National Assembly for Wales

I'd like to welcome everybody to the meeting of the Children, Young People, and Education Committee today. The public items of this meeting are being broadcast live on Senedd.tv and a Record of Proceedings will be published as usual. Aside from the procedural adaptations relating to conducting proceedings remotely, all other Standing Order requirements for committees remain in place. The meeting is bilingual, and simultaneous translation from Welsh to English is available. We've received no apologies this morning. Are there any declarations of interest? Sioned.

Diolch, Sioned.

We'll get on to the first item on our agenda, which is our evidence session 3 on mental support in higher education. I'd like to welcome all the witnesses that have joined us here this morning. We have Andy Bell, deputy chief executive officer for Centre for Mental Health; Sian Taylor, clinical lead for primary child and adolescent mental health services, Aneurin Bevan University Health Board; Angela Lodwick, head of service, s-CAMHS and psychological therapies, Hywel Dda University Health Board; Richard Maggs, medical director for adult mental health services, Swansea Bay University Health Board; Andrea Parry, team leader, Iechyd Da youth health team, Hywel Dda University Health Board; and Emma-Jayne Hagerty, clinical lead specialist, eating disorder service, Aneurin Bevan University Health Board. Thank you all for joining us. We've got a large panel this morning and lots of questions to go through, so I hope Members and witnesses can be as succinct as possible. As a rule, I'll generally go to you, Centre for Mental Health, to answer the questions first, and, hopefully, the relevant health board representatives perhaps can each take a question unless it's directed at an individual. So, we'll move straight into our question session this morning, and the first set of questions is from Buffy Williams. Buffy.

Thank you, Chair. Thank you all for joining us this morning. My first question is: to what extent are there gaps in the information about mental health conditions from students in higher education? How should these be addressed and, also, by whom?

Andy.

Thank you. It's a really interesting question. I think one thing we do know that is positive is that young people and young adults are more aware about mental health and have more understanding and language around mental health than ever before, and that's due to the fact that we've had quite a significant cultural change in our willingness and ability to talk about mental health, and a lot of the awareness and anti-stigma campaigns have, I think, opened up conversations, but, inevitably, there's a gap around mental health literacy, and there still is a lingering issue around stigma and not really knowing what to do with that.

I think, inevitably, we need to use lots of different routes to get messages across. We know that everyone receives messaging differently. Different media work for different types of people. We mustn't make assumptions about students and their preferred methods of being communicated with, or indeed communicating with one another, but I think we know that messages from peers are often quite powerful—so, people that they have some kind of affinity with. But I think it's also important we take every opportunity to build up students' knowledge about mental health, whether that's through an information campaign at a very high level, or whether it's a one-to-one interaction with a tutor or somebody that they have a connection with in the university. There's no bad way to do that, as long as it's done well and empathically and compassionately.

Thanks, Andy. Does anyone to come in from a health board? No. Buffy.

Right, I'll move on then. To what extent is the higher education student population atypical and needing targeted mental health support? Do mental health conditions for other young people compare to their peers in higher education?

Andy.

This is a really interesting point. We know that the age group that students in higher education predominantly come from have very high and rising rates of mental health difficulty across the UK. I am drawing on data here at UK level, not at Welsh level; it's important to say that. Other colleagues may have more data that's closer to home. But I think what we know is that rates of poor mental health are rising, particularly in the 16 to 24 age group, and particularly among young women. That's where we've seen the biggest increase over the last decade or so in poor mental health. We know also that people who go to university tend, on average, to have better mental health than those who don't, and, so, while it's really important to understand the particular needs and concerns of young people who are in higher education, we mustn't overshadow those who are not in higher education, who generally have significantly higher rates of poor mental health, and may be missing out on the kind of support that is rightly provided when you are in a higher education setting.

So, clearly, there are some significant differences. There are also big inequalities within the student population. We know that women students, unsurprisingly, given what I've just said, are likely to have higher rates of psychological distress than men; LGBTQ+ students, overseas students, and certainly students who are from more disadvantaged backgrounds, are more likely to experience mental health difficulties than others. 

Thank you, Andy. Does anyone want to come in from a health board, before I bring in Ken? No. Ken. 

Thanks, Chair. That was really interesting, Andy, what you were saying about younger people in particular showing increased signs of mental ill health. Would you say that this is across all conditions and across all severities of conditions as well? Are we seeing an increase in, for example, low-level anxiety, depression, as well as more serious conditions, like multiple personality disorder and schizophrenia, or is there a specific set of conditions that we are seeing a particular rise in?

A really good question. I think, for young people, mental health diagnoses are often quite difficult to make. So, I think, what we're seeing is rising levels of psychological distress, and whether that comes in the form of one condition or another—. Many people, during their course of being treated for mental ill health, may find that they get lots of different diagnoses at different times. I think we're certainly seeing an increase in prevalence of mental health difficulty.

It's worth thinking of mental health as a spectrum, by the way, rather than a binary thing, so it's not the case necessarily that you're either mentally well or mentally not well; we're all on a spectrum. And many young people are in that area of the spectrum where they may have poor psychological well-being but not necessarily a diagnosed mental illness, or a diagnosable mental illness. So, I think, what we're seeing is more young people going up to the wrong end of the spectrum, if you like. One thing we have noticed, particularly over the last two years, is a very worrying increase in young people being referred for treatment for eating disorders, and that is a very, very concerning issue, and I'm sure that colleagues here will have a lot more intelligence about that, because we know just how serious eating disorders can be. 

Thank you. James.  

My question is: you said there's a big difference between young people who go to higher education and university have better mental health than those who don't. I know you've said that social deprivation is a factor. Do you think there are any other factors that play into that? 

We know that deprivation is probably the biggest risk factor for poor mental health in any society, and, certainly, in the UK today, and, of course, particularly, facing a cost-of-living crisis, that's very acute. I think the other thing about young people who don't go to university is that, by and large, they may well be in a workplace, or they might be in more financial difficulty, certainly with less certainty about the future, and so, there may not be that structured mental health support available. If someone goes into an apprenticeship, for example, or into employment, it then depends on how good the workplace is in terms of supporting their mental health. And, of course, for many young people who don't go into higher education, there is that greater uncertainty about what prospects they may have in life, and they may be dealing with quite a lot of other difficulties, and just knowing, in a sense, that they're missing out on something. 

Yes. Sorry, Chair, if I can just jump back in there, I think that's a very important point. Because of the way work life is set up at the moment, almost every job across the country requires you to have a degree, and I think people who don't go to university do feel that, 'My prospects have been narrowed'. So, it's interesting that you say that, because it’s something that I hear quite regularly.

Thanks, James. Buffy.

Thank you, Chair. We know that our young people find that there’s a stigma surrounding seeking mental health help. What do you think can be done to break down the barriers? And also, how do you think universities and educational settings can make it more accessible for our young people to access mental health help without them feeling that there is a stigma attached to it?

Andy.

Do you want me to go? I think, again, multiple routes have got to be the answer here. Just to tackle the stigma question, the way stigma works with mental health is complex and we see it in a number of different ways. One piece of work we did talking to students in further and higher education found that one of the biggest barriers to help-seeking if they are experiencing mental health difficulty is a view that there’s a lot of pressure now to succeed at university, both socially and academically, and if you’re seeking mental health support, that therefore implies that somehow, you’re not doing well—you’re not making friends, you’re not a great social success, you’re not getting on with the course. The way stigma operates is really interesting, and we need to see that it’s different in different circumstances, and so, I think there’s something about ensuring that there are different routes to support. Obviously, the use of digital technology allows many different routes to getting access to support now.

We evaluated the excellent Student Space initiative that Student Minds developed in 2020 and found that it had provided a different and really interesting route for students to seek support for their mental health. But of course, you also do need traditional services available, face-to-face support—we know that’s really important for many people. Online isn’t necessarily a simple replacement for face-to-face support—far, far from it. So, I think it’s really finding multiple routes, and a ‘no wrong door’ approach is helpful, and of course, if you’re proactively asking young people about how they’re doing, and you’re creating those conversations in just routine ways, you’re perhaps more likely to identify someone before they’ve reached the point where they’re really hitting a crisis.

Does anyone from the health board want to come in? No? Yes—sorry, Andrea. Angela.

Thank you, Chair. I just wanted to mention the all-age single point of contact that Hywel Dda has established, which is the NHS 111 option 2. I think that gives us an excellent opportunity to showcase the services available within the mental health services, and I know that colleagues in adult mental health have been going out to our universities and our colleges to share what they offer. They’re leaving business cards and the aim is to provide sessions on mental well-being and break down those barriers that stigma carries about mental health. So, I think that will be a really good process for us to use, and I think that will also be supported by the school in-reach services that myself and my colleagues on the consultation are involved with, in that we are now present in all schools, and that will extend to colleges within our area in due course, and I think that’s a good opportunity, again, to break down the barriers and promote good emotional well-being and reduce, hopefully, the impact of mental health conditions. Thank you.

