Y Pwyllgor Iechyd a Gofal Cymdeithasol

Health and Social Care Committee


Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Gareth Davies MS
Joyce Watson MS
Ken Skates MS Yn dirprwyo ar ran Jack Sargeant
Substitute for Jack Sargeant
Mike Hedges MS
Rhun ap Iorwerth MS
Russell George MS Cadeirydd y Pwyllgor
Committee Chair

Y rhai eraill a oedd yn bresennol

Others in Attendance

Dr Julie Keely Coleg Brenhinol yr Ymarferwyr Cyffredinol Cymru
Royal College of General Practitioners Wales
Lisa Turnbull Coleg Nyrsio Brenhinol
Royal College of Nursing
Professor Euan Hails Coleg Nyrsio Brenhinol Cymru
Royal College of Nursing Wales
Professor Keith Lloyd Coleg Brenhinol y Seiciatryddion
Royal College of Psychiatrists

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Claire Morris Ail Glerc
Second Clerk
Dr Paul Worthington Ymchwilydd
Helen Finlayson Clerc
Lowri Jones Dirprwy Glerc
Deputy Clerk
Philippa Watkins Ymchwilydd
Rhayna Mann Swyddog
Sarah Hatherley Ymchwilydd
Steven Williams Swyddog

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 yn y Senedd a thrwy gynhadledd fideo.

Dechreuodd y cyfarfod am 09:29.

The committee met in the Senedd and by video-conference.

The meeting began at 09:29.

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

Croeso, bawb. Bore da. Welcome to the Health and Social Care Committee this morning. This morning's meeting is a hybrid situation, so we have some witnesses and Members participating virtually and some here on the Senedd estate. As always, Standing Orders remain in place as they normally do. Members are obviously welcome, and witnesses, to speak in either Welsh or English. I move to item 1. Are there any declarations of interest this morning? No. We do have apologies from Jack Sargeant, and Ken Skates will be substituting for him later this morning on our second panel.

2. Anghydraddoldebau iechyd meddwl: sesiwn dystiolaeth gyda'r sector gofal sylfaenol
2. Mental health inequalities: evidence session with the primary care sector

With that, I move to item 2. This is in regard to our mental health inequalities evidence session. This morning we have witnesses from the primary care sector. Good morning, bore da; welcome to you. I'd be grateful if you could introduce yourselves for the public record. Shall I start from my left?


Hi, everyone. I'm Professor Euan Hails. I'm a member of the Royal College of Nursing board Wales and a mental health nurse by background. 

I'm Lisa Turnbull, I'm the policy, parliamentary and public affairs manager for the Royal College of Nursing in Wales.

I'm Julie Keely, I'm a GP in Brecon in mid Wales, and I'm chair of the south-west Wales faculty of the Royal College of General Practitioners.

Thank you for being with us this morning, I appreciate it. We're just making sure that we've got the microphones all working in order. There we are. Thank you. Diolch yn fawr. 

Can I perhaps just ask Dr Keely first of all? Can you perhaps tell us some of the ways in which GPs have contributed to tackling mental health inequalities?

GPs have been willing and able, and flexible, in working with our partners in secondary care. We are very aware already of certain groups who are at higher risk of mental health issues, and also groups who are less likely to be provided with good care. There are certain groups that we have been mindful of for many years, for example people with learning disabilities, those with severe mental health issues. As I'm sure you know, many patients in that group die 15 to 20 years earlier than they should do based on physical symptoms, not only their mental health issues. That's for many reasons. Mental health issues may affect their ability to engage with health screening programmes. Many of them smoke. They're on drugs that can make their physical health a lot worse, for example antipsychotics. Often, they don't attend for monitoring, and it's constantly trying to chase people and keep on top of the job. 

Likewise, with learning disability groups, there is a lot of hidden physical morbidity, and for both of those groups in particular, we focus additional energy on undertaking physical examinations to detect other morbidities in addition to the mental health problems that are already known to us at an earlier stage, where, hopefully, we can make some impact. 

There's also massive inequalities when it comes to people at extremes of age. Scarily, there's a 20 per cent prevalence of mental health problems in young people. Pre-pandemic, they were the stats. I suspect, probably, during the pandemic, and post pandemic, certainly for my patch, we're probably looking at 30 or 40 per cent. That's for many reasons—social isolation, lack of contact with school peers, lack of provision of additional social activities to maintain good mental health. They've all been taken away during the pandemic and are gradually being reintroduced again. But there's a huge need that is currently being unmet. 

Likewise, with other extremes of age, for patients in the over-65 groups, there is a relatively high prevalence of dementia and depression, and the pandemic has really exacerbated that. A lot of people rely on their social network, having contact with other people, just a friendly face, someone to say 'Hello', to know that someone cares about you, and have become quite lonely and depressed consequently. Sadly, that's been the case, and continues, to a greater extent, in that vein. And with the pandemic as it is at the moment, I don't think we're entirely sure where it will all lead. 

There's also, sadly, due to a crisis with mental health staffing, not enough resources to deal with them in secondary care, which we fully appreciate. The services have been under-resourced, understaffed pre-pandemic, and that's just been exacerbated. A lot of people have left due to ill health personally, and particularly well-being issues and mental health problems in those service providers. And that's not just for secondary care; I think that's also happening in primary care. We're seeing lots of people, for example, retiring earlier than they should do, or would liked to have done or planned to do, because they have been adversely affected by the pressures of COVID and how that has impacted on them personally and professionally, and have actually left the health profession, just adding to the current crisis. 

But we try very hard to maintain contact with people and be that first port of call in primary care, and that has remained the case during the pandemic. 

Thank you for setting the scene there. That's helpful. I think Members will want to dive into some of what you said in their questioning. And to colleagues at RCN, you can probably guess my question, but the same to you in terms of how nurses have helped to contribute to tackling mental health inequalities. 


Thank you very much. I think the first thing to say really is to explain that we have mental health nursing—. So, when you graduate and qualify as a nurse, the four fields of practice that you would graduate in are adult, child, mental health, learning disability. So, we do have a section of the workforce that is specifically skilled and educated to respond to mental health issues. We then also have a variety—and my colleague will go on to say a little bit more—of leadership positions after that, people who would specialise in, say, eating disorders or particular types of trauma. We also have particular interventions. We also have consultant nurses—those kinds of levels of practice. Of course, the general nursing population as well—so, if we're talking about different specialities—will intervene in different ways; so, children's nursing, school nursing, health visitors, a nurse working in A&E. So, there are a variety of nurses in different positions and specialities that will have different opportunities to engage with mental health, whether that's around prevention, resilience work, whether it's around mild issues—so, dealing with mild anxiety and mild depression—or whether we're actually talking about the more specialist interventions.

I think one of the areas that we've tried to focus on in our written evidence, and we'd like to highlight today, for inequalities, is the services and workforce for people with severe and enduring mental health issues—that we do feel that that has had a lack of strategic national focus from the Welsh Government in recent years, and that the workforce is not sufficiently planned or developed. So, what you have there is you have a situation where the people in the greatest need are those that are actually unable to access any kind of service, or have to wait a long time. The capital estate itself, if you look at the in-patient estate, is very poor. And that creates a number of vulnerabilities then on particular groups in that. Then, if you look in that small population, so you're looking at particular groups, whether that's people with learning disabilities, whether that's very young people, or whatever you're looking at in that group, then those inequalities are further worsened because those services are just not there or not appropriate for those groups.

So, those are the areas that we do specifically want to draw attention to. We do think that nursing has a huge, huge contribution for that particular group—whether it's efficient nursing to take care of people who need, for whatever reason, short or longer care, in terms of residential facilities, or whether we're talking about nursing in the prison population, or whether we're talking about nursing teams in the community who would do interventions. So, nursing has the solutions to those issues, but there are simply not enough people out there with the right level of skills to provide that care and level up that field. So, I think, as a general introduction, that would be the key point that we would want to be making. I'll just turn to my colleague to see if there's anything they'd like to add.

I think the evidence from both people has covered the area we're looking at. I've been a mental health nurse since 1984, and I'm also a cognitive behavioural psychotherapist and an EMDR psychotherapist. Nurses deliver nursing interventions, but they also deliver psychological therapy-type interventions. I'm also a consultant nurse, so I consult and manage, lead, develop and supervise people. Nursing and nurses across all areas, be it primary or secondary health, have a vital role within the delivery of care to this population. Most of the wards are staffed by nurses, most of the areas like the emergency departments are staffed by nurses, and medics, obviously, as well.

I think nursing has a vital role to deliver and enable the population and ensure that they can actually do what they should be able to do, get the interventions that they should be able to get—medical interventions, psychological interventions and social interventions. Nurses are instrumental with the multidisciplinary team in leading on those sorts of issues and delivering care. Basically, if you get sectioned, one of the first people you're going to see, apart from the sectioning doctor, and maybe the social worker, would be a nurse. It's the nurses who deliver the interventions that make people better, to an extent, with the extended multiprofessional team, and they've got a gamut of skills. You could argue that there's really not enough of them knocking about at the moment, be they mental health nurses or general nurses.

Can I just pick up on a point you mentioned, Lisa, about the workforce? I'm just thinking about what actions and priorities you think need to happen from Government in terms of supporting the workforce, particularly when there are perhaps mental health issues that some of the workforce are facing themselves. What are the priority actions that need to take place to support the staff themselves, particularly thinking in terms of the workforce and retention issues that we have?


Yes, well, okay, a number of things: I think the first thing is about being seen and being valued and recognised. So, that is about planning. That is about having a postgraduate, specifically mental health workforce plan to provide those kinds of career structures and access to continuous professional development, so that people can feel that they’re going into a career and they’re recognised. So, what I would say—. I think that is an important point about value and recognition, and access to CPD is important.

