. So, yes, I guess it's difficult. I think, obviously, the mental health and the psychological well-being of people is very important, because we need that in order to continue to function, and to take that away to meet, as you say, the physical needs is possibly not the most helpful thing to have done. I think we can certainly learn from the first lockdown, and if we then find ourselves in a second lockdown—that actually that isn't going to happen, or we would hope that that wouldn't happen again, and to say, actually, yes, the psychological needs of people are just as important and to keep those staff where they are in those services.

Okay. Can I ask about data and transparency, then? Because Welsh Government set up a mental health COVID monitoring group. Do you know anything about the data arising from that group? Were your teams asked to provide data for that group to demonstrate that you were continuing to provide services?

I'm not aware of that, but I will go and take a look at that and feed back to you.

I'm not aware of that either. But going back to your previous question, I'm not aware that consultant psychiatrists were redeployed to COVID wards, but what happens is that mental health units became COVID wards. So, I'm a psychiatrist, I've been a psychiatrist for over 20 years. It's a long time since I treated infectious diseases, but, suddenly, I was going around managing infectious diseases, checking oxygen levels. I think what we haven't perhaps recognised is that, particularly for in-patients in psychiatry, psychiatrists suddenly became infectious diseases doctors. They were managing the so-called milder cases, but bearing in mind that many of those milder cases became very severe cases very quickly. So, it was a slightly different form of redeployment.

Okay. And finally from me, then, Welsh Government has said that it wants to retain a lot of this virtual working. I've been quite concerned about that in terms of mental health, and you've raised some concerns today. Are there any aspects of what we've developed to deal with COVID that you think are good and should be retained? And what do you think we should be worried about?

I think for me, actually, for psychology, the use of remote and digital platforms has been very helpful. It has plugged a certain need there, and, actually, we'd be keen to continue with that. And there's that blended workforce, again, thinking about staff well-being, as it's increased, I guess, the workforce to be able to do some work from home as well as in an office base. But, also, in terms of delivering services, it's been helpful there. I mean, naturally, as we've already spoken about, we do have to be aware of those people who are digitally poor and don't have access to that. But I certainly see a place for it to be integrated into what we were using previously. Sorry, I've forgotten the second part of your question, so Dr Maddock, if you want to come in there.

11:50

I agree with Dr Nam; I think a blended way forward is appropriate. So, I've mentioned, perhaps, some of the difficulties, but also there are a lot of positives to this. So, for example, so many patients, when I was working in the community, couldn't come to appointments because they suffered from phobias and anxiety, so you take that problem away. For some young people, actually, they prefer to have video consultations, and I think the Welsh Government has led the way on virtual consultations, bearing in mind that in many parts of Wales, the distances between locations, particularly in Powys and west Wales, are vast. So, actually, if you're reducing travel time, you're potentially increasing access to services.

And here I have to give a shout out to the CWTCH Cymru project, which was a pilot project in child and adolescent mental health services, and the technology-enabled care Cymru project, which was a project that was rolled out prior to COVID and led by Professor Alka Ahuja on secondment to the Welsh Government. So, I think, actually, the Welsh Government has been at the forefront of using virtual technologies, even prior to COVID. I see this as something that should be part of patient choice in the future.

Diolch yn fawr. Yn olaf mae'r cwestiynau sydd o dan ofal Andrew R.T. Davies. Andrew.

Thank you very much. The final section of questions comes from Andrew R.T. Davies. Andrew.

Hello and thank you both for your evidence so far. The joy of having the last set of questions is that sometimes some of the territory's been covered, so please feel free not to comment if you feel you've already covered it in the evidence you've given us. Both sets of witnesses have touched on the backlog that was existing in dealing with cases in mental health prior to COVID, and we know, obviously, with the closure of some services during the crisis, that waiting times and that referral into services are greatly increased. Would you subscribe to that fact that waiting times now are far more severe than they were prior to the COVID crisis, and in particular around the support for people who have experienced bereavement? I'm quite keen to explore this area, because, quite rightly, a lot of attention has been focused on those who've lost relatives through COVID itself, but, obviously, the normal bereavement process that people would be able to undertake in, say, a hospital setting or home setting, where relatives would come and have those final moments, is no longer able to be facilitated. For some people, that's a massive burden for them to carry that does have massive mental health implications further on in their lives. So, I'd like to understand, on those two points, have you any views you'd like to submit to the committee so we could include them in our report?