Thank you. Buffy.

Thank you. We know that there are inequalities in terms of mental health provision across the board, especially for students from ethnic minority backgrounds. How do you think we can address this? Also, I know that all education settings provide their own standard of mental health provision, how can we ensure that each university or educational setting has a good standard and a good quality of educational psychology? Because from my own experience, I know that each college I've visited and each comprehensive school that I've visited, they’ve all got their own way of doing things. How can we make sure that that standard, that good gold-quality standard, then, is met across the board?

Andy.

Thank you. That's a really good question. I'll take the racial inequality point first, because I think that's a really important one. And, again, it's really important to say that we know that people, particularly from black African and Caribbean communities do not, for very good reason, trust mental health services. Very often, you have an adversarial relationship with schools and with the police, and that extends, unfortunately, to mental health, and we know that that means that people aren't getting early support and we know, indeed, that there is a greater risk of poor mental health among people from racialised communities, and their experience of services is very much poorer.

I think what we do know is that, where mental health services reach out and work alongside and in partnership with communities and community organisations, you get a much more accessible, open and safe feeling to the support. So, I think crucially, we need to understand those dynamics, we need to understand how structural and systemic racism work, and so, we need services that respond to that. And, again, if young people from a community see services run by people like them with a similar experience to them and they are outreaching and proactive and they create a sense of safety, and they're informed by an understanding of racism and racial trauma, rather than just assuming that if we say, 'We're here' loud enough, those services will be trusted—. So, I think that's crucial to address the inequalities that we know exist there.

I think the other thing that is really important to say, thinking about the whole institution now, is that there's growing evidence around the importance of what you might call a whole-school, whole-college, whole-university approach to mental health. It's jargon we use a lot in mental health and it's probably worth saying what that really means, which is essentially that the culture and the processes of that institution, be it a school, university or college, consider, think about and support mental health from day one onwards, and for everyone in that community, including the staff members, who often get forgotten in this conversation. So, you create a nurturing environment, you create an environment where people feel safe, where there are positive relationships and where everyone is supported where possible to enjoy good mental health in schools. It's about putting it on the curriculum as well, of course. And I think if you're doing that consistently, then you can begin to create a culture where mental health is supported. It's not about creating extra work, it's not about putting yet another burden on people who are already working very, very hard, it's about creating a supportive and nurturing environment. And that takes time. You can't do that overnight. But I think once you start to bring those principles into practice you've got a much better chance of creating a good, supportive environment for people.  

Thank you, Andy. Anyone else from the health board? No. We'll come on more to mental health support within universities later on as well. Thank you, Buffy. We'll now move on to questions from Sioned Williams. Sioned. 

Andy. 

Gosh, that's a complex question, isn't it? It's really difficult to disentangle the different factors. So, we need to be mindful that they interact with each other. And I think one of the things that is really interesting is, when you look at surveys or you look at qualitative research with young people—and we're predominantly talking about young people; not all students are young, of course—but when we look at the age group that's predominant in higher education, and particularly those who are in a higher education setting, very often, it's the same things that affect everyone's mental health: it's worries about money, and I think that is particularly acute right now; it's worries about relationships; it's feeling insecure; it's experiences of discrimination, exclusion and isolation. So, we know there's a big list of risk factors for poor mental health. And of course, the more of those risk factors you have, the more severe they are and the longer they go on for, the greater your risk is of having a mental health difficulty.

So, although it's very difficult to isolate them or say, 'This one is more important than that one', I think we do know that financial exclusion is a really major one. And I think, again, for anyone at university, there is now greater pressure because of the knowledge that you're racking up a lot of debt, the knowledge that the future labour market may not be as welcoming of people graduating from university as it used to be. And I think, inevitably, there is the extra pressure for students who are away from home, again, to settle into a new place to learn the things that you have to do as an adult away from the supportive environment you may have been in. 

And of course, there are very, very particular issues for care-experienced people going into that environment. It's difficult when you've got a family environment you come from and go back to; anyone who has been in the care system will know that that is a really vulnerable time in your life. It is just an age where there is a lot going on that can affect your mental health. So, again, some of it's about the university experience, but a lot of it is about the experiences that young people bring with them and the anxieties they have about their future. 

Anyone else? No. Sioned.

We've done a lot of work looking at the impact of the pandemic on mental health for people of all ages, and we looked particularly at students when we were evaluating Student Space. I think what's clear is that it has created multiple pressures, and again, they're not all applied equally.

For every student, of course, their education has been disrupted massively and that's a fairly universal experience. Young people who were at university during the lockdowns will have either not been at university or been in really, really pretty awful situations, particularly overseas students of course. All of that university experience will have been completely blown to pieces for some students, or a large part of it. Those coming to university now will have been at school or college during that time, so, again, that will have affected their experience coming into university. But again, it's not equally experienced. There will be young people who've experienced traumatic grief and loss; there will be students with health problems, both physical and mental health problems, who would have been at greater risk from the virus and indeed from the restrictions that were necessarily created around it.

And then, of course, the cost-of-living crisis comes on top of that. And, again, one of the things that we were concerned about in relation to the pandemic was the economic effects. What we're now seeing is more and more people being pushed into poverty and those who are in poverty going deeper into poverty. We know that that creates a risk to mental health; we know that that has a major causative effect on experiencing mental health difficulties—it's not an association, it's not a coincidence.

In terms of things that the Welsh Government can do—all Governments can do—the first thing of course is to protect people from poverty, and if you can't protect people from poverty, protect them from the worst impacts, so make sure people are getting what they're entitled to, that there is as much financial support as possible, and indeed, that mental health support is there, available, easy to access, and that there aren't long waiting lists and long waiting times for getting hold of mental health support when you need it, and if you do have to wait, that there is support while you're waiting, and that that support doesn't presuppose you have access to the right devices and internet connection. Because again, we can create a new disadvantage for people that are financially disadvantaged if we're relying on online access to services to get you in.

Anyone else, to add to that? No.

The means by which you could do it is outside my area of expertise. I think the thing that I would say as clearly as I can is: if students are facing poverty, and in a really serious financial situation, if they're really worried about being able to keep things going over the winter in particular, particularly students who are more vulnerable, then you are going to create suffering, and if you can create buffers against that, and you can create a system where there is a degree of certainty about your ability to get through and cope financially, then that is going to help to support their well-being at a time when there may be a very inflated risk.

Andy, do you want to start?

Yes. This is really interesting. I think mental health services had been kind of toying around the edges of working remotely and providing support through digital tools for some time prior to the pandemic, often on quite a small scale, and I think what the pandemic did is suddenly make that the main route by which the majority of services could reach people.

Very interestingly, some data that was published yesterday across the UK showed that for mental health services for all ages, we're now back to about 50 per cent of support being provided face-to-face, but only 7 per cent is being provided online, so the remainder, about 40 or so per cent, is being done by phone, which of course is a rather old technology. This is for people of all ages. Services for young people have tended to favour online and digital routes, but nonetheless, across the whole, we're seeing a lot of use of phone. I think inevitably, working remotely with different types of media—. And for some young people, or people of all ages, text-based support is a really helpful adjunct, or, indeed, a different way of getting support. So, there's no way of saying, 'This group of people benefit from digital, this group of people prefer phone, and this group of people want face to face.' It doesn't work that way; it's often about individual factors that determine what your preference is and what you find most helpful.

I think what we know is where we are having remote-based support, you really need safeguards around that. You need to ensure that the person feels comfortable, that they have a safe space where they can engage with mental health support—not everybody does. Not everyone has a secure internet connection or the right kind of devices, so, again, we need to think about how you wrap support around someone who might like to engage online but that's not straightforward for them. And, of course, you need to ensure that the people working in that service know how to use that medium properly. Again, there may be some forms of mental health support that can be done remotely, and some that can't. It's very hard to support someone with their physical health, for example, remotely, but reminding people about appointments and, indeed, some peer-support groups can work very well online. For some people, it's very much a preference, because it's more convenient, particularly if you're in a rural area and you've got a good internet connection, which, itself, is a bit of a stroke of luck. But, again, where you don't have to travel, that can make mental health support more accessible to someone if it's really quite difficult to get to the kind of places where it tends to be provided.

Thanks, Andy. Anyone from the health boards, Sian or Emma-Jayne? Would you like to come in? 