I think other specific points about supporting the workforce that might be helpful and necessary is that we have seen during COVID the use of counselling telephone helplines for staff and they have been extremely well received, and I would suggest that that is a good initiative. I would also suggest, and I think it would be remiss of me not to mention this: if you are going to demonstrate to your staff that you value them and it’s an important career that you want to provide—a service you want to provide to the people of Wales—you do need to pay nurses effectively and reward them for their job. Because if you’re asking people in a situation like this to make decisions about human rights, to make decisions about therapeutic interventions, you’re making decisions that are genuinely lifesaving and life-altering. You’re talking about a high level of decision-making skill, experience and knowledge. And you’re also talking about a very high-challenge environment—high-reward and high-challenge environment. If you want people to go into that as a career and stay in that career, you need to reward them appropriately for the job that they’re doing and the Welsh Government has to recognise that as a significant issue in the years ahead. And that is currently not happening at the moment.

So, we do have a situation where—. I have to say, the Welsh Government has increased the number of mental health commissions for mental health nursing, so we are producing more mental health nursing graduates, which is a good thing and it is something that we should be very pleased about and we do recognise that. But producing them is one thing; keeping people in the profession over the long term, once you’ve invested that public money, you need to actually then educate and keep people in that for the longer term—not just for five years, but for 10 years, 15, 20 years, over their working life. And to get those skills and that population, they need to be rewarded appropriately.

That's a clear message. Did you want to add anything at all in terms of workforce well-being?

From general practice? Yes, I think supporting the care givers is probably a huge priority that we all have to recognise. We’re human too. Okay, we’re trained, we’re professionals, we are taught and supported, to some extent, to monitor situations and manage stress and deal with very high-risk situations, but it is absolutely essential that the workforce aren’t forgotten when it comes to managing their own stress, providing them with support. It’s not just financial rewards; it’s 'Thank you for doing the job' and some recognition of what we do and how we do our best to deliver the services, albeit whatever constraints there are at the time. It’s vital to support all members of the NHS workforce and social care workers, indeed, in my view, but that is a huge, huge issue.

And there are lots of ways that pressure could be taken away from primary care when it comes to supporting patients with mental health problems, for example, to try and reinstate and greatly increase our social prescribing access. That was an absolutely wonderful huge plus. We see so many patients. I did a straw poll of one of my surgeries a couple of weeks ago and 40 per cent of patients in that particular one surgery, which isn’t uncommon, basically required some social support, which wasn’t necessarily medical intervention from myself or my extended team or secondary care; it’s just to have some positive activity to improve their physical health and their well-being and promote good, psychological health as well. And, sadly, there were wonderful seedlings of social support for people pre COVID and, again, they’ve disappeared. So, I think there should be a huge emphasis on redeveloping those accesses for people to have that support, and not just from primary care signposting people, as there are lots of people in the extended team who can do the job. Community pharmacists could take a role in that, for example. They see lots of people coming in wanting Kalms tablets or antihistamines to help their sleeping and can have that conversation with them in a quiet area as well. But I think it will require a lot of joined-up thinking to give people the support for their physical and mental health to take things forward in the future.


Thank you. I know we've got a lot of questions to get through; do you mind if Members interrupt you if we're not quite getting to the nub?

That's fine.

I want to talk about the accessibility of services. We've heard that GP appointment booking systems and triage systems, such as NHS 111, can be very difficult to navigate. I was supposed to say for 'significant numbers of people'; my experience is that they're very difficult to navigate for almost everybody. This can be due to language—. It's more difficult for people who've got a language barrier, and it's also more difficult for some people with neurodivergent conditions, but it's very difficult for all of us. I tend to get three or four complaints about one surgery a week, about being able to get appointments. But how could services be made more accessible to diverse groups of people, who are lower down the list of being able to get through? They're not the ones who do 80 phone calls between 8:00 and 8:20 in order to try and get in. They sometimes will have one go, can't get in, and just give up.

I agree with you that there is a lot of pressure in primary care at the moment. In my practice, for example, we've had a telephone-first model, where patients phone and speak to a GP and a GP will phone them back within an hour or more urgently than that, if it's required based on the clinical scenario that we're faced with. We have systems in place. There are flags on the patients' notes. For example, patients who have learning disabilities or who have chronic or severe mental health problems, patients who have a new diagnosis of cancer, as well, patients who are palliative, there are alerts so that they're automatically diverted straight through to a GP. Patients can use technology, if they so wish, although a lot of my elderly patients are not particularly into that, which is perfectly reasonable. They can contact us via the practice website. They can actually come into the practice and go to the receptionist and say, 'This is my issue, I need to see a member of the team; can you sort me out please?' and the answer is 'yes.' They may have to have a seat for a few minutes, but they will be directed to the appropriate person. Everyone is seen the same day if they need to be seen. It's a negotiation between the GP or the practice nurse or other healthcare professionals in the team and that individual as to how best to manage the problem, whether that be in person or on the phone, or send it on to another service as appropriate.

Thank you very much. That's not necessarily a common experience of most of my constituents who contact me. I won't name the surgery, but I get three or four complaints a week about one surgery, about not being able to see a doctor. People now use the accident and emergency triage system because they can't get in to see a GP. I think what you've outlined is a really brilliant system; can you share it with some of your other colleagues, and perhaps they can do the same thing?

Maybe there's an advantage of not having an A&E and being in a rural practice, because it's beholden to us to manage whatever needs to be managed in our community and to be committed to our patient population and their health needs.

I think what we would add is that there are services that are designed for people to access. So, A&E is a good one and a GP might potentially be another. I think, rather than trying to retrofit that service, you might want to be thinking about, if you're thinking about interventions or reaching out to different groups of people, you might be talking about putting people or different types of practitioners in an entirely different place. So, you might actually be then talking about that kind of community work where people are. So, I'm going to turn to my colleague now, who may have some specific examples of that, but if you're talking about youth work, if you're talking about working with people who've just been released from prison, talking about different populations, you might be talking about actually trying to reach that population in a different way.

Yes, most certainly. I was the first episode psychosis lead for Wales for a number of years, and one thing we attempted to develop was to remove the location of the service away from the traditional mental health delivery, i.e. St Cadoc's, Whitchurch, et cetera, et cetera. There's a service in Australia, in Melbourne, called Orygen, and they've developed shop-front services in big shopping malls and shopping centres and things, really, so you can co-locate services in completely different areas, and then people feel a lot more comfortable to go to them. You can deliver services in gyms, in leisure centres, et cetera, et cetera. So, you need to slightly think outside the box, so instead of going to the traditional mental health area that has some level of stigmatisation to it—and even with young people it still has stigmatisation—you go into a completely different area, staffed by different staff with a different experience and a different skill set, really. So, you're integrating, to an extent, primary care and secondary care, but delivering it in somewhere that's different, like popping into the nice big shopping centres in the middle of Cardiff and you've got a unit there. You can pop in; people don't know what it is. It's completely unstigmatised and you can walk in; it's not a problem. My wife works at Swansea University and volunteers in a dementia hub in the shopping centre in Swansea every Sunday, and people just pop in for a chat and a cup of tea; you know, it's different.


Many years ago—one of the disadvantages of being in a role for this long is you have good memory—we prepared an extensive briefing for the health committee at the time that I could revisit, which was looking at the evidence that emerged from the walk-in centres that were introduced in England back in the sort of 1997-98 period. What emerged from that evidence was while they did not solve the policy question that they were created for—they didn't magically reduce pressure on A&E—what they were very good at is exactly that. So, where they were very good is where they had a specific population and an issue like sexual health or respiratory health or mental health, they were actually taking the services to the population with specialist practitioners. So, that model clearly works.

Another thing—

Professor Hails, do you mind just moving your mike a little bit closer? It's one of our witnesses; one of our Members is just having difficulty hearing. That should be fine.

Another thing that we've done in CAMHS services is we've sort of amalgamated—. The majority of health boards now provide a CAMHS service that is primary care and secondary care based, and they've all got a single point of access with a 'no bounce' policy. So, people come into the single point of access and they get directed to where they need to go, and it's a single point of access for health, for social services, for education, et cetera, et cetera, so you've got all services in one area, provided in one easy point to actually access.

Another thing that we're trying to develop now are places of safety. Instead of going to the emergency department or going to a 136 suite, you can go to a sanctuary instead of being admitted to the units, because as you know it's very difficult to get admitted to any of the mental health units, really, and from a CAMHS perspective, it's virtually impossible. So, you can go to a non-threatening, non-judgmental area that's again removed from a hospital situation and you can stay there overnight, and then again in the morning, you can go home instead of being admitted into hospital. So, lots of the health boards—supported obviously by the Government and other areas—are trying to develop really rather innovative and new ways of delivering service. And I think it fits in with—

It's music to my ears to hear that. Unfortunately, I'm in an area, as I know a lot of my colleagues are, where these services do not exist. It's still very fragmented; there isn't joined-up thinking. I would love to have a single point of contact for access for mental health care services. At the moment, we're so understaffed locally in secondary care, it's impossible to find the same person there from week to week at times—

Yes, I agree.

—which is very distressing for us as well as our patients. So, we need to have a concerted approach to have joined-up thinking and have a single point of access, and services that are dictated by local need. They will be different. Wonderful that you have psychotherapy services; you wait for almost three years in the area I work in for psychotherapy services. We have no ADHD assessment services, for example; CAMHS is not joined up; a lot of the work is done by primary care as well as our secondary care specialist nurse. There has been no consultant in post for years; we now have a locum consultant, thankfully, and we end up liaising more but admitting people to secondary care in crisis.

Dementia care in Swansea in that centre is very good; I've visited it. But often these things are just one-offs. You have it in Swansea, you don't have it in Llanelli, for example. I think that's perhaps one of the things we want, which I'm glad you've highlighted.