I think that's a really important point about bereavement, because, as with so many other elements of our society that we took for granted, the natural grieving process, the social support of the funeral, people coming together, people breaking bread together, people giving comfort and support—that's been taken away. I think that is something that we will probably see the consequences of in the future. We're still at a relatively early stage, but I think that is an area where potentially—. Normal grief reactions would not come to the attention of mental health services, but if the normal bereavement reaction is in some way disrupted, which it has been here, there is the potential that there is an abnormal grief reaction that can go on into depression, anxiety and other mental illnesses. So, that is certainly something that is a risk factor for the future.

On the second point about waiting lists, I don't have actual data about waiting lists, but given the fact that services have been necessarily disrupted, there has been a reduction, from what we know from our own surveys, in regular appointments, and overall, probably an increase in some emergency appointments, particularly in general adult and liaison psychiatry settings. Because of that reduction in regular appointments, we have a cohort of patients who have had stable mental illness who are starting to become unwell because they haven't had that support. Secondly, we are, I think, likely to see an increase in referrals to services because of all the factors we've spoken about that have increased the risk of mental illness, particularly social isolation, economic hardship and untreated physical illnesses.

11:55

In terms of bereavement, as you say, we're seeing—. Many people are going to be experiencing a huge amount of loss. There's a huge amount of complexity, I guess, in the loss that people have experienced, as we've talked about, in terms of not being able to see loved ones prior to them dying, whilst they're severely ill in hospital or in the care home. Again, I guess it's thinking about being careful in terms of, again, pathologising that, of any abnormality. I guess there's definitely going to be a different complexity in terms of these bereavements as opposed to, perhaps, bereavements where people were able to be with their loved ones, or be comforted and things like that. So, I'm not entirely sure in terms of the voluntary sector and the bereavement services there, and how well equipped and how much more equipped they are in terms of knowing that there'll be perhaps more need for their services. But, shall we say, it is likely that, I guess, perhaps if they're not available to help support those people with their grief reactions, they may end up then being left deteriorating so that they then do need more of the mental health services of Part 1 and Part 2 of the Measure.

In terms of waiting lists, certainly in my service we're aware that our waiting lists are increasing. Our ability to meet the waiting list within a reasonable time is breached, and will continue to breach as the demands on the service increase, and, yes, if the workforce doesn't help, there's no funding there to help the workforce, to increase the workforce, to meet that need—.

The real concern as well here is obviously those who maybe are struggling on, almost trying to shake off the issue. This morning, for example, I went up to fill my water bottle in the tea point and there's a notice up there, 'It's good to talk, and if you see someone's who's struggling a bit, put your arm round them'—[Inaudible.]—I subscribe entirely to that message. But, very often, that's the start of a process of assistance, and, given COVID has closed many of the basic as well as the acute services down, or the routes into those services, the ability to support those individuals who are soldiering on at the moment is a real concern. Have you experienced much of the inability of people to access services that you could give us examples of that maybe would help us in our report? Because, obviously, understanding that first point of entry into the service, and being able to access it in as simple a way as possible, is most probably the best way the policy makers can act here, because that way then you capture people at the very early stage, instead of letting a problem build and they end up ending up in the acute sector. So, have you got any examples—I've put it in a very complex way, but have you got any examples you could give us that would show the closing down of routes into the service?