I agree with everything Andy said. A lot of it is personal preference. For us, we have to still see a lot of our patients in person because of the physical health monitoring aspect involved, but we do continue to provide support to any of our patients that move away to university virtually. There is a challenge, because a lot of our patients, just because of the body image concerns and things, don't like to be seen on screen or see themselves on screen. We're just in the process of purchasing a licence for an eating disorder evidence-based Recovery Record app that allows us to interact with patients on a daily basis through that app as well. We've used it a couple of times with some patients, so it's going to be really good that we will be in a position to offer that to everyone.

That sounds really interesting. Does anyone else want to come in? Angela.

Thank you, Chair. I think the pandemic enabled us to use the digital resources that we've developed much more effectively. Certainly, across mental health services within Hywel Dda, they were classed as front-line services, so face-to-face assessments and interventions continued, albeit supported by the Attend Anywhere and consultant—[Inaudible.]

We might have lost Angela—

We've also got a number of new digital resources to use now, such as Kooth and then also SilverCloud for cognitive behavioural therapy online. So, we're able to offer young people a range of support and interventions. That, I think, is a good thing, and is based on preference and that blended approach. Thank you.

Thanks. Richard, did you want to add anything?

I'd just echo that, really. We obviously accelerated the use of digital platforms during the pandemic, but continued to offer face-to-face. It's a variety of online resources that have been described that I think most health boards probably use. The roll-out of the '111 press 2' gives people access to immediate contact with a mental health professional, so they can triage their level of need, so that they can fit into the appropriate tier of the service. I think it's important to distinguish people who have or are maybe developing symptoms of serious mental illness, so that they would have access to early intervention, psychosis-type services—[Inaudible.] 

Sorry, Richard. We can hear someone else on the line at the same time, so it's not very clear. You might need to use your headset, I think, perhaps, Richard. 

Sorry.

It's okay. Try now.

I've pretty much finished now, really. I was just talking about the 111 early intervention in psychosis, distinguishing between different tiers of mental disorder and the different services that are available depending on the severity of your condition. Earlier, there was a discussion about incidence and prevalence of various disorders, and, I think, the incidence and prevalence of serious mental illness tends to run fairly steady over the years. I think it's probably worth acknowledging that there's clearly a rise in anxiety, depression, et cetera, et cetera. One thing that we've seen in Swansea bay is a massive increase in referrals for attention deficit hyperactivity disorder assessments from the universities, which I think is quite an interesting phenomenon—probably multiple explanations for that. I'll stop there. 

Thanks, Richard. Sioned. 

That's it. Diolch, Gadeirydd.

Thank you, Sioned. Questions now from Laura Anne Jones. Laura.

Thank you, Chair. On mental health support within universities, and following on from what Buffy said earlier, evidence has highlighted the importance of giving students a consistent standard of support, regardless of where they live or study. We've heard some great examples of best practice already today, and also I'm aware of something in the Aneurin Bevan health board that offered peer-to-peer support online, which I thought was a great scheme. How can Welsh Government ensure a consistent standard of support, given the diversity of the student body and the range of providers who are involved in providing support? Thank you.

Andy. 

I think that's really challenging, isn't it, because there isn't clearly just a single route; there isn't just a single model that you can use. To some degree, of course, it is about ensuring that you are commissioning the services that we know provide good-quality clinical support. As Richard mentioned, if you're a young person with the early experiences of psychosis, that's very serious and you do need to make sure that you've got access to evidence-based interventions, using an early-intervention-in-psychosis-type model, for example. So, it's about ensuring that you're using the evidence base, which is always emerging and always changing, that you're using the evidence according to how it should be provided, and that those services are faithful to the model. That, again, is really important.

But, inevitably, I think it's also about understanding the student experience, and ensuring that there are ways of hearing from students about how effective the mental health support they've got has been, and ensuring that there is always that kind of feedback cycle involved. There clearly isn't just a single approach that works, so it is about having that range of different types of support, and ensuring that, when you're seeking feedback, groups that don't often get heard so much or whose needs are not considered so well, an example of which might be the overseas students, for example, that their voices are heard in that. 

I think, as colleagues were mentioning earlier, there is also the crucial factor of young people who are coming to university who are already in contact with mental health services in their home area. There is a real challenge about ensuring that there is consistency of support, if they're going to university somewhere outside their home area, and, indeed, of course, going back, because it's not a one-way journey. So, again, really thinking about systems of support that follow the individual—easy to say, fiendishly difficult to do. It's a really complex area to have that assurance that the services are meeting people's needs, but the best way of finding that out is probably to ask.

Sounds good. As Laura mentioned Aneurin Bevan in her question, Sian or Emma-Jayne, do you want to add anything?

A lot of work has been done with public health, going into colleges and linking with students and with student unions, and with trying to find a better way to provide that support. You were talking about the whole-system approach, I'm working in CAMHS, and very used to parents being a big part of the support system, and I wonder do we think enough about who to put in the room, and how we think about parents, because you don’t stop being a parent of a child just because they turn 18 or go off to university. I think the relationship’s different, but I wonder we how we also use parents as a resource, and to support parents going forward in having a role, because I think young people are in contact with their parents a lot, or can be. Just thinking about supporting parents and what their role could be there, too, as well as peers. We’ve talked about the peer support that’s needed, and I think that’s really, really important.

Thank you. Laura.

Thank you. That’s a really valuable contribution, I think, and something for us to think about. Following on from what you just said just now, it’s really important that we don’t create a postcode lottery of support. Just to diversify a bit, is there a way that best practice, and things that are working, are shared across Wales? Is it shared well enough, in your opinion? Or should there be something established along those lines? Thanks.

Andy, did you want to—?

I’m going to have to leave that to colleagues who are based in Wales, because obviously it would be unfair to even venture a comment.

Okay, thank you, Andy. Aneurin Bevan. Oh, we can’t hear you, sorry. Oh, we’ve got you now.

Sorry. I can only speak, I suppose, from the eating disorder service perspective, but we link up very closely across Wales. We have a number of different forums where the eating disorder services, adults and CAMHS, get together. When we have transitioned students from one eating disorder service to another in Wales, that goes quite smoothly through the care treatment programme approach. The challenge is more when it comes to transitioning outside of Wales, and services there. So, we have good forums, we have an all-Wales special interest group for eating disorders, and our sub-group meetings and things, but I’m not sure about more general mental health.

Just in terms of the schools in-reach, my understanding is that the schools' in-reach teams are starting to be formed in schools right across Wales. There is a national forum for that to be shared, but you’re right, it is a bit bitty, and there isn’t one place that all the best practice is shared, and I think that would be a really, really good idea.

Angela or Richard? Do either of you want to come in? Richard.

Yes, just in terms of psychological therapy, Matrics Cymru gives guidance on delivering evidence-based psychological therapy across Wales, which I think is applicable to every health board. So, there’s a standard, if you like, of evidence-based practice that all health boards are expected to deliver on and report on, and that will also include waiting times.

Thanks, Richard. Laura.

Thank you, Chair. Sorry, I believe we might be going on to a bit more of this later, but maybe it’s something to consider, the cross-border issues there. To the Centre for Mental Health, you’ve evaluated the HEFCW-supported initiative Student Space; how effective has the service been, and are there other practical interventions that the Welsh Government and the regulator could take to ensure students receive that consistent standard of support? Thanks.

Andy.

Thank you. We’re really impressed with Student Space. Inevitably, it was quite challenging to get data on the extent to which students have found the actual interventions available on the portal helpful, and that was beyond the scope of what we could do, but I think what we were able to find is, first of all, that it offered a valued and valuable extra form of support, particularly during a difficult time, and actually it’s a resource that should and could have longevity. I think we were particularly impressed by the fact that Student Space had worked very hard to produce high-quality information and advice, that they linked with higher education institutions in doing that—they didn’t just go off and do something separately—and that they had a really strong sense of working with particularly marginalised and disadvantaged groups of students and providing resources specifically to meet their needs. So, I think, for us, Student Space has really created a positive and compelling resource for students’ mental health. It’s got a lot more potential to be used much more widely than it has been, and we hope to see it grow over the coming years. So, again, it’s not about seeing online support or this resource as being a replacement for other forms of support; it’s about being an additional resource and something that can help, potentially, to link students up to support available locally, by providing that connection. We’ve been incredibly impressed by what was produced with actually a very, very small resource.

Thanks. Laura.

Thank you. The new commission for tertiary education and research will play an important role with regard to student mental health. How would you like the new commission to approach working with the healthcare sector, and do you have any recommendations for the commission as it begins its work? Thank you.