We're also concerned about the lack of translation services for people, especially those from ethnic minorities, who often rely on their children to translate for them sometimes quite complicated medical items, which are beyond the linguistic skill of children within their age group anyway. We've had a request, where we went on a visit, for a medical translation service.

There is a medical translation service, sometimes pre-organising appointments, so if it's an acute event, it can be quite tricky, but you can pre-organise them. Likewise for patients with certain disabilities; if you need a sign interpreter as well, that can be arranged. It's not a problem.

Can I just say that my sister is profoundly deaf? I know just how difficult it is to get someone to come along and sign. I also know how incredibly difficult it is, having arranged for somebody to come along and sign, to actually have them there at the appropriate time. If you go to the Welsh Government, talk to lots of people, we've got this wonderful system, but, with things like signing, it can be very difficult to get somebody there at the appropriate time, even for an appointment that has been made for some time.


I appreciate that. Thankfully, we try to remain flexible in our approach and our practice, certainly, and if they turn up an hour late, so be it, they're still seen, we still carry on with the appointment, because it is important. We need the help of another professional in those circumstances.

Thank you very much. I'll just finish with this. I think that the way you deal with your services would appear to be an exemplar for other GP services across, certainly, Swansea, and I would imagine through the rest of Wales. Is there any way that you can use it as an exemplar?

I think we do our best, but there are lots of practices out there who do their best, and I'm very assured of that. I'm very fortunate to visit lots of practices as a GP appraiser, and there's a lot of good practice out there. But it's important to highlight what can be improved, and feedback from patients and their families is always welcomed to help us improve our services.

No, it's a really important point. I suppose what I would say is I would, first of all, start by echoing your earlier comment, which is that it is around national planning. We are able to see from the census the languages that are in use in very small areas of Wales. We can pin that down. So, the question remains: why is this not being taken into account in our workforce planning? The Welsh language is a big example of that, but there are other examples as well, like sign language and also other languages. But if we can actually, again, encourage and reward people for linguistic skills. If people are comfortable during the period of education, they've had access to resources in different languages, they're comfortable in those different languages, then they can actually start potentially to deploy them. But this needs to be recognised as a very specific skill. Again, I go back to my point that if you're going to ask people to use high-level skills, you have to reward them for that. But there are things that we should be able to do with both the pre-reg and post-reg education, and access to CDP, to ensure that people, if they're in the area and they suddenly think, 'Well, do you know what, I would like to develop my skills in a particular area. I'm serving a population with this language need. I'm going to go and refresh some of my skills', because, when we're talking about mental health interventions, two very different types of language can make a profound difference. If you're talking about psychological therapies, you're talking about, of course, a very advanced level of fluency, but if you're talking about, for example, making someone comfortable at home, feeling welcome or feeling trusted, then you are potentially talking about a relatively low level of being able to be comfortable or familiar. The Welsh language is particularly significant when we're talking about dementia care, for example. I think it's worth highlighting those points, and it goes back to HEIW and planning.

I think it's an interesting point, as well, because if you take your argument to its logical conclusion, if you're dealing with people, or you're working with people with a serious and enduring mental health problem, or a learning disability, and they have communication problems, the whole difficulty is just ramped up. And if you've got a workforce that isn't able to actually (a) deal with the information or the talking difficulty, and (b) the mental health or the learning disability, then you're in a very difficult situation and the person's going to feel frustrated, they're going to leave, they're not going to get treated. So, you do need a highly skilled, multifaceted workforce to actually deliver that level of intervention to that level of population.

And confidence as well. I can't speak specifically to mental health nursing, but we do have statistics from our membership that show, for example—and I know the point is wider than purely the Welsh language, but just to illustrate—we have about a third of our members that speak Welsh. That isn't the same necessarily as having the confidence to utilise that Welsh professionally. So, again, that's something about not only the desire to support your team, but the time. Everything we're talking about here is about time. Outreach, CPD, skill development—if you don't have the time to do that, because there's not enough of you, all of that stuff goes by the wayside, because you're down to the very, very minimum that you can possibly do. And that's when things start to slip, the services start to suffer, and we see poor care being delivered. And it's one of the reasons why, of course, one of our recommendations is about the extension of section 25(b) of the Nurse Staffing Levels (Wales) Act 2016, because we want to see some priority given to safe and effective care specifically in in-patient mental health—because of that.

There we are. We've had about 10 minutes for each, and we've got three sections left, so about 10 minutes for each section, just to give an indication. Gareth Davies.


Thank you, Chair. I want to focus my questioning on awareness and training. Just to kick off, do you think that mental health is adequately covered in medical and nurse training? And what proportion of that training is allocated to mental health in undergraduate medical training, GPs, adult nurse training, children's nurse training, et cetera?

Very quickly, just to go back to the point, I think it's worth bearing in mind the difference between those who are graduating after following a mental health nurse route, so they would graduate as a mental health nurse, and those who are following adult, child and learning disability routes. And there are differences and commonalities there, but just to illustrate that point. And then, afterwards, of course, you would do various levels of Master's, PhD or different qualifications, so just to say that there is a range of skill levels in nursing. 

Yes. I'm aware of that, but in terms of general nurse training. So, I'll redirect my question and ask: in generic training, what proportion of mental health awareness is there in those courses?

Again, it's a good question. I spoke at a conference last week in the Hilton and we had student nurses in the audience and I asked them, 'How much mental health training have you had in your training?' and they said, 'Virtually very little, if any at all'. And then I clarified and said, 'Have you had any CAMHS training?' and they said, 'No, we've had no CAMHS training'. So, you could probably look from the whole point of view of general nurse training, and you will have mental wellness, you will have some mental health and you will certainly have an introduction to mental ill health and serious mental illness, but it doesn't form a large percentage of the course—you could be looking at days, hours, more than weeks.

And then, what you're talking about when people are actually in place is the placements that they do, so there's the education in terms of what they receive and then there are the experiences that they have, which are also part of that education. So, for example, if you had a situation where, say, a nurse who was being trained as an adult nurse or a child nurse, they could do some mental health placements, they could learn from that environment. And then, of course, you've also got the issue of once they've actually graduated and they're in place, have they got access to continuing professional development? So, they could be working in an A&E environment and they could think to themselves, 'Do you know what, what I actually need in this environment is some extra education and training about how to do interventions with some of the people I see, or how to refer people or how to recognise issues'. So, then the question is: how does that person access that? So, all of those things, we would say, absolutely need to be improved—at all of those different levels, improvement needs to be made to ensure that people have access to those skills.

Part of my role as a consultant nurse is to train, supervise and enable non-mental health nurses to deliver low-level psychological interventions and mental health work. I've developed a 20-credit module for school health nurses and health visitors at the University of South Wales on their advanced practice course—basically, how to do low-level cognitive behavioural therapy. But apart from that, they hadn't had a lot of training. But from a mental health perspective, working with our general nursing perspective, we do offer support and we do offer supervision and we do offer training. It depends whether or not they've actually got the time and the space to do it, because everyone is somewhat busy.

As you'd expect in GP training, we're generalists. Mental health issues feature very high on our curriculum—not just diagnosed mental health conditions, but bearing in mind that, for at least a quarter of our patients, there is a psychological element to their presenting problem, even though that may not be the reason why they've lifted the phone or come in to see me today. We put a big emphasis on training on psychological health and managing mental health issues. Most GP trainees have the option to do a formal psychiatric post for six months if they so wish, and that could be in adult mental health, it could be in older adult mental health, child health or whatever is available, depending on the scheme in Wales.

We put a very big emphasis as well in GP training, including, as part of the half-day release education programme organised by the programme directors for the local schemes, on mental health problems, how to manage them and giving people a flavour of what's available in different areas, because assuming the generic, 'This is what you can do' doesn't mean that it's available to all, sadly, when they qualify, depending on where they end up working. We also have a system of self-directed learning, where trainees have a dedicated session every single week, and a lot of them use that to gain skills—for example, to get an insight into what psychotherapy is about, what the CAMHS service can deliver or what a learning disability service delivers, et cetera. So, we try very hard to make sure that people get exposure as part of their formal training, if you like, but also on the job, because a large part of what we do does involve mental health issues, and at the end of every surgery, trainees are debriefed by their trainers and supervisors and have the opportunity to discuss mental health issues, and to identify learning needs and also the facilities to negotiate, to address those, both within and outside the practice. So, I think we work very hard to try and make sure that we look after our GP trainees. There are lots of CPD activities for established GPs, and the multidisciplinary primary care team as well, and they are well accessed. With remote meetings now, they have been even more accessible than they've ever been, which has to be a good thing.


So, there definitely seems to be a need, then, for role-specific training rather than more generic stuff, and do you think there needs to be a better understanding of the needs and experiences of different groups and communities, and the things that affect different people in different areas in terms of neurodiversity, disability awareness, sensory stuff? I think there's a definite need for that, but how do we get there? What do we need to do?

I think you're absolutely, completely right. I think that's exactly what's needed, and definitely the role-specific stuff is helpful, because it's more practical, it's more, usually, at the right level. What I would say is—again, going back to your point about general nursing rather than, say, mental health services, but it's true for mental health services too—access to CPD is lower in Wales in the NHS, not even in the independent sector, than it is in England. Now, there's no particular reason for that, and it's been that way for a number of years now, because the financial pressures are just as great in England as they are here, yet there seems to be an issue with releasing people, even for 15 minutes, in order to do this. So, there seems to be some sort of cultural issue with access to CPD in the NHS, which I think we need to tackle.