Perhaps I can't answer the question directly, because I'm not aware of services, particularly mental health services, being shut down, but obviously the access has been restricted. So, the doorway has narrowed, the entry has narrowed. But I think in terms of—. I think it's going back to Mr Rees's question as well about disadvantaged groups, which we had talked about, and there are two groups really. I think carers, because carers' services—many of those are voluntary sector services or services such as day centres, and I don't have data, but I believe that a number of the services that would relieve the pressure on carers have been shut down. We know that carers suffer from chronic stress, and if you take away the support system for carers, you are creating—well (a) you are increasing the risk that those carers will no longer be able to cope, and you will have people they're caring for who will require support in other sectors. So, I think the services that support carers indirectly are ones that are worth looking at.

And the other group that we perhaps haven't mentioned is patients living in group homes, particularly patients with a learning disability who are living in group homes. I'm sorry that this is a slightly indirect answer to your question, but, within group home environments and hospitals such as my own, it's been difficult to arrange visits, because you're trying to balance the risk of bringing this infection into the hospital environment or group home environment. So, for many months, patients or people living in those group homes may not have been able to see their loved ones.

So, I apologise that it's a slightly indirect answer, but I really think those indirect support services are probably the areas, and particularly maybe voluntary sector-run support services are the areas, that will perhaps have the most impact in many ways. 

12:00

That's very helpful, in fact, actually, looking at those support services, especially respite for carers. Of course, without that respite, obviously, that puts a huge mental as well as physical demand on those individuals. And if that stack of cards falls over, there's a whole pile of implications there, then. So, that's very welcome to broaden our horizons, shall we say, in terms of support services. 

I'd like to add to that in terms of carers and respite. As Dr Maddock said, those voluntary sectors, the clubs and those kind of things that have closed down, but also, for those, where they are able to find a respite placement, then, obviously, to get in these places, there needs to be a period of isolation to ensure that no risk is then brought in. And of course those dementia patients, many of them cannot cope with that period of isolation; it's very confusing and very distressing. So, again, it leaves it back, then, falling onto the carer then struggling still to cope but not wanting to put their loved one into that distressing situation so that they can get some respite. 

I guess, coming back to—. You were saying about the stopping of services. I guess access, as we said, has narrowed, and I guess our point as well is about, in terms of helping to reduce distress, making it as community based as possible and opening that out. So, we all need to work with statutory and non-statutory services together to make sure it's a larger, cohesive mental health service family, and it's all about making it more accessible. I was given some data earlier—. Forgive me if I'm wrong, I know there was some data from Mind Cymru that said that there was a proportion of people—adults and young people—who didn't access help due to their feeling that their mental health needs weren't worthy enough. So, again, this is, as you say, the cohort we're talking about. You don't want those to be left to fester and to grow to the point where they're going, 'Okay, now I'm bad enough, now I can access this, x, service.' So, I think, yes, a lot of thought needs to be had in terms of changing communities' viewpoint, really, saying, 'It's okay to not be okay. You're not alone.'

Just when—you were saying about that kitchen thing: connection is the one thing I guess people are missing throughout all of this. I hear many people, the older generation, going, 'Oh, during the war—. At least you've got food, you've got water, you've got your amenities.' Yes, they're right in that sense, but what's missing, what they had then, was that they were able to huddle up, they were able to connect, they were able to touch one another. That's what we don't have now. And social connection and physical connection is a fundamental human need, and, when we're missing that, it snowballs into bigger things.  

Can I just add one final point, if I may? In the last evidence session, we did touch on talking therapies, something that I fully support and actually think is an undervalued asset, to be honest with you, to the health service and should be expanded greatly. One of the issues that has been raised with me is that, if someone does present at a GP, there's no national register for the GP then to signpost—accredited national register, that you know that the GP would have someone to signpost you to, like a counsellor or someone who could help you with talking therapies. Would you support the provision of a national register that would identify those types of services in areas? 

Yes, I guess what we always have to be cautious of are the skills and expertise of these people, and ensuring they are adequate enough. And I guess there are various registers, national registers, around in terms of who is out there, because it sounds like you're talking about more independent practitioners, as opposed to services that are being funded by the national health service or—.