Andy.

Well, I’m sure colleagues here from the mental health sector will definitely have views about how they would like to work with it. I think the crucial thing is that we bring together the different forms of knowledge. There is that intersection here between the education world and the health and care world. That, often, is where we struggle to create the right support. They’re often not even speaking the same language. We found that particularly with schools, when we’re talking about school mental health. Often, healthcare and education professionals don't really have the same understanding of what we’re talking about. So, inevitably, there has to be a coming together, there has to be a co-production of knowledge and, crucially, of course, the partners in that have to be students themselves, and diverse groups of students themselves, because their views and understandings will be incredibly important.

We do sometimes find that how services are perceived by young people in particular is very different to how professionals believe they are perceived by young people and, indeed, parents. So, it’s fundamentally important that any solutions are properly co-produced and that students themselves are right at the heart of that process. It shouldn’t just be that they’re the end product, if you like.

Absolutely.

Yes, absolutely. Does anyone from the health boards want to come in? Angela.

Thank you. Yes, I think Andy’s right in the sense that it’s really important that we hear the voice of young people and students in particular when we’re developing new services. I think we can learn from the work that’s been undertaken with the school in-reach projects across Wales at the moment. There has been a robust evaluation of the pilots, and hopefully we’ll have a further evaluation of the impact of that on not just students, but also on the educators as well, because the whole system is being supported. So, I think that’s a really important way forward.

That sounds really interesting. I think it would be good for the committee perhaps to see some of that evaluation as well, if that’s possible. We’d be very keen. Laura, did you—

Thank you, Chair. That’s great.

Lovely. Thank you. Ken Skates.

Thanks, Chair. I’m going to ask about interactions between healthcare and education providers in a moment, but before I do, I have, perhaps, a question for Andy. It’s a bit of a difficult one, and apologies for asking such a pessimistic question, but is it the case that, no matter how much intervention is made on the part of the Government, healthcare providers and providers of various mental health support services, we’re going to see over the next decade a continued rise in the numbers of young people and people in general in society presenting with poor mental health and mental health conditions, as a consequence of the pandemic and of ongoing anxiety over the cost-of-living crisis? And is it the case that interventions will only, if you like, flatten the curve—they won’t halt that rise in numbers over the next decade—or are you more optimistic? Do you think that if we do have an overwhelming and really concerted intervention and collective effort, we could actually slow down more quickly and turn the corner faster in terms of that increase in mental ill health?

Thank you. I work for a charity, by nature I’m optimistic. You’re right, if we look at what we are projecting in terms of the long-term impact of the pandemic on mental health and the impact of growing levels of poverty and financial difficulty—and indeed, we have to include within this the climate crisis and conflicts as well—there are numerous pressures on particularly young people's mental health, but actually across the population. The inequalities that we've seen and described will only get worse if we do nothing. I think, inevitably, a mental health difficultly prevented is much better than waiting for something to become either really serious so that a person goes to crisis point or will need some kind of support.

One of the things we strongly recommend—and I think with the Well-being of Future Generations (Wales) Act 2015 Wales is a step ahead of other parts of the United Kingdom here—is, if you think about policies from the perspective of what would support good mental health in the population and what would reduce inequalities, then the policies being made would hopefully have that test of what would help to produce good mental health in the population and what will help people living with mental health difficulties to have a better, fairer chance in life. So, I think there are things we can do to prevent problems in the first place.

Inevitably, the real challenge for mental health services is that, across the board, they probably only meet about a quarter to a third of mental health need now across the whole population, and that's the case consistently across the UK. That's very challenging to hear, but it is the reality, broadly. And so, inevitably, there is always unmet need and that unmet need unfortunately can sometimes lead to people getting into a crisis and, therefore, the care they need is much, much more expensive than if you'd met that need early, as well as someone experiencing huge amounts of distress. And of course, the more you focus your services on meeting people's needs in a crisis, the more people will end up in a crisis and so services get stuck in a really—. I mean, this is an awful position and this is not the fault of the commissioners and service providers. We know that where you have austerity policies around mental health or indeed public services full stop, you create actually more expensive services in the end, because more people need more expensive help.

We really do need to find a way of shifting the focus towards earlier intervention, towards relatively inexpensive services that can help people quicker. I think what colleagues have described about the in-reach with schools is a good example of how you can begin to shift that dial. It's good that it's being evaluated robustly and there will be opportunities to learn from that first phase. I've always been impressed by the fact that Wales has policies around having counselling available in schools. It's in secondary schools. Why it wouldn't be in primary, I don't know, but at least it's in secondary. 

I think the more you focus on early intervention, the more you try to shift resources towards early help, the better system you'll have, but I think it's inevitably very, very difficult when you are dealing with crises. You can't leave people in a crisis without support. That's clearly completely unacceptable. And the more resources are stuck there, the harder it is to shift towards earlier help.

Andy, that's really, really interesting. Would you therefore advocate increasing significantly the amount of counselling available in schools and for all ages of young people?

Yes. Obviously, there is no reason why primary schools should benefit less from counselling than secondary. Counselling will meet some people's needs in some ways some of the time, so it's a great service to have within schools. That shouldn't be the only thing. You're not having a whole-school approach to mental health if you have a counsellor and do nothing else. But if you don't have counselling available, you probably can't say you've got a whole-school approach.

I'm just going to bring in James Evans for a second, Ken.

On this point, it is very important that people get help when they ask for it. We are seeing that the referrals are going up—they're going over the four-week wait time and that is even for counsellors in schools. So, I'd like to know what your thoughts are on where the third sector can fit in this as well. What can healthcare providers push to the third sector to actually give those young people that initial conversation, that initial assessment? When people reach out for help, they should get it straight away, because they've obviously reached crisis point to get there, and then the delay of getting that person seen can be critical. So, I'd like to know how you think the third sector can do more to assist the healthcare profession in seeing young people in a timely manner.

There's a huge diversity now of voluntary and community sector services supporting mental health, from well-being support, if you like, at the very, very preventative end, through to some clinical services that are probably working at just the same level as NHS or local authority-funded services. I think we've been certainly impressed with a lot of the voluntary and community sector organisations that we have had the good fortune of evaluating around young people's mental health. We think that the early support hubs using the youth information, advice and counselling services—YIACS—model are particularly impressive, because they offer early, easy-to-access help without need for a referral or an appointment for young people. We think that is a particularly attractive model.

But there is no single approach. I think a lot of community-based organisations in particular provide valuable and valued support for young people who just don't want to go near statutory services. Unfortunately, what we often hear is that parents battle to get a young person help from a statutory service. They go along, it's very, very clinical, it's an environment they don't feel comfortable in, and sometimes, there's only one contact, because they don't actually find it meets their needs. And so, for some people, it may be that a different type of approach is more helpful. So, again, I think what voluntary and community organisations can do is bring that diversity of types of help to the system, working alongside in an equal partnership with statutory services, who of course are providing those vital services that meet people's needs when they most need it.

I am going to get onto the questions that I was going to ask about education providers and health providers. Just one more really quick question, though, Andy, and it concerns unresolved shame. I think most policy makers appreciate the contribution that unresolved trauma makes to lifelong mental ill health and poor mental health. Do you think policy makers fully appreciate the role or the contribution that unresolved shame can make to poor mental health? It's something that I think practitioners would probably recognise, but I'm not entirely sure that policy makers really appreciate the role that shame can have in contributing to poor mental health—or am I being unfair?

Good question. I don't think I know the answer. I don't think it's talked about very much. I think we're only beginning to really understand what trauma means. We continue to, for example, imprison women when we know the huge proportion of women who go to prison who've experienced trauma in their lives; we put people in restrictive environments. I think mental health services are still only just learning to deal with trauma, let alone other issues that people have got.

But, again, if we take a social model of mental health and we think about poor mental health as being a function of the lives we've lived and the things we've been through and the experiences we've had, and we think about mental health services as being there to support people to deal with those things and to have a better opportunity in life and to resolve whatever those difficulties are, then we can begin to build services and policies around that. That's really important, I think. But for many, many people working in health and care services, the experiences of the last two to three years of the pandemic are going to be particularly challenging for them. We know that there are phenomena like moral injury, for example, that can affect people very, very long term. So, there's a lot of stuff to work through.

Thanks, Andy. Unfortunately, we've run over time here, so I think if everybody is okay, we'll write to you with our further questions that we have. We really appreciate you taking the time today, but obviously, lots of Members had lots of things to say, and we really appreciate all the evidence that you've given. So, I'm just conscious of time, and I know we have a number of questions that we would like to ask, so we will put those in writing. But thank you very much for joining us this morning. We will be sending you a transcript for you to have a look through in the coming weeks, but we really appreciate your evidence that you've given. Diolch yn fawr. 