But I think the other thing that's worth pointing out is that nurses don't have any built-in time in their contracts. Even though they obviously do need to do all of the learning and reflection and everything that all the professionals need to do in terms of revalidation, they don't have that built in like some of their colleagues do. So, actually, making those provisions available is a way, because people—. Very often, there is excellent education available on, say, learning disabilities and dementia or specific cultural issues or linguistic issues, and people know that they're in need of it and want to access it. But if you're talking about coming home after a 12 or 14-hour shift and then you've got caring responsibilities, when precisely are we expecting people to do this? So, once again, it's a really high expectation on these people, and yet not necessarily rewarded or recognised or given the opportunity to actually reach that level, just criticised when they don't.

So, what do you think needs to change in that sense, then? Do you think it needs to be contractual things in employment laws?

I'd like to see a performance target for the NHS on CPD, because we know how many people are—. Even their mandatory training, and even issues on the ward like health and safety or refresher courses on CPR, we know that people aren't actually hitting the targets that they're supposed to on that. So, let's make that an actual performance target if that's what we feel, as a country, that we need to make sure that our professionals have got access to skills. If we can't, let's do that.

I think it's the right sort of CPD,  because, working in a health board, you have to hit a certain level of mandatory training, and it doesn't really have a huge amount of relevance to what you do clinically, but you have to do it, and if you don't hit it, you can be penalised. But, as a nurse, you don't have to be clinically supervised to practise; you do as a psychologist, you do as a psychotherapist, you do as a medic. So, the focus seems to be slightly skew-whiff from the actual clinical intervention you're delivering more to the fact that, 'Have you done your health and safety training' or 'Have you done your fire training?', which I'm not saying isn't important, but there's a skew-whiff away from the clinical intervention, to an extent, really. And I think if we could redirect the area to that, it would be really, really important.

Certainly, I trained a number of my junior nurses in cognitive behavioural therapy on the Cardiff course and, as soon as they qualified, they were poached to somewhere else because they went to a more senior position. So, you've got those sorts of difficulties, because mental health nursing is a small catchment pool, really, and most people are actually trying to appoint people from the same area. And if you can go to a different health board that supports you in a different way to do what you've actually been trained to do, you'll go there more than staying there where they say, 'Sorry, you can't do that; we're too busy to supervise you.'

That's where the national approach is important. And one little point I would add here to this is the role of the consultant nurse is critical, right, in terms of developing not just the nursing staff, but other staff as well in terms of provision of that education. So, if you don't have those senior consultant roles—and we don't have enough in Wales, and we don't succession plan for them—that tends to fall apart. So, what happens is you might get a consultant nurse moving to another role or retiring and then you have a situation where the health board is, like, 'We can't really find anyone to replace.' That's why we're saying that there needs to be some kind of Health Education and Improvement Wales national plan for actually developing these kinds of skills in the workforce as a whole, because otherwise what we're doing is we're seeing a population need, we're trying to hastily design a service to fit with the people we've got as opposed to actually producing the people we need to match that need.


How do we better diversify the mental health workforce then? I suppose, in Wales specifically, an example of that might be getting more Welsh-speaking mental health nurses in west Wales so that they better reflect the communities we serve. So, how do we make steps and improve that? Is that through education or is it making the career prospects more attractive for people wanting to—

I'm afraid, on this, you'll have to give just a one-sentence answer. I'm sorry, apologies.

Career pathway—most nurses, when they become senior, become managers; they lose their clinical role. So, if you had a career pathway—in one sentence—that covered clinical work, educational work, management work and research work, it would be a lot easier for people, because to become a senior nurse, you become a manager, often.

One sentence would be: demonstrate to young people in different communities that it's a rewarding career.

For primary care, get out there and blow the trumpet and say how good we are at what we do and how we work very well as a team, and we've embraced other healthcare professionals helping us fill the gaps with our GP workforce. The only way forward is to identify people, enthuse them to do what we do, let them come and see what happens and, hopefully, learn from that and get them involved, and particularly at an early age, put emphasis on schoolchildren and people who are about to go to university. It's trying to get people enthusiastic to come and join us and see what we do, and the potential to do even better than we do currently.

Thank you for being so succinct on that to help us get through all of our questions. Joyce Watson. 

Thank you. I was waiting to be unmuted. We've had lots of evidence about the very strong link between the prescribing of antidepressants and poverty, the reason being that the GPs have got nothing else to offer. Is that your experience?

I think there's always something to offer. We're there and we offer support, and that in itself is a plus. There are some services available for patients, and we try to make the best of them, for example, with this splurge in IT development in the UK, we've now been able to offer more online facilities, things like cognitive behavioural therapy online for patients. Not everyone, I appreciate, can access those. Counselling services are available, but, again, during COVID, sadly, not as available as they used to be, which is a huge issue at the moment, and waiting lists are rising. We all know that, for mild to moderate mental health problems, counselling or CBT are just as effective as medication.

I think, in all honesty, people use the resources that they have and try to give the patient the best deal they possibly can. There are a lot of patients who openly admit that, in order to engage with these therapies they aren't in a good enough head space already, if you like, as they tell me, to actually engage with them. Sometimes, they opt for medication so that it will improve their mood, their concentration and their enthusiasm and reduce their anxieties sufficiently so that they can engage with other therapies, but medicine isn't always the answer. I fully believe that. There are lots of other options, the problem is having them equally available to all of our patients regardless of their background and the issues they're experiencing. It should be a tailored programme of treatment for that individual patient based on their needs and their wants.

Antidepressants do work, they're effective for mild to moderate anxiety and depression, the evidence is clear. But exactly as my colleague has just said, equally effective are other types of interventions as well. I think it has—. I'm hesitating, because a lot of the information that I have is actually pre pandemic, and I think it would be interesting to see how the pandemic has affected it.

What I was about to say is that I think in the last five years, the situation for GPs has improved tremendously. I think they have more access now to available alternatives. I think, certainly, there was a point when it very much was the case of wanting to help the people in front of you, but not having any other thing to do, then you only had that option. I'm hesitating slightly because I think, possibly, it would be interesting to see what the impact of the pandemic is on some of those, and I think maybe some of those interventions—I'm particularly talking about some of the social activities, for example—will have been halted. So, I'm hesitating slightly, but I think that that situation, generally speaking, has improved.

I do think that you make an excellent point about the link to poverty. Poverty in itself is a stressor. Not being able to have a roof over your head or feed your family or do any of those basic needs that people have is profoundly difficult to cope with. We're seeing that in our own membership at the moment, as well as in the general population, so there absolutely is a link between poverty and mental health, generally. I think having the range of interventions available for GPs in those areas is really, really important. Again, I'm not quite clear if we have a national picture of that.


I'm sure we don't, because it varies so much. Even in my neighbouring practice, 15 miles up the road, they have access to different services compared to my practice, and that is the case throughout Wales.

Can I bring Joyce back in? I'll come to you then, Mr Hails, if that's okay.

I'd like to move on, then, to ask—. You've all mentioned the interconnectedness that needs to happen to treat the whole person, not just the problem they're presenting with, so, are there any structural or professional barriers to a more joined-up approach between services that will meet people's needs in a more holistic way?

Did you want to come in first, Mr Hails, or somebody else? No. Lisa.

'Yes' I suppose is the answer. I think, going back to the group that we particularly want to highlight, which is people with severe and enduring mental health issues, or some of the populations we've highlighted—say, for example, the prison population or other areas—you're talking about people who obviously have a range of needs. They have clinical needs and health needs, but also, potentially, issues with housing, holistically with their life, so, access to education or employment. So, clearly, they need a range of services to be supported and they need individuals who can access that range of services.

So, from that, I think it's fair to say that our clinicians—. I think my colleague said, nurses are often in the place that's actually doing the co-ordination between those services and actually bringing them together. Anything that can facilitate that is helpful. So, where there are structures in place to facilitate that communication, where professionals have got the time—and I go back to this business about time, because if you're short staffed and you don't have time, ringing people, chasing people and coming back on that message, all of that is taking a considerable amount of time to organise. So, where people have the time and the ability to bring people together, then that works.

Now, clearly, as well, we also have to watch out for any barriers in the way of budgets. So, facilitating that in one place can be useful. Professor, are there any examples of where there are some good joined-up services?

If we could kick off with Julie first and then I'll come back to Mr Hails.

Thank you. I agree with you wholeheartedly, Lisa. Time is an issue. Staffing is an issue. In primary care, physical space in your building is an issue. We would very much welcome—. When we had a social prescriber in our practice as part of a pilot a few years ago, it was wonderful. Patients who were poor, who had lots of housing needs—. I'm a GP, I can 'Doctor Google' things like everyone else. But at the end of the day, having this lady, who was absolutely wonderful, she knew up-to-date information about housing and benefits, et cetera, which I'm not a source of information on, really, I'm as good as Joe Public and what I can find on the internet—. But having somebody like that, having the space and the time and the right person with the interest, the motivation and the training to deliver that service, and to keep up to date with what's available and to support patients in general is what's needed. And that is, you may say, nothing to do with medicine, but it's a good place to house such wonderful people in practices, because there's already a structure there. We’re lucky that practice premises, although they are inadequate in size, are developed, and their patients know they're accessible, and they know how to use the services. It would make a huge difference to practices to have that single point of contact, to join up the social and the medical care for patients, because it is a massive problem. And there are lots of people with mental health issues who have low-level mental health issues, who just need that support to help them see the wood from the trees and move forward with trying to solve their problems, and at least getting some support to do that.


Sure. I’ll just bring Mr Hails in, just to be brief, before I come on to Rhun.

I agree. I think if you look at the link between primary care and secondary care—. When I used to work in the Maudsley many, many years ago in London, I was a CPN, a community psychiatric nurse, and I was based in a local GP surgery. We used to work really rather closely with the GPs, and we used to see certain people that they would have seen, or maybe didn't need to see, because they needed to see a mental health nurse. But those sorts of positions don't really exist anymore because of the acuity on the secondary services.