12:05

In an ideal world, the health service would commission them but, regrettably, there's very little commissioning going on, so I certainly think commissioning of those types of services is an area that could be explored. But, in that absence, obviously you do have to look at the independent sector, then, you do. 

Yes, and I think, as you say—. You're right—it is very important to make sure that the public are able to access those people. I guess the public don't know what is an appropriate level of training for people to provide. I guess some of us are very good at making our CVs look very impressive but, actually, behind all of that is a lot of air. So, I think, if something like that were to happen, I guess it's to ensure where the level would be in terms of what's an appropriate level of service for GPs to feel comfortable, I guess, to signpost on to. 

Ocê. Wel, diolch yn fawr. Dyna ddiwedd y sesiwn. Mae'r amser ar ben. A allaf i ddiolch yn fawr iawn i'r ddwy ohonoch chi am ateb y cwestiynau mewn ffordd mor raenus ac aeddfed? Diolch yn fawr. Fe fydd hynna'n ychwanegiad sylweddol at ein tystiolaeth ni gogyfer ein hadroddiad diweddaraf ni. Felly, diolch yn fawr iawn i chi. Mi fyddwch chi yn derbyn trawsgrifiad o'r trafodaethau yma i chi allu gwirio eu bod nhw'n ffeithiol gywir, ond gyda chymaint â hynna o ragymadrodd, diolch yn fawr iawn i chi. Dyna ddiwedd yr eitem yna, ac mi wnawn ni symud ymlaen nawr efo'r eitem nesaf. Diolch yn fawr iawn i chi'ch dwy. Hwyl. 

Well, thank you very much. That brings us to the end of that session. Our time is up. Thank you very much to both of you for answering the questions in such a comprehensive way. Thank you very much for that, and it'll be a valuable contribution to our latest report. So, thank you very much to you. You will receive a transcript of the discussions this morning to check for factual accuracy, but, with those few words, thank you very much to you. That brings us to the end of that evidence session, and we'll move on to the next item. Thank you very much to you both. Goodbye.

Diolch yn fawr. 

Thank you very much. 

4. Papurau i'w nodi
4. Paper(s) to note

Ac i'm cyd-Aelodau, rydym ni'n symud ymlaen i eitem 4 rŵan a'r papur i'w nodi. Mi fyddwch chi wedi darllen y llythyr gan y Gweinidog Iechyd a Gwasanaethau Cymdeithasol ynghylch canolfan ganser Felindre arfaethedig, yr un newydd. Hapus i nodi'r papur yna? Dwi'n gweld bod pawb yn. 

And to my fellow Members, we've moved on to item 4 and a paper to note. You will have read the letter from the Minister for Health and Social Services regarding the proposed new Velindre cancer centre. Are you happy to note that paper? I see that everyone is content. 

5. Cynnig o dan Reol Sefydlog 17.42(ix) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod
5. Motion under Standing Order 17.42(ix) to resolve to exclude the public from the remainder of this meeting

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod yn unol â Rheol Sefydlog 17.42(ix).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting in accordance with Standing Order 17.42(ix).

Cynigiwyd y cynnig.

Motion moved.

Cyrraedd eitem 5 felly, a chynnig o dan Reol Sefydlog 17.42(ix) i benderfynu gwahardd y cyhoedd o weddill y cyfarfod hwn. Ydy pawb yn gytûn? Dwi'n gweld bod pawb yn gytûn, felly dyna ddiwedd y cyfarfod cyhoeddus. Diolch yn fawr iawn i chi. 

We've reached item 5 and a motion under Standing Order 17.42(ix) to resolve to exclude the public from the remainder of this meeting. Is everyone content? I see that you all are content, so that brings us to the end of public meeting. Thank you very much. 

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 12:07.

Motion agreed.

The public part of the meeting ended at 12:07.