To Members, we're going to take a very quick five-minute comfort break before our next evidence session.

Welcome back, everybody. This is our fourth evidence session on mental health support in higher education. I'd like to welcome our witnesses here this morning. We have Dr Liz Forty, Royal College of Psychiatrists in Wales; we have Dr Julie Keely, Royal College of General Practitioners; and Dr Kim Dienes, lecturer in psychology at Swansea University. You're very welcome here this morning; we really appreciate you coming in to give us evidence. Obviously, Members have lots of questions to ask you and lots of things to get through, so just to remind Members if they can be as succinct as possible, and if you could do likewise in your answers. I'll start with the RCGP to answer questions first, followed by the Royal College of Psychiatrists and then Dr Kim Dienes, unless the questions are directed directly at you. So, just to let you know that. We'll make a start, and we've got some questions from James Evans.

Diolch, Cadeirydd. This is for Liz and Julie, and I'll be very brief. What are the main challenges that you face in supporting the mental health and well-being of our student population? If you could ask for one thing from the Government and health boards, what would that be? 

Shall I go first? One thing—that's challenging. Obviously, for us it's the increases in student numbers in terms of students accessing support through universities and their ability to get access to services through the NHS. Sorry, I'm not sure I can do one thing—

Go on, that's fine. 

In terms of the main things that we're struggling with at the moment, it's providing access to services, so psychological therapy, particularly things like CBT and trauma-focused therapy for students, and getting that in a timely fashion. At the minute, the waiting times are just too long for students to be able to access that whilst they're at university. And then the other thing that we are struggling with is screening for neurodevelopmental conditions, so things like ADHD and autism. Those, I would say, are the main things.

And if the Government could help you, what would you—?

One thing that has started to help is the mental health university liaison service that has been funded. That, I think, is key to us moving forward to improving the links between the university and the NHS. That's probably a really good resource in terms of thinking in terms of moving forward about how we can deliver those clinical services, but within the university setting, perhaps. So, that's something that would benefit from having a longer-term vision about how that's going to develop going forward so that we can be aware of how we can implement that and use that to the best of its ability within the student population. That's probably the main thing for me at the moment. There is one other thing, actually—

Carry on.

The other main issue we have with our student population links particularly to our students on healthcare courses—so, medics, dentists, nurses, these kinds of professions. We, until very recently, for our medical students, for example, had access to psychological therapies through HHP, which is now called Canopi. That's been extended to health and social care professionals, which is really good, so that service is for all health and social care professionals now, but it's no longer providing a service for students. Actually, because students are the most vulnerable population in terms of developing mental health conditions, it, to me, seems not very sensible to not be allowing the students to be accessing that at an early stage when they're most vulnerable, so waiting until they graduate before they can access that service. It should be something that's available to students. Canopi is set up to deliver therapies on a large scale with clinicians. So, actually, to me, that seems like you've already got a service there that could increase capacity and deliver services to students as well—the healthcare students.

Great. Julie, do you concur with Liz's comments?

Yes. I completely concur with you—what you're saying—Liz. I think, probably, at the top of my wish list is to emulate what Cardiff University have actually done. I know it's been described as 'bridging a gap'; we'd like it to be a permanent bridge of a gap, and not just Cardiff University to get on board, because we desperately need access for students. I'm a GP in a rural area, so most of our students, they all go away to university. But they struggle to register with the GP; they're homesick; it's all new; managing your time, your money; getting on with new people and all that, and that's really tricky. And when you don't have that network and support of your family and your friends and your practice—. We were very strong advocates for what we call 'relationship-based care', which the college has published a paper on recently, and it's so important, particularly with mental health, that people have that confidence and trust in other people, so they're more likely to open up and be honest about how they're feeing. 

I certainly know there's a huge problem with students who go to universities, at the minute, registering with a practice. My daughter's a prime example: Aisling is on her second university course, but in the first one it took her three months to actually register with a practice. Thankfully, she was fit and well; she was just on some repeat medication, which wasn't a big issue. But some of her friends had quite severe psychological problems, including those who already had diagnoses, who just couldn't even register with a GP and, therefore, couldn't get access to services. So, she was involved in trying to help set up—. In the student support services, she was the chair of the committee for that, and they worked really, really hard and were innovative, got a nurse to join the team, and the chaplain was a trained counsellor. So, they had some pathways to just have a bit of tea and sympathy, if that was all you needed—'I'm having a bad day, and I miss everybody, and it's awful, and what am I doing?' through to 'I really need psychological help.' But you need to have that professional, that triage level—. Signposting is great, but you need to pick up the people who need that more intensive input, and that's a huge issue, and the continuity as well.

Liz mentioned medical students. Students these days are on a lot of courses where there's a vocational element, so they may not only be living at home and living in the university town, they may be away on attachments for several months at a time, and that continuity is lost. We don't know what's happened either way; we don't get any communications about what's happened; and getting information, even from their practice, if they do manage to get registered and be seen, is basically lacking. There isn't a joined-up system to get that information, so we're doing a disservice to these young people at the moment. 

That's very important, and, I think, you said that continuity as well—. 

Yes, it is. 

That's very important, and it comes on to my second question. What we talk about in Wales and across the UK is the 'missing middle', isn't it?

It's huge. 

It's people who are going from the specialist services—from CAMHS—and then they go into adult services. It tends to be that student age, doesn't it, where people are lost in the middle. You talked about Canopi, for example. What sort of services do you think could be set up to support those people when they go at 17, 18, 19, 20, 21? They're going through university; they don't seem to be picked up now. What sort of service would you like to see implemented, that could actually help those people to transition to adult services—the people who are in severe trauma, that type of thing—who do get missed? How could we put something in place to eradicate that with our students? 

Currently, a lot of it depends on them getting registered with a practice and, as a practice, as with my own patients, I can communicate directly with the new practice as to what's going on. We give people physical copies of their records to try and enhance that continuity, but it's really tricky sometimes. But, if they haven't even managed to get registered, it's very, very difficult. But they need signposting on site to what's available, and they need someone who has that quick access into the more specialist services, because, often, I don't know what's available in Oxford or London or wherever, but there needs to be somebody on the ground, so to speak, who does, and who can do that assessment and signpost them on. I think that's crucial to develop a service that is fit for purpose. 

I think there are particular issues as well with the students maybe coming from England or Scotland, actually, as then the transfer of information is even harder. 

It's awful; it really is awful. 

So, they're starting from scratch almost, if they're students coming from England and Scotland to Wales. 

Often, by the time we've actually got the information or they've been referred to services with waiting lists as they are, they've moved on to somewhere else by then, and then they start all over again. So, it's pretty difficult for them at the moment. 

Obviously, the Welsh Government have got their 'Together for Mental Health' plan—

Yes, fantastic. 

—which does raise all these issues. I know that the National Union of Students have said that they want more of a focus in that plan on actually supporting young people in universities. How do you think we can get more emphasis in the 'Together for Mental Health' plan around supporting our young people in our higher education settings? Anyone can start on that. Kim, we haven't had—[Laughter.]

Absolutely. I can go and I can jump in. So, right now, we have a situation where we have about 3.7 per cent of people actually using mental health care when they enter the university. At the same time, if you look at statistics, 31 per cent of people actually have mental health issues while they are in university. So, we need to actually have that transition in care and it's a really serious issue.

Possible ways to do it: you have the barriers to information transmission that actually need to be addressed, okay? That's something that actually could happen at the level of the Government, because right now we do have these kinds of barriers to information transmission. That's something that I can't speak to specifically, but we definitely need it. We are seeing it in our students right now. I have already had three come to me this year. It's been two weeks. So, this is something that we definitely need.

One thing that I think could happen is, when you actually have the admission process at university, identification of mental health issues upon admission is something that could really help. So, not just having a centralised admissions team that just puts the students through, but actually having some sort of process that would enable students to identify themselves as possibly needing mental health upon admission. At the same time, we see skyrocketing rates, in that first year, of mental health issues. It's one of the most serious things that we see in ONS data.

The transition, which we'll talk about later, has a lot of identified stressors that contribute to elevations in mental health. So, what we need to do is possibly implement some universal guidance to academics—who are usually the first point of contact: they go to their lectures; they are mentors—some sort of module that academics could take that would provide them with an ability to communicate about mental health resources available, which currently does not exist. We have one on money laundering, but not mental health.