I think a good example of care is the way that the primary mental health services and secondary mental health services have actually come together now, and they provide a seamless level of care virtually from tier 0 up to tier 4 and if someone needs to be admitted, really. I think you can look at most of the health boards and you can find good examples of that. I think, also, if you look at the way that the third sector organisations and secondary care and primary care are starting to work together now as well, I think you've got good examples of innovative and different ways of working. But I think, as we're talking about nursing and medics, enabling medics and nurses to work outside the traditional institution and to work in the community, I think, will actually alleviate and target some of these more pronounced difficulties. If you've got a CPN working in a deprived area, it will help people, because they don't have to go to the GP, where they may not be able to get to, the CPN will come and see them in their home. It just makes things easier for people, really.

Thank you. We'd better move on for time. Rhun ap Iorwerth.

Diolch yn fawr iawn. Mae'n ddifyr iawn gwrando arnoch chi ac rydyn ni wedi cael atebion cynhwysfawr iawn yn barod. Felly, jest i fynd cam ymhellach ar gwpl o'r materion sydd wedi cael eu codi'n barod, ar y pwynt yr oeddech chi'n ei wneud, rŵan, ynglŷn â dod â'r trydydd sector i mewn i weithio ochr yn ochr â gwasanaethau iechyd, ac ati, pa mor agos ydyn ni at allu dweud ein bod ni'n creu cymdeithas sydd yn cefnogi pobl efo llesiant ac iechyd meddwl? Ydy hynny'n rhywbeth y dylem ni fod yn anelu amdano fo—creu'r gymuned ehangach yna sy'n cefnogi pobl?

Thank you very much. It's really interesting to listen to you and we've had really comprehensive answers already. So, just to take this a step further on some of the matters that have already been raised, on the point that you were raising there about bringing in the third sector to work side by side with the health service, et cetera, how close are we to being able to say that we're creating a society that supports people with their well-being and mental health? Is that something that we're going to be aiming for—creating this wider community that will support people?

I think I'd like to return to my initial point about, perhaps, the lack of focus at the moment on people with severe and enduring mental illness. In the last decade, there's been a very welcome focus and a sea change in terms of national policy about understanding that mental health is everyone's business and understanding that we can all improve and work on our mental health together. And a lot of very, very important interventions are now being made available for people with mild to moderate anxiety, depression and those kinds of illnesses.

There was always going to be a group of the population that, through trauma or whatever other reason, has actually got much more severe needs. That needs specialist skills and it needs specialist services to support. I think what's important is that we make sure that we have the continued investment in those services, in the people and the capital estate as well that is needed to support and look after that particular group, and make sure that they have the best outcomes and have productive, enjoyable lives because they are us; we are them. This is what could happen to us, it could happen to our loved ones. This is a part of humanity. And I think there is a real danger that some of the focus, the very important focus—and I don't want to detract from that—on prevention has almost got us to the point where we're thinking, 'If we invest enough in this side, we will somehow prevent or not need mental health services', and that's a sort of weird, slippery and not-very-logical train of thought. So, yes, we do need all of those interventions as a society, and part of that range of interventions is caring for a very particular group of people with very particular needs. That, for me, is the aspect that needs to be brought back in to the mental health strategies at the moment, to have this holistic picture of mental health services.

Where do you think we are on that balance between building a society and communities that support people's well-being in general and making sure that we have the more specific interventions?


I think the will is there, I think the message is very clearly stated, hopefully, by all of us in the NHS that people with mental health problems have the same equity and right to access medical care, or social care, or whatever meets their needs. And that is something we need to emphasise. There are certain groups we know—patients who are poorer, LGBTQ patients et cetera, people from ethnic minorities—where there is a certain mystique or disbelief that something can be done to help them and that it isn't really a valid problem, compared to a physical illness. I think that message needs to be given very loud and clear. But I think there is a will for people to come forward, and certainly during the pandemic I think we've seen a huge increase in the number of consultations with mental health-related issues, particularly with young people, because people's lives have changed immeasurably—from, 'I'm isolated, I'm furloughed, I don't know what my work future will be', to 'Now I have no job and I haven't got any money, and that's making me feel depressed and anxious about the future.' And I think people are getting the message they should come forward. I think they're worried there aren't services there to meet their needs, that nothing can be done. I think we need to give a clearer message that we are working together, that something will be done, and the something to be done will be appropriate for that individual to best meet their needs in the current constraints that we have, and hopefully identify services that need further development and work together to do that. 

I think that, thinking about the third sector and the secondary and primary care sectors working together, there are good examples of that. If you think about many of the first episode in psychosis services developed in the health boards, they're partnered with either Adferiad Recovery or Mind, and they both work together to deliver a state of the art service. But, again, it's to the higher poorly population more than the lower poorly population. Quite a few of the charities or third sector organisations employ quite a number of nurses now as well, and they deliver nursing-based and nursing-focused interventions, working again quite closely with the primary and secondary care services. 

Often, there's a mist between the health and the third sector and social services, and sometimes when you're actually looking at more of a behavioural approach than a health approach, that can sometimes get slightly difficult, because health may not deliver that and social services will deliver that, but social services can't deliver that because they're so stretched, then health ends up delivering it. So, I think there are good examples of all of the services working together, but I think so much more could be done. And again, as we spoke about earlier, changing the location of the delivery, moving into a third sector organisation—and if you think about the sanctuary provisions, most of those are actually delivered by third sector organisations partnered up with the health boards. So, I think it would develop maybe an easy to access service, or one that you can access in a slightly different place rather than having to go to the emergency department or having to go to the old mental health facilities, really. I think it would be good. 

Thank you. And just one last question. Building on the comments that you made about social prescribing and your use of the benefits of that, just briefly, as we look to make recommendations at the end of this work, is investing in identifying the potential of social prescribing—should that be a priority for us?

A massive priority. It's absolutely vital that we do that. There are lots of people who would benefit greatly and avoid developing chronic physical and mental health problems as a result of that intervention early. 

Does that include understanding better what social prescribing could be?

Indeed. It has massive potential. I think it should be area-specific as well. There are generic principles, but it would really make a huge difference to the well-being of the general population, and I think it's essential to have that system and support available alongside conventional medicine, whether that's in primary care, secondary care or community mental health services. It is essential that we have that whole picture and support the person in the way they need to be supported at that time. 

I think it's interesting, if you look at the National Institute of Health and Care Excellence guidance for depression, which were republished on 29 June, I think, and if you're talking about someone with moderate or mild to moderate depression, the first thing a GP would be offering them is a social prescription—

Yes, if we had them. 

—'Increase your activity, reactivate yourself, join a local gym, go and do this.' They'll consider that before they consider cognitive behavioural therapy, which is the evidence-based intervention of choice, or before they consider any form of medication, really. And if people can access those facilities without having to pay through the nose for them, because if you're looking at deprived people or people without a lot of money, they're not going to go, because they can't afford it. So, that sort of stuff would, you know—.


Indeed, it's hugely important. We all know that exercise, in particular, is very beneficial. Having social contact with other people is very beneficial for mental health as well, and various groups—you mentioned the dementia one in Swansea, which is very successful. It's just having that point of contact support for the patient and also for the families, and that is absolutely vital to improve the health service that we're delivering and the holistic care we should be delivering for patients. 

Yes, fabulous. We've got Men's Sheds. [Laughter.]

Thank you, all. Just to finish our session, just tell me in one sentence what your key recommendation would be when it comes to supporting reducing mental health inequalities in Wales? 

Well, I'm going to cheat, I'm afraid. I'm going to have to say there has to be two. I think there has to be a postgraduate mental health workforce strategy, looking at how we get those people at the right time in the right place. But I also do think it's time to change the law and extend section 25B to in-patient mental health care. We have a lot of laws in the aviation industry, in childcare, in dog kennels about having the right number of skilled staff to look after people safely. I think we've demonstrated that that works very effectively in adult and children's medical and surgical wards. So, I think the same provisions should be made to the very vulnerable population in mental health.

I didn't mind you cheating there, because that was a very good succinct answer. So, thank you, Lisa. 

My perspective on it would be, basically, if you think about tier 0 to tier 4, to have the appropriate and correct level of service to the need of the person actually where they can access it, but not forgetting people in tier 3 and tier 4. Social prescribing is excellent and offering education support and physical activities will help, but it still won't mean that people won't become seriously mentally ill in the future. So, I think we need to think about the whole population as a continuum, from low-level psychological-type interventions to high-level interventions, and when people may need hospital as well. So, I think you need to think about all of it, really, not just front-ending it.  

I think we need to work on developing the workforce in health and social care to deliver holistic care to the patient, bearing in mind their medical, psychological and mental health needs at a given time, with an emphasis on developing the specialist services equally to supporting patients at the lower level who don't require as intense treatment or interventions, and hopefully, through intervening early, avoiding people developing chronic mental health problems. And also, should they develop mental health problems, that we have mechanisms in place to identify those and intervene early, and that they have the opportunity to see the right healthcare professional to deliver the particular care they need. 

Thank you very much. Diolch yn fawr iawn. Thank you for your clear succinct answers to that last question. We really appreciate it. And sorry for having to rush you through some of the earlier questions in order to get through all that we wanted to ask today, but thank you very much. Diolch yn fawr iawn.

We'll take a 15-minute break now because we need to do some technical bits as well, so we'll be back just after 10.45 a.m. 

Thank you for the opportunity to speak to you. 

Gohiriwyd y cyfarfod rhwng 10:33 a 10:46.

The meeting adjourned between 10:33 and 10:46.

3. Anghydraddoldebau iechyd meddwl: sesiwn dystiolaeth gyda'r sector gofal eilaidd
3. Mental health inequalities: evidence session with the secondary care sector

Welcome back to the Health and Social Care Committee. I move to item 3, and this is in regard to mental health inequalities, and we have an evidence session this morning with the secondary care sector. Our witness this morning is Professor Keith Lloyd. Professor Lloyd, I wonder if you could just introduce yourself for the public record.