Another that might help is actually some sort of mandated mental health module for first-year students. So, when they actually attend university, something that would actually help inform them about both the rates of mental health issues in first-year students, how serious an issue this is, and also for the individual universities, signposting them towards things that they can actually do to get help.

Now, the help available is a separate issue—the number of resources available—and that's something that I'll speak to later. But I think that communication is something that's lacking right now, and targeting that communication and that information transmission is what we need to do.

Can I say that I just think that it needs to be part of the fabric of the university and the culture there that it is good, if you have mental health problems, to seek help, and this is how you go about doing it? I think that that needs to be integral in any service. If there's some way of making universities accountable for actually providing that service and that initial triage assessment, and making sure that the person gets to see the right therapist, appropriate to their condition, as well.

The university should be responsible for promoting the good physical and mental health of the students—it's not just mental health issues; it's just in general—and trying to highlight those issues and to encourage people to register with a GP and to access services. But if they are on site, I think that the majority of students will probably access them a lot quicker, and hopefully it will be a faster route. I know that we are all resource poor at the moment with these things, but it certainly is worth trying, and that would be an ideal service, really.

I think that 'Together for Mental Health' could promote the links for more joined-up working between schools, FE and HE. At the moment, it feels very separate to me, and I don't think there is much cross-working, and there certainly isn't any kind of information sharing, really, going on. A lot of the students that we see, it's not the first time that they are having issues. They have experienced issues in school and in further education as well, and I think that improving working relationship, going forward, would be important, and I guess that's something that could be led by 'Together for Mental Health'.

Also, working with key stakeholders—so, all of those groups and students—to look at 'Together for Mental Health', which I guess you will be doing, is important as well. Some of the things that we need to think about are the particular student groups as well. So, we know that some student groups have lower rates of declaration. So, engineering students, for example, and medics and dental students have much lower rates of declaring mental health issues when they start at university. So, maybe targeting specific groups of students, and those that are more likely to have mental health issues—so, LGBTQ students, international students. There is robust evidence around certain groups experiencing higher risk, and we could be targeting those groups better.

If you'll permit me, Gadeirydd, I have one more. I'm sorry if I'm going to jump on somebody else's question. So, do you think that there should be more of a standardised approach across universities in Wales as to how they share information and how they provide support for people? What I'm hearing from you, and what we've heard from other evidence, is that it's quite sporadic across Wales. Certain universities are independent in their own right, and they can provide the level of support that they want. So, do you think that, from Government, there should be that standard level of service that is mandatory right across the sector—that we should do this, and information should be shared, right the way through? Is that something that you would like to see?

That would be fantastic to see, yes.

I apologise to colleagues if I jumped in on their questions, because I do feel like it was an appropriate time to raise it.

It would be lovely to see, but also, if they could communicate with primary care as well. I must say that, particularly during the pandemic, we had lots of patients all over the country and further afield in university, who were still phoning the surgery, where they knew people, for support. It's very difficult then to deliver the on-the-ground needed further therapies because we don't have access to them. But communication would be very much welcome.

Could I just say too, in reading 'Together for Mental Health', there are eight areas, and young adults aren't mentioned? It's left out, and I think we know that, and I think that's why we're here. Actually having that revision, which I think you're trying to do now, is something that would really help further something that could be universal, for universities to have that standard of care that is needed and, right now, is very absent.

Lovely, thank you.

Thanks, James. Ken Skates.

Thanks, Chair. I was really interested in hearing about how there could be mental health checks upon arrival at university, but in terms of the roles that education providers have in terms of promoting good mental health and taking care of those who have poor mental health, how useful do you think it would be to have a consistent threshold or guidelines on where the responsibility of healthcare providers begins with regard to mental health conditions?

Who wants to start? Liz.

I think in theory that would be useful. In developing that, again, it will be key to involve key stakeholders in that process, because sometimes it's very clear cut and then there are individual student cases where it's not so clear cut. So, I think having, again, clinicians, academics, university staff and students involved in developing any kind of plan like that would be really important. But I think, generally, having some shared agreement, particularly within Wales, about where those kinds of boundaries are would be really useful for students in particular, as well as healthcare and academic staff. 

And often they don't know where to go, or where to start. 

Kim, did you have anything to add?

Absolutely, I think that consistent guidelines for that would be very useful. Unfortunately, there's a lot of variability where students need healthcare providers to take over, if that makes any sense. So, while it would be useful to have a standardisation, because there's so much variability in where individual students might need a GP versus not, I think that might present difficulties in some ways as well. Again, the most important thing is the communication pathways, so, being able to get the person help when they need it, which right now, we're talking three-month waiting lists—it's not there.

Ken.

Thank you. What are the barriers to effective information sharing between health and education providers? How would you address them?

I think some of it's about understanding, from the healthcare professionals, from students and from university staff about—people are very worried. There's still stigma around mental health, and students in particular have concerns around sharing information around mental health, particularly those that are on professionally registered courses where there are concerns around fitness to practice and things. I think healthcare professionals in universities, sometimes they're not clear on exactly in which situations they can share information, how they share that information, and what they can share. So, again, I think guidance for staff, clinical staff and those in academic settings, and for students, about when information might be shared, how we can share that information, and how we can do that securely would help people in terms of their confidence in terms of sharing information. So, education and training, I think, is probably key there. And again, maybe developing a working group, an expert group, that has knowledge about that kind of particular sharing of information, so that they can help develop the guidance and also provide advice to staff where needed.

That would be very helpful. But also, the electronic transfer of records, we have a huge issue in primary care regarding that. I have patients, some in university who are new to the area, and some people who've just moved to the area, but it could be six months before I get the medical records, which is astoundingly bad. You may be lucky enough to get a one-page summary that isn't accurate and doesn't give the whole picture, so it has limited usefulness for us. It is so slow. It's incredibly cumbersome.

So, would a student NHS passport help, do you think? Is the creation of such an information portal even possible?

We have piloted something like that in Cardiff, actually, and so it has been piloted amongst a few students, and for some students, they find that really useful. Whether it would be for all students, again, it depends whether students are happy to disclose that kind of information. But certainly it's a more student-led, student-focused way of them having control of sharing that information, and with who they want to share it. And it certainly helps students to not have to repeat verbally that same information, that same history to all these many, many individuals that they currently have to do at the moment. I think that can particularly help where students are in a home setting, a university setting. As we said, we've got healthcare students across Wales, all in different locations and regularly moving locations, and it would really help in that situation. I think the main barrier to that at the moment would be funding and finding an appropriate fee platform to do that. 

Julie.

Yes, I think the last thing you need if your mental health is not good at the time is to have to go through the whole story with yet another new person, and I think that's immensely stressful for people of all ages, not just young people, but particularly for young people who feel that, sometimes, we're just being difficult and asking some them things and raising past traumas that they haven't had the opportunity to get some help to deal with. So, it is quite difficult at the moment. 

Ken.

Are there any estimates on the cost of introducing this, of rolling this out? 

Not that I'm aware of, but that's certainly something we could look into. 

There's shaking of heads.

That would be incredibly helpful; if we're going to be making recommendations, I think we're going to have to cost them, and this seems to be a recommendation that we should consider very carefully. Just one last question from me, Chair. Do you think that healthcare providers, such as GPs, psychologists, psychiatrists, need to build closer relationships with universities? And, if so, is there a role for Welsh Government in encouraging and facilitating this? 

Okay, we'll go Liz, Julie and Kim, because I'm sure you've all got views on that. 

Yes, I think that certainly is important. At the moment, I think most academic and clinical staff would probably say—. Again, we've talked about the information sharing issue. The other issue, I think, is probably the time that staff have available to do that. We've got to be open about that. I think services such as the mental health university liaison service are key in moving forward to developing and improving those links and having established systems so that people in Wales—university staff and NHS staff—know how to do that, and they know who the contacts are, not one specific person who might move, but a service that's set up and is key to that, so that all they have to do is know that that service exists and that's the contact that they have, and establishing that in a sustainable way, going forward. 

I think it's very important, looking at the system, that it should be mandatory, in my view, that it's something that that institution or that university should be responsible for signing up to. So, you need to have the will there, as well as the funding. But you do need to have the personnel, particularly. An ideal system would be having a mental health nurse doing the triage, being involved, and integrating that with NHS care so that it would be a lot more seamless. That will take money and time and more staff, of course, which is an issue at the moment, as we're all aware.  

Kim.

Right now, unfortunately, we have three big businesses, where you've got the Government, you've got NHS and you've got the universities, and having them communicate across those different silos is quite difficult, and I think that you guys are trying to do it, which is wonderful. But, putting things in place where we can do that would be fantastic. I think the mental health university liaison service right now is just in Cardiff. If we could roll it out in different areas, we'd love to have it in south-west Wales as well. It would be something that would be fantastic. I think also, actually, doing something where you get people from these different groups together, like a conference or something where we can come together, discuss and brainstorm, might be something that would be very useful. So, having stakeholders like this in this environment, but perhaps also finding solutions together, might be something that would be a good option. 

I think we should be very proud of the exemplary project as has happened in Cardiff this year, and it's something, if we can get it right and communicate it well to others, that other nations will benefit as well from. It's a system well worth emulating. 

Thanks. Ken, was that your final question? 

That's perfect, thank you. Thanks, Chair. 

Thank you, Ken. Laura Jones. 

Thank you. I think the gentlemen have asked most of my questions, but that's fine. [Laughter.] I think we can all agree on the importance of having that consistent approach across the board across Wales for all students, no matter where they live, and you've already touched on that information sharing is absolutely key in that, and the sharing of best practice. A forum for that was one of the things I was going to ask about as well, and then rolling out that example of Cardiff uni, for example. When it comes to something like an NHS passport, something along those lines, it's quite a good idea. How do you get past the general data protection regulation problems of that—of sharing between the UK et cetera?

The patient holds the information and it's their decision to share it or not, and to share the appropriate bits of the information that they see as being relevant. 

Okay, thank you. As someone who works in a university—you've touched on this—how effective is the support that's already there for the university well-being service? To what extent can this address the main mental health issues affecting students, compared to services that need to be accessed via the health providers?

The Welsh Government has put funding in to supporting student mental health, and particularly the student support service over the past couple of years in particular, and that has really helped to allow us to provide services to more students and to provide more new ways of delivering services. And that's been really important, and that's going to have to continue, going forward, with increasing numbers of students accessing support. I think where we struggle is where students need more specialised support. So, we have lots of students with histories of trauma and, at the moment, they can't access appropriate therapy. As I said, we have students who appear to have ADHD, autistic spectrum conditions, but we can't get assessment, and if we can't get them assessed, they can't get the support within the university that they need. So, essentially, we're holding back, and that inequality is persisting because these students can't get access to the care they need. Or even, actually, in lots of cases, the kinds of adjustments that we could put in place in university if they could get access to that screening. Similarly with students needing access to eating disorders services, it just takes so long at the moment that, again, those students aren't getting access to those services.

I think student finances, as well, at the moment is quite a big issue, particularly for students who are from less affluent backgrounds. They tend to be quite disadvantaged because many students can afford private therapy. A lot of students now will access private, particularly online therapy, because they can't wait for it through the NHS. But students from less affluent backgrounds can't access that, so they're the ones who aren't getting the support they need.

It's not just true for students; I think it's true for the population in general, and you see it every day—young people, older people. Just getting access to what somebody really needs is the main issue at the moment.

If I may, Chair, I just wanted to ask about—you touched on it earlier—the support for students when they have that year abroad, if that's the course that they're taking, and how they are reached—

Yes, and some do shorter periods abroad. Some of them—let's say, for example, they're medical students—may do blocks of several weeks through to a few months, and move around the country, in Wales, on many occasions in that time frame. And they're constantly playing catch-up. They may have latched into a system and think, 'Wonderful, this will meet my needs', and then they move off somewhere else and they can't access it anymore. Obviously, doing a lot of things remotely has enhanced that, so I suppose there's been some benefit of COVID and how we can now communicate, and we're a lot more flexible in that. But it is a disadvantage to keep moving, and the lists are such that you're just about there and ready to go and then you're off somewhere else and no longer have access, or you've moved out of area.

Particularly abroad, yes.

I think Kim wanted to come in.

Yes, I just wanted to speak a little bit to that point, because there's actually, I think, quite a bit of variability from university to university and the kind of care they can get, so, in some ways, I actually think it's not only the specialised service that they need. The rates of anxiety and depression skyrocket in first years. That means they can't focus, they can't do their academic performance. You're going to have drop-out, you're going to have attrition. So, actually providing, perhaps, more support—like already is true in Cardiff; it might not be as true for the rest of Wales—to have these mental health advisers, to have mental health nurses, access to some sort of system of care, where students know where to go and have academics who know how to show them places to go is something that we really need. So, it is the specialised care, it is the more severe care, but having something in place that is universal, something that is in place where students incoming—. That first year, that transition to university is one of the biggest transitions in life and it's one of the biggest stressors in life, and it's one that leads to skyrocketing rates of mental health that might not have reached levels where they're going to have psychiatric care or going to have really advanced care, but they actually need the support. So, more mental health advisers and more structured care would be very beneficial, I think.

Yes. Okay, thank you. That's really interesting. How can healthcare providers and education settings collaborate to address the underlying causes of mental health problems and promote good mental health for all students? I mean, Dr Forty was talking about information sharing again between the schools, FE and HE, so I'm thinking that would probably help, but how do you think the new commission for tertiary education and research could contribute to that collaboration?

With the universities having some system in place where people who have all degrees of mental health, if you like, have someone to talk to. There's the example, as I said, with my daughter and what they set up, which worked really well. They trained up peer supporters with basic counselling skills, just to be a listening ear and a friendly face, and to know what to watch out for—how to promote active listening and to actually signpost people, but also pick up on red-flag warning signs, where this person needs more input, and having a structure then to pass them on immediately—and 'immediately' is the important bit—where they have a further assessment by someone who's specifically trained to do that, and then send them on to general mental health services, or the more complex problems need specific services. So, it's trying to develop those links, and having someone who has an overview on the ground, really. But universities are completely diverse, and Cardiff are very lucky as they've got a great system, but there are a lot of universities where there's virtually no system, I'm afraid. 

Thank you. Thanks, Chair. 

Thanks, Laura. James, did you want to come in?

Yes, on that support element, on the third sector as well, do they think they can play a big part in actually supporting the healthcare profession as well?

Yes, they certainly can.

Because we tend to hear that sometimes the third sector feel a bit pushed out. But, they can actually deliver those initial conversations and initial assessments. Like you say, with mental health support for young people, people are waiting over four-plus weeks now, which is against target times. If those young people could be seen by someone very quickly in the third sector, do you think that could really help as well?

I think it would help a lot, provided the person has the skills, the training and the confidence to identify when someone needs more intensive help. That's vital as well. But, yes, I think a lot of—. Certainly, listening to the peer support group, they were very much—. There was a lot of tea and sympathy; they went through a lot of biscuits, I think, as well. But it all helps if somebody is just lonely and is just having a bad day, or they're worried about the academic bit, or their money, or their mental health in general. All these things integrate together, don't they, really, to add up to an even bigger problem. It's their first time away from home, it's not a great place to be, and with COVID it's been even worse because they haven't been able to see people face to face and make friends, and that's been really tough as well.

Kim or Liz, did you want to add anything?

Yes, I guess just to say that I think that links in back with what we were talking about on joined-up working, really. So, we know what organisations are able to offer, but, particularly with COVID, some things are no longer available. So, we need to be confident that when we're suggesting students go down these lines, that that service is available, that we know what's available, and also, really, that we know that it's got an evidence base as well. So, I think it's about that kind of sharing of information, as we've talked about, amongst those professionals, and looking at delivering those kinds of evidence-based interventions and us being confident that they're available to students when we're recommending them.

I wanted to add too that there also need to be more people on the ground, as we're talking about with tertiary care. There are different things, for example, with improving access to psychological therapies and things like that—a different level of training. Right now, we have assistant psychologists and psychological well-being practitioners. I direct a Master's programme in clinical psychology. We have a big programme at Swansea. They want to go out, they want to be able to help, and a lot of times there aren't jobs. If we could create training for people who are perhaps not clinical psychologists, like the clinical associate psychologist training programme that's being rolled out, that's something that we could really look at linking into college counselling centres or university counselling centres, for example, to get more people trained on the ground. 

Brilliant. Great. You're giving us lots of ideas here. We'll move on to questions from Sioned Williams.

Diolch, Gadeirydd. I'm going to speak in Welsh, so if you don't understand, you need to put your headphones on.

Liz.

I think some of these I've mentioned. So, I think, particularly, financial concerns have always been and are increasingly in this current climate a concern for students. So, the university has kind of increased its hardship funds and things, but, actually, that alone is not enough to support students generally and the impact that their finance and their living situation has on their mental health is something that we as a university can find very difficult to support them with in terms of their mental health if those conditions and those issues are ongoing. We know, as we've talked about things like transition and moving away from home, those are evidence-based facts that we know influence the risk of mental health issues in students, and, clearly, again, COVID—so, students not having had assessments, not having had face-to-face teaching. The learning of our current first and second-years over the past few years has been so different. We've definitely seen increased rates of anxiety and depression as a result of that, and students just really having to adjust to different ways of learning. Students already have to adjust to different ways of learning at university, but the impact of COVID has really emphasised that.