Hello, good morning, pleasure to be here. My name's Keith Lloyd, I'm a professor of psychiatry and am representing the Royal College of Psychiatrists.

Thank you for being with us this morning. We greatly appreciate your time with us. The pandemic has, of course, affected all parts of the population, but I wonder, from your perspective, what groups of people or communities do you think have perhaps been more affected by the pandemic in terms of mental health and their well-being.

That's a very good question. Given the focus, I think poverty is a major factor here. About a quarter of the Welsh population lives in poverty. It costs Wales about £3.6 billion a year, which is a fifth of the Welsh Government budget, as you know. Poverty means facing constant insecurity and uncertainty—housing, poor mental health, low educational attainment, unemployment, loneliness, low social mobility. The power of communities in Wales and the skills and abilities of the people within them are a major asset that needs to be recognised, supported and used.

So, a few facts and figures just to back that up, and to answer your question directly. Children and adults living in the lowest 20 per cent income bracket in Wales are two to three times more likely to develop mental health problems than those in the highest. That's been exacerbated by the pandemic. Those on housing benefit are more than twice as likely to have a common mental health problem than those not in receipt of housing benefit. Employment status is linked to mental health outcomes. Those who are unemployed or economically inactive have higher rates of common mental health problems than those who are employed. Employment is generally beneficial for mental health. However, the mental health benefits of employment depend on the quality of work and work that's paid. Work that's low paid, insecure or poses health risks can be damaging to mental health.

The final statistic from me is that, each year in Wales, between 300 and 350 people die by suicide, which is around three times the number killed in road accidents. It's the leading cause of death for men aged 20 to 49, and the leading cause of death for everyone under the age of 35. There's strong overwhelming evidence of a connection between socioeconomic deprivation and suicidal behaviours. Areas of higher socioeconomic disadvantage in Wales tend to have higher rates, and the greater the level of deprivation experienced by an individual, the higher their risk of suicidal behaviour. We can talk also about the impact of the pandemic and health inequalities on ethnic minorities, children and young people, people with neurodevelopmental disorders like learning disabilities and autism spectrum disorder, LGBTQ+ individuals, and older people.


Thank you very much, Professor Lloyd. That's helpful for setting the scene for the rest of the session, so it's appreciated. Gareth Davies. 

Thank you, Chair, and good morning, Professor. I want to focus on recruitment, retention and well-being. We've heard a lot about long-term capacity issues in parts of the mental health workforce. In which mental health professions specifically are the main gaps and recruitment challenges, and what are the reasons for those?

Most people with mental health problems who seek medical attention are treated by their GP or in primary care by the primary care team. They refer on a proportion of those to secondary care, and the vast majority of people are then seen in community mental health teams. Wales has the highest percentage of vacant consultant psychiatrist posts in the UK; more than one in 10 posts are vacant. They're important in providing specialist and expert input. There are shortages of community psychiatric nurses in some areas, and of social workers as well. The Welsh Government has done a great deal with the ‘Train. Work. Live.’ campaign to increase recruitment into psychiatry over the years. There's probably more that needs to be done now. We're not doing enough to attract and retain psychiatrists into Wales. 

Thanks, Professor. In written evidence, the British Association for Counselling and Psychotherapy described its members as an underutilised workforce and an untapped resource. What are your views on that?

I think there's a huge opportunity, which Health Education and Improvement Wales have recognised, to create other roles to support mental health services. Associate clinical psychologist is a new role that Health Education and Improvement Wales is about to create, which will actually increase the availability of people skilled to deliver psychological therapies in primary and community care settings. 

What action is needed to ensure long-term workforce sustainability and keeping people in jobs, and making psychiatry and mental health an attractive profession to come into, and to indeed stay in, and making it more effective to use other health professionals as part of multidisciplinary teams?

We need to make it easier for retired psychiatrists and those taking time off to care for children or relatives to return to work. We need to support new credentials, bringing in other people. Physician associates, advanced nurse specialists, pharmacists and advanced paramedic practitioners can all play an important part in the skill mix here. 

What are the key factors in terms of the impact on the well-being of the workforce, and what do you think the main problems are, the barriers, to tackling some of these problems in the recruitment and retention of psychiatrists and mental health professionals on the whole?

There are a number of factors. I think many people are exhausted by the pandemic and have sought to exit the professions. We've seen that across medicine and nursing. Interestingly, in my other role in Swansea University, this is the first year that we've seen a dip in applications for people to do nursing courses, and that's not unique to us; that's occurring in the other universities across Wales that also run those training courses. There's something about the terms and conditions and the workload that we need to do to make people want to go into those careers. 

Thanks, Chair. Professor, can I just ask about unmet need? Do we know the degree of unmet need for counselling services in Wales? Are you able to estimate at all the figure, the number of additional counsellors and psychotherapists that we would need in Wales to address that unmet need? Because it strikes me that there is a huge unmet need at the moment, but we just don't know the scale of it, and therefore we can't put a figure on the number of additional counsellors that we really do desperately need.


Workforce planning in healthcare is challenging. Health Education and Improvement Wales are creating this new profession called associate clinical psychologists, who will help address that workforce. I guess the easiest way to get into your question is to look at the waiting times for these therapies. Over the course of the pandemic, a lot of these therapies have moved online, which works for some people, but obviously digital exclusion can be a problem for others. So, I think we're going to end up with a mixed economy, where some people are content having therapies delivered online, whereas others would prefer to see them delivered face to face.

You asked the question just about psychological therapies, but we kind of have to look at the whole range of treatments and so on that are available for people. In some areas, for example support for people with neurodevelopmental disorders like autistic spectrum disorder, the waiting lists for access to therapists is very, very long; in some services, it can be a couple of years. For the first tier of psychological therapies that people with common mental health problems like anxiety and depression need in primary care, we could probably double the size of the existing workforce, and they would simply absorb the demand that's there.

I want to talk about—and you did mention them—ethnic minority communities and mental health Act reform. We've heard from people specifically in the ethnic minority communities, and they've told us that they can face significant cultural and language barriers when trying to access support, particularly culturally aware counselling services and lack of translation. How can we begin to address some of those very complex issues?

Discrimination and inequality increase the risk of developing mental illness. People who are subject to inequalities go through life with high levels of stress and mental distress, which places them at higher risk. Then there's the problem of access to services. Services are less friendly and welcoming, or appear less friendly and welcoming, to people from some communities than others. Black people of Caribbean and African heritage are all significantly more likely to be compulsorily admitted under the mental health Act than their white British counterparts. And that's multifactorial. It's about when people seek help, it's about whether the services are accessible, it's about perception of risk—there's a whole range of things. There's also a growing body of research to suggest that those who are exposed consistently to systemic racism are more likely to experience mental health problems such as psychosis and depression.

You mentioned translation services. That's a slightly separate point, because that's particularly a problem around asylum seekers and people who are from communities where it's not the norm to speak English or Welsh. Translation services are not run from within the NHS; they're mostly outsourced, and it can be very difficult to access translation services in a timely fashion when you need to see somebody in a crisis situation. So, that would be one simple measure that could be addressed to help quite a significantly disadvantaged sub-group of people who use our services.

You mentioned a few things, and you did say that there was evidence backing up those from, particularly, Caribbean backgrounds. It would be helpful to us if you could give us some of that information, so we can look at it, to make recommendations. If you think you're able to do that, it would be useful for us.


There’s a whole body of evidence that goes back many years on the use of the mental health Act and different ethnic groups. There have been national UK surveys of ethnic minority mental health, and I guess it would be easiest for me to send that evidence on to the committee via the college after this meeting, but there’s a good body of evidence there that would help you.

I thank you for that. You did say when we were talking about this particular group of people that very often they find themselves, according to what we were told just two weeks ago, misunderstood—that their cultures are completely misunderstood or ignored in many cases due to that misunderstanding. You also mentioned the impact of being subject to racial abuse throughout their lifetimes—probably, many of them. So, how can we connect those things? We’ve talked at length about poverty, and there were many figures that were startling, but it must apply in the same way to people who have been subject to perhaps physical and mental abuse just as a consequence of who they are.

Yes, it does. In the training of psychiatrists, cultural competency is a core thing that people are trained in to try and help them understand other perspectives and other communities. But there are subtle things that happen in the way the health service operates—micro-aggressions. We see the same thing in the training of our students from different health professions. Certainly, in healthcare settings, what we try and train people to do is to be able to call out micro-aggressions or avert racism when they see it to try and make it easier for people to modify their behaviour.

I want to talk about barriers for other groups. Older people, you stated, are much less likely to be referred for mental health support than the younger population, even though we know that older people are more likely to have things like dementia. What's the reason for this and how can this unmet need amongst older people be addressed?

For older people, age discrimination is associated with worse psychological well-being and poorer physical health outcomes. So, older people are less likely to be referred on to the most appropriate services and there's a higher risk of their needs being overlooked. There are assumptions that people make about ageing, about what's normal ageing, which isn't really the case. So, people with dementia—early-onset dementia—are treated in particular ways. There's been research that was very prominent in the news recently about continence aids and people with dementia—everyone automatically assumed that people with dementia are incontinent—and how that can change people's ability to remain independent.

There are some interesting things happening with older people as well, so, for example, substance misuse in older people—there are almost no services for that. Alcohol misuse is prominent amongst older people—that doesn't really get addressed through services. In the same way that people with learning disabilities suffer from what's called 'diagnostic overshadowing', where people don't see past the learning disability, sometimes people don't see past the older person to the human underneath.

I'm glad you mentioned alcohol, because there are groups of older people who use alcohol and going out as a substitute for social interaction in a more normal sense. I think that perhaps—. Well, I'm not supposed to think, I'm supposed to ask you: would you agree we need to pay more attention to that?

Yes, I would.

Thank you. I want to talk abut the deaf community. I'll start off by saying that my sister is profoundly deaf and I hear all sorts of things about how (1) there is no specialist deaf mental health service in Wales, and every time I talk to people they tell me that you can have access to sign language within the health setting. I know how difficult it has been for my sister to get access to sign language within the health setting, even when it's well organised and for a period in hospital that has been arranged six or seven weeks before. Do you recognise that, and should more be done?


Thank you for raising the issue of deafness. That's also a very important factor, generally, for people with lower levels of hearing loss, who tend to be older, because that can have a profound effect on their mental well-being. Making sure that an older person has got a working hearing aid can be transformational for their well-being and their ability to interact with other people for loneliness, isolation, and just to maintain their cognitive functioning. It really makes a difference if you can actually hear what's on the tv and what people are saying to you. So, in terms of—. Sorry, go ahead.

In terms of services for people who are profoundly deaf, you're right, we don't have services for that in Wales, and it's a gap in service provision that could be addressed. It's a service that would need to be provided on a national level. I know that, regarding sign language, it can be very difficult to access people who are skilled in British Sign Language in healthcare settings. I saw a presentation last Saturday from a group of medical students in Swansea who have started up a group to teach one another how to use British Sign Language in medical settings, so there are initiatives like that, which could be encouraged and more generally applied.

Thank you. I was going to say that I'm president of the Swansea Hard of Hearing Group, and this is mainly a group of older people who've started to lose their hearing and have lost their hearing over a period of time, and that brings intense loneliness, from my experience. Do you recognise that, and what do you think can be done?

I do recognise that, certainly. It's about people having access to affordable hearing aids in a timely fashion and the sort of social prescribing and access to support and accurate diagnosis of their hearing problem in the first place.

Thank you. I live in Swansea, and I know the difficulty people have not just getting hearing aids but getting hearing aid batteries. The places that used to provide them no longer provide them, and they have to go to either a hospital or one central clinic. Do you recognise that?

Yes, I do.

Thank you. We talked earlier about people with neurodivergent conditions, and you mentioned it earlier. Is there a danger—and I think you're going to say 'yes', but I have to ask it—that, if somebody's got a neurodivergent condition, that that's all a health professional sees, and they don't actually see the mental health anguish behind it?

Yes, that is a significant problem. There has been a huge increase in the number of people who are coming forward wondering if they do have a neurodevelopmental problem, either autistic spectrum disorder, attention deficit hyperactivity disorder, or other conditions. The services simply aren't available to assess that demand, and it's problematic for people with that to then get support. It's the same issue as with learning disability, where people tend not to see past the actual condition, but it can affect the way you interact with the world, and, particularly, some autistic people with perhaps high-functioning autistic spectrum issues can feel very isolated and alone.

My final question is, and it's going back to older people, on the role of loneliness and isolation in the effect on mental health. I've spoken in the previous discussion about the importance of Men's Sheds, for example, but actually having an opportunity for people to mix socially in non-expensive settings.

Yes. So, this is a really good opportunity for community interventions between different agencies and bodies, because that loneliness and isolation is everybody's business, effectively, and you can see initiatives—you mentioned the sheds, for example—I know the Ospreys, for example, do a walking rugby for older men, and for women, actually, as well, and that's a very good way of getting people to socialise and to just meet other people and have a bit of fun, which is actually what will make a difference, and the range of agencies that needs to be brought in to address these kinds of problems in communities is very broad, and it's not simply about mental health services; it's about the whole voluntary sector, the third sector, and the role they can help to play here. And they need adequate funding in order to do that.


Thank you very much. There's also walking football. Thank you.

And walking football as well. Yes, indeed.

Yes. Thank you. Professor, in regard to Mike's set of questions, is there anything that Government or policy makers need to do or do differently to address some of the issues that have been discussed with Mike's line of questioning?

Obviously, charitable funding—. Government is a major player in charitable funding, and thinking about how to co-ordinate that around these kinds of challenges that affect such a significant proportion of the Welsh population could have significant economic benefits for the whole economy and be consistent with our approach as a country to disadvantaged groups. So, I think, yes, Government can have a role in trying to co-ordinate that. In a sense, it's there in policy, in the well-being of future generations and other places, but it's about actually following through on that and delivering it in a multi-agency way.

Are there any specifics in terms of recommendations that you can think of around that? I'm thinking, for example, I know we recently met groups that talked about how some pots of funding are often for limited periods, or for project work and then come to an end, and it's difficult to then establish that funding longer term. But is that an issue that you see, or are there any other areas around Government funding that you can make a specific recommendation around?

I think we could come back to you with some specific recommendations about that. I wouldn't want to pick one single area out, but I think continuity of funding would be an important consideration for those third sector agencies who are very much involved in this type of work, and seeing it co-ordinated as well, centrally by Government, might be helpful.

Professor, I'm just going to ask a few questions about awareness and training. First of all, do you think that there is a sufficient understanding of the impact that unresolved trauma has on people, both in terms of sufficient understanding within health services, but also within Government?

And within communities too, I would add.

A good example would be—. You'll all be familiar with all the work that's been done around the country on making people know how to respond to somebody having a cardiac arrest, about CPR training, about the availability of defibrillators and so on—which is fantastic; that's brilliant. I think we're becoming much better as a country at recognising the signs of when mental health can be problematic. The first thing is about normalising the conversation around mental health, which is absolutely vital, and there are a number of champions and advocates in the Senedd about that, so recognising people who might be more at risk is also really key, and we haven't really spoken about severe mental illness, such as schizophrenia and bipolar, yet. There is a real need to socialise the broader conversation about that.

The college has recently launched a public mental health implementation centre with a number of expert advisers including Sir Michael Marmot, on who a lot of this work on poverty and mental illness is based, but my colleague Professor Ann John is part of that as well, and she may be known to some of you from the work she does as the suicide lead for Wales.

So, there are some specific measures we can take around public understanding of mental illness, and the work that happens with mental health first aid is brilliant. That's a good example. That should be funded and continue to be funded. Counselling and advisers in schools is really important. That really does fit with the well-being of future generations, and that's an extremely good investment in our young people. So, those would be a couple of things I'd out pick out there.


Thank you. I have to say the work of Ann John was fabulous in terms of the other committee that I'm on, the Children, Young People, and Education Committee, and our inquiry into support for young people who have mental health challenges within school estates. 

In terms of awareness, do you think we need to have improved mental health training for GPs and other healthcare staff, in terms of some of those areas that we've already touched on, the need for more disability awareness, sensory impairment awareness, neurodiversity and so forth?

So, the primary healthcare team are really at the front line of healthcare delivery in the country, and elsewhere in the UK, and the model is at breaking point, I think. In terms of training, still only about half of GPs have ever done any training in psychiatry as part of their professional development. So, they have to learn a number of different specialities. If you look at the WHO, World Health Organization, data, depression is second to back pain in terms of the long-term burden of disease that its puts on the population. Many GPs tell me that they don't have the same level of confidence about diagnosing and treating mental health problems that they do about treating asthma, high blood pressure, diabetes, and we see that coming to us in terms of people being referred much sooner down the treatment pathways than they would be to, say, a respiratory physician or a cardiologist. The problem in primary care is bandwidth; the solution is broadening the range of professionals who can deliver services in primary care, and skilling some of them up to be better at doing mental health care is absolutely vital. 

Thank you. If I may, Chair, just one more question, if that's okay, and it concerns the link between unresolved trauma and addiction, whether it be addiction to gambling or substance misuse, whatever it might be. Do you think there is sufficient understanding of that link, and what should Welsh Government do to be, if you like, promoting to, particularly, primary care the need to ensure that patients who are displaying mental health problems are not then more susceptible to addiction? Is there any way, do you think, that prevention of addiction could be incorporated into the support, early intervention, that people displaying mental health illness get?

So, several bits to that. Substance misuse services in Wales are very stretched. They're in a better state than they are in England, for sure, but would benefit from more investment. The issue about the link between that and trauma is certainly that many people who experience trauma—sometimes it can be a single event; more often than not it's complex and multiple events, which can be either things people experience as children or things that, for example, veterans experience in the course of their service—. So, there can be a range of different things. 

In terms of the services that we provide in schools to young people, actually recognising people who are at risk of different forms of neglect and abuse early on is critical, and that, again, is multi-agency. Once these things have developed, people need access to specialist psychological therapies; there are no drugs for that, essentially. We can use drugs to help a little bit, but, primarily, the need is for specialist psychological therapists, and access to those is limited for that group of people. There are specific treatment modalities that are very effective, but the challenge is making those services accessible to people at a time they feel ready and able to use them.

Diolch yn fawr iawn. A very good afternoon—no, morning, still; I'm getting ahead of myself. If we look at the need to work, as so often across health and care, in a joined-up way, getting agencies to work effectively together, what are the barriers to making sure that that does happen in the case of supporting people with mental health?

In terms of working across service boundaries, you see in community mental health teams people from a range of different health and social care professions; I think the barriers are where people go into professional silos as a way of managing their workload and push people between one area and another by creating barriers. Adequate funding for social care is probably crucial to that.


Are we seeing examples of good practice where people are able to come out of their silos and work effectively, and what does that look like if you are seeing good examples?

It looks like a seamless service, where people are able to access the range of services and support that they need across the piece. So, I guess the sort of thing that you'd see as an example of that would be—. I mean, we've spoken about employment, the link between employment opportunities and the prevention of mental health problems; the design of mental health services, so you could look at co-locating advice centres within mental health services, or vice versa; likewise, equipping advice staff with further mental health awareness training so that they can signpost people to other services. Critically, access to services needs to be improved. The waiting lists that we have for our services wouldn't be acceptable in any other area of medicine. You wouldn't accept it for cancer care, you wouldn't accept it for any other area of care and we shouldn't accept it here.

You'll find examples of good practice everywhere, it's just underfunded and the waiting lists are unacceptable. The targets that exist around acute care are much more a priority for health boards than those around mental health, because they aren't measured by the Government on so many things. For example, in in-patient settings, staffing levels only apply to acute care, not to mental health care. That would be one very specific example of that.

When you have different parts of the system working effectively together, does that clearly lead to better outcomes for the patient, for the individual, in that you're more likely to see a more tailored, a more nuanced set of treatments and support, if you like, drawing on the different elements of expertise offered by those different partners?

Yes. There is huge potential for social prescribing to work alongside these sorts of initiatives. Thinking about the people we've spoken about earlier, if I'm seeing an older adult, who is socially isolated, I can treat their immediate mental health problem, I can point them to other professionals to help them with some of their physical health problems, but it can be quite a challenge for me or other people to identify the social opportunities for them to engage with groups in their local community, either face to face or online if they prefer, to enable them to deal directly with their loneliness. So, if we could get the third sector and advice services working more closely with mental health services, then we'd really be doing something.

Are we exploiting the potential of social prescribing at all? Are we pushing the boundaries of what you can achieve through social prescribing, given that, in theory, it's a positive thing and most people will talk positively about social prescribing? Are we social prescribing enough?

Social prescribing is not a universal panacea, it's part of a complete package of care that people need. There's probably more that could be done around it if it were joined up. You could start very simply with knowing what resources are currently available in your local area—those sorts of resources are not usually terribly easy to find in one place.

Is that happening? Who should be doing that? Who should be leading the work of identifying the potential of social prescribing and spotting those things that people like you can use?

It would be something that Government could encourage the third sector to do in collaboration with ourselves. For example, I can think of good collaboration between the mental health charity Hafal in Swansea, where they provide an interim level of support for people who don't need admission to specialist services but who might need more support than they would get simply by being seen and then sent home again. So, there are initiatives like that that are examples of good practice. So, I guess Government could have a role, essentially, in measuring whether or not health services have got that sort of information correlated, up to date, and whether the connections exist and are made. It's not expensive. There's not much cost there.


Yes ,okay, that's worth us considering as a committee. Finally, perhaps, to what extent can we expect the creation of strong support networks, the bringing together of all these different agencies and third sector groups? To what extent can we expect that to create a kind of safety net and support mechanism that works in a successfully preventative way in terms of mental health and well-being?

Well, it's a really good question. I think what I'm suggesting is rebuilding the social glue of society that's been dismantled over many years by underfunding, and the opportunity to create that kind of help and reinforce that social glue in communities. So, I think what I'm saying is, anything that increases the cohesiveness of communities and their ability to work together to solve the problems of members in those communities has to be a good thing.

And nipping problems in the bud by having a supportive community that recognises the need of people around well-being and mental health needs.


And very finally, your thoughts on comments made by our earlier witnesses this morning who said, 'Yes, that's all very well, but we can't just think in terms of the nice preventative stuff, because, actually, people will still develop serious mental health illnesses that they'll need treatment with, and we can't be drawn in by hoping that the preventative stops all that from happening.'

Well, that's absolutely correct. We need the more—. No-one would suggest that we stop funding intensive care units because we need to increase the number of people being vaccinated against COVID, for example. So, the same would apply to mental health services. We need to make sure that the people who need the highest levels of care have those services provided. An example would be—we don't currently provide specialist in-patient care for eating disorders in Wales; we send people out of the country. For some of the people with schizophrenia and bipolar with the most complex needs, we still send them out of the country. There should be a priority about providing those services as close to people's homes as possible, when it's safe to do so. But some of the most vulnerable groups—young people with eating disorders or people with schizophrenia—we're sending them hundreds of miles away for treatments in other parts of the UK.

Yes, and we're looking at mental health inequalities here. The most vulnerable, the ones suffering as a result of the inequalities are the ones that are going to bear the brunt of having to move away and find that most difficult and not have the family networks that can support them.

Yes. Because of transport—and as you say quite rightly, the focus is on health inequalities and poverty—if your family member is being treated a long way away, you're simply not going to be able to go and visit them.

Thank you. I just want to go backwards slightly. You gave us some startling figures on the rates of suicide, and the 20 to 49-year-old male being probably the most likely to commit suicide. So, whilst you were talking, I wanted to explore the pre-20-year-old male, because we've got to that stage, and the facilities available to them in their communities that might make them feel less isolated, less alone, more able to communicate their feelings, which is often cited as a real potential for suicide—and I might be wrong in that. So, in all your assessments, have you looked at the diminishing availability of provision for young people within their communities as a consequence of budget cuts over the last 10 or more years that might help, and if you have, do you think there's any correlation?


That's a really good question. First of all, young men and adolescents are less likely to seek help than their female counterparts traditionally. Emotional literacy—training for that in schools is a really important part of the curriculum and should be improving emotional literacy. It's becoming more the norm for people to express their feelings now. I think that's a generational cohort effect, and that's really positive. We're seeing that in young people coming to university, for example. I appreciate they're, by and large, not in that most socially excluded group that we began by talking about, but even in that group, the level of need for mental health services and access to them has gone up considerably post pandemic, or now that we're living with COVID.

The second part of your question is about what's available for people. We assume that actually having the availability of clubs, societies, groups, community groups, community facilities is a good thing and can help provide positive role models for people from particular communities to be able to see people succeed. People need to see people from whatever their community is succeeding in and be shown ways of changing their lives and their situations. So, that social glue, those things that have disappeared from our communities, would be invaluable to put back and maintain. You're on mute, Chair.

Okay, somebody will unmute me in a moment. Can you hear me now okay? Can you hear me now?


Thank you. Throughout the session, professor, you've perhaps identified some areas of good practice. Do you think enough is being done to identify and share good practice in Wales, and if not, what needs to happen?

I think there's a need both to identify areas of poor practice, but also to celebrate areas of good practice and to acknowledge them. So, we probably don't do enough in that respect through reward and recognition of various kinds for services and community groups that do things. Where there are things that are successful like that, it's a real opportunity to celebrate achievements and success, and we should do more of that.

Yes, thanks, Chair. It is directly relevant to this point. Professor, have you come across Greater Good at all, at the University of California, in Berkeley, which is specifically what we're talking about now, a facility online for sharing best practice?

I have not come across it, but I shall go and look it up. Say more, please.

I just wonder whether it would be worth an academic institution in Wales, or a family of academic institutions in Wales, following the lead of the University of California, in this case of Berkeley, with a publicly accessible tank of resource and best practice directly with regard to well-being and mental health. It's a fabulous online resource, well worth taking a look at, and I'd really value your views on whether something could be replicated of this nature in Wales.

What we can do is—. That's really interesting, I'll certainly go away and have a look at that. We can come back to you on that.

Thanks, Ken. I suppose, what I'm asking, Professor Lloyd, is we can identify good and bad practice, and where we identify good practice, we can celebrate that, of course, but whose job is it is to ensure that that good practice is spread around? Whose responsibility is it to do that?

It's everybody's responsibility. The Royal College of Psychiatrists is about looking at the quality of services, about the training of its members, and we do that as a college—we celebrate good practice in our services where we see it. The RCN does the same thing for its members.


But we can celebrate, can't we? But when it comes to—. We're recognising that's good practice, it's right to celebrate it, but how do we ensure that good practice is spread across to other parts of Wales where, perhaps, there are gaps?

So, there's fairly good evidence that it can take several years for good practice to be disseminated and put into practice in other places. There's a whole industry of looking at how we can do that quicker. I think Government does have a role to play in that by highlighting that good practice and suggesting where it can be put in place more generally, but so do the professional organisations like the Royal College of Psychiatrists, the British Association for Counselling and Psychotherapy and the RCN and those other organisations, to do the same too.

This is probably the final question now, perhaps to help sum up this session. When it comes to tackling inequalities in terms of mental health, as a committee our job is to influence Government and we'll make a series of recommendations to Government. This is the last evidence session, actually, before the Minister comes in to present to us. What more can Government do? Our recommendations are to Government. What could and what should Government do? And what do you think should be covered within their new mental health strategy? Give us those bullet points from your perspective.

Okay. In the same way that the well-being of future generations is about joined-up policy making across different sectors and areas, Government needs to take the same approach to mental health, because there are so many different factors: poverty, employment, loneliness, social isolation. The approach need to be pan-Government and pan-agency, so that it recognises the multifactorial, multi-agency, multisector nature of these issues, and a commitment to reducing poverty and its consequences should be at the heart of that.

How do they do that?

You've mentioned, of course, making sure it's a pan-Government approach. I understand that's an action to Government, but how can Government address some of the other issues you've just outlined there?

Governments of all political persuasions want to see full employment, so they can promote meaningful employment that's fairly paid with reasonable conditions; by making services available in a timely fashion; by giving equal weight to mental health services as to physical health services—I think we still don't do that; by helping to recruit, retain and support the workforce—

How do they do that particular element of helping to recruit and retain that workforce? Is there anything around that point that you can make a recommendation around?

Yes, sure. Through the 'Train. Work. Live.' initiative, psychiatry was one of the areas that Welsh Government gave additional financial incentives to people into the profession, and that had a clear impact on recruitment into the profession during the time that that was in place. So, that was a good thing. It's about how we maintain that.

It applies, probably, to other professions as well, because, as I say, we're seeing a dip in people coming into those professions at the student level now as well, despite the upturn in young people in the population looking for those sorts of educations. So, doctors in Wales are still paid less than their equivalents in England at most career stages, so there are things like that that people could look at. But I'm aware that we're just one of the professions and it needs to look right across the piece at how people are rewarded for their work.