I think the other main areas are thinking about those particular groups who are more vulnerable. We know that young women, for example, as we've talked about LGBT groups—. There are risk factors that we know make some people more likely to experience mental health issues.

I think it's multifactorial. It's stressful meeting new people, especially if you tend to be anxious in such situations. There are a lot of pressures, of exams, deadlines, new ways of working, be it due to the pandemic or a new way of organising yourself so that you can do your studies and still have a life and enjoy yourself. They're all tricky things. A lot of people are very homesick and miss that social support they have. That's been compounded by the pandemic, and they haven't had the opportunity to make new friends and new structures for social support with people around them. I think maintaining relationships with family and friends has been very difficult for students at the moment with distancing and not being able to travel as much. Until recently, that's been really difficult. 

Another thing that I get quite a few calls from patients who are away at university on is that they struggle with managing their own money—they haven't got much money to begin with—and finding accommodation. Getting a house is a big deal. That is immensely stressful if you're on someone's sofa for a few weeks or months until you manage to get a roof over your head. So, there are lots of things contributing to that difficulty, particularly in the first year, as Kim said.

Kim, did you want to add anything?

Yes, absolutely. We know that there are a number of stressors that are very salient to the transition to university, but one of the biggest is the change in social support when you're going into new environments. The lack of social support is something that's been highlighted in our focus groups with university students, and then of course in ONS data, with increased rates of loneliness from the social isolation, but also just from the lack of the expected social support that they had within the university. It's something that, as we know, has increased mental health conditions hugely.

They've talked about loss—lots of different kinds of losses, loss of financial support. A lot of them are reporting loss of hope, which is very unfortunate, especially in the cost-of-living crisis. They're about to go out and get jobs. There are no jobs, and they're very scared about that. This age group also has had a lack of trust in their Government, a bit, and also in the universities. They kind of feel like the last ones to get the vaccine and the ones that are being blamed for a lot of behavioural stuff within COVID, like they're the ones who are going out and partying and getting people sick. They're feeling very alienated, and I think that's something that has to be addressed through communication, perhaps—a kind of comms initiative—and then also through interventions like you guys are trying to bring out now.

There are groups of students who, I think, are focusing very much on them balancing their life and their academic activities and moving forward to make plans for the future, but there are lots students, I know, who have major caring responsibilities themselves, whether that be children they're looking after, elderly relatives, or people with disabilities. They're probably a group who need a lot more support than we currently are in a position to offer. It can be very difficult to balance all those things.

That's a really good question. That's part of why I do my research; I'm a stress researcher. A lot of the models we work from are things called diathesis-stress models, where you have risk factors already. Some of our risk factors might be the unequal groups that we've talked about, where you've already had discrimination or experiences of discrimination, and you go to university and it acts as a major stressor that triggers mental health onset. So, that's part of the reason, biologically and psychologically, for this increase in mental ill health—that you might have these risk factors that then are triggered by going to university. It's that isolation, but also just because it's a stress that makes your body—. I do cortisol research too. Your cortisol spikes during the time when you go to university. And then part of the problem is that a pandemic comes along, and it's also a chronic stressor. So, what you have is you have a perfect storm for university students of both a stressful time in their lives that’s causing biological reactivity in addition to a psychological response on top of a pandemic and a lot of fears and anxiety. They talked about worrying about meeting people again after lockdown, about leaving their room. We ran focus groups with university students specifically who spoke about the loss of physical activity as being a huge issue in their mental health—so, actually, the ability to go out and engage in physical activities. They talked about the loss of social support, which I’ve already addressed. Pretty much everybody talked about mental health issues.

We also did focus groups with postgraduate taught international students. I think the international student community is one that we could really target. So, we have people who are over here for a year, and we had students talking about not having met a single person other than their doorman during the pandemic. I think we had 100 per cent of our focus groups, which is not a huge amount of people but still crazy, reporting mental health issues from the PG international students, who were from 31 countries, 68 students. And it’s something that is a huge issue that we saw in our research, that not only is this situation that’s already there for university students exacerbated by the pandemic, but then you have these groups that are already at risk, as we’ve already mentioned—young women, minority ethnic individuals, LGBTQ people. Men often don’t seek psychological help in universities. I know this is often not brought up, but this is actually a group that is at high risk of actually succeeding at suicide. Male suicide rates are higher, and this is a group that doesn’t seek help and also a group that might not be as willing to talk about what’s going on. So, this is again a group that we do have to bring up I think as well. And so, yes, we’re seeing a lot more self-reported stress, biological stress reactivity, and we’re seeing a lot of the sources that we mentioned there.

I think we’ve already mentioned some of the benefits in terms of accessibility of learning online. It enables students sometimes to be engaged in social support, so maybe to go home and be wherever they need to be at that time for them and they can still engage in their learning. And I think lots of students now, particularly those who are based throughout Wales on placement and things, for example, are able to access support now that they couldn’t before the pandemic, and that has been really positive.

Clearly, I think there are some students who need face-to-face support, treatment, who weren’t able to get that in COVID, and to a certain extent still have some issues with getting that now. And I think really we probably don’t fully understand the implications of that at the moment. We’re just starting to see, I think, some of the more long-term impacts of the pandemic on student mental health, and I think what we need is research to really look at what those longer-term impacts are and to look at the benefits and advantages of learning virtually, treatment virtually. On all of these things we need research. We’ve got the Wolfson Centre and the National Centre for Mental Health at Cardiff University, research organisations already that are able to look at this, and I think we should make use of those research groups in Wales to be able to look at this, going forward. So, I think that really does need to be a priority.

Julie, did you want to—?

I think for a lot of people with mental health issues, you have to be in, as I’d probably put it, the right headspace to engage with online therapies in particular. There’s nothing like having that friendly face and a listening ear for that initial assessment just to hear you out, help you try to figure out what’s actually going on and what help you need. And I think even that initial contact would benefit a lot of people.

There’s a big survey, the student COVID-19 insight survey in England, which has wonderful evidence on how COVID has impacted the students. I couldn’t find anything like that in Wales, so that actually might be a wonderful survey evidence base, going forward. But actually there’s a big difference between online learning and mental health support online, and I think we have to differentiate there, because I think about 70 per cent of 75,000 students said that they actually want face-to-face mental health support. So, it is wonderful for accessibility. If people have their preference, they usually want to see a person, I think the evidence shows. However, blended learning, online learning, increases accessibility wonderfully, so I think we have that differentiation there.

Obviously, the student numbers have not increased at the same rate as staff numbers have increased. Staff have essential teaching and research demands that they have to meet, and quite often pastoral care of students can take second place to that. I'm not saying that's right or that that should happen, but that is what happens. 

I think also the demands that we're seeing now in terms of students accessing support and why they're accessing support change, and the support that they need has been changing to a certain extent as well. So, I think providing that training for staff—. And, again, the Welsh Government has helped in enabling that certainly to happen at Cardiff—I'm not sure about the other universities. There have been positive steps in that direction, but that's something that we need to continue so that we can make sure that we're supporting the staff that we have got to feel confident and able to support students appropriately. But really, we need investment in staff in terms of specific support service staff, but also in being able to allow all academic staff to ensure they're able to support students appropriately and have got time in their job plans to do that.

We also need to support the mental health of the staff we have—to keep them well so that they can carry on doing their job. That is a very important issue.

I think this is a really important point. Often the academic staff is the first point of contact for students—it happens a lot. So, this is really something that we need to work on. And there is support there for staff to understand, but there's nothing that structured—there's nothing that I think is really formalised. I'm a clinical psychologist, in addition to being a staff member, and a lot of times I have people ask me what they should do. Even something as basic as a one-on-one suicide assessment—some sort of training to help staff understand how to help students off the bat and to just do a little mini assessment—would be something that I think would be very useful. And I don't think it's something that's standardised right now. I've been at five universities now and there's never been—here and in America too—anything consistent really to help staff understand how to take care of the students, but there's also not the support for it. We're incredibly overburdened with the number of students right now and the staff is stretched tight. We're expected to take on higher administrative roles to help these students, so our time is administrative as well as research and teaching, so they're asking us to take on additional training and then engage in pastoral care on top of that. There needs to be support for that, not just in increased numbers of staff but also time—we need time.

And priority setting as well. We have lots of training that staff could engage with, but until they're in that situation where something happens and they think, 'I could have done with training on this', it's not training that they go and look for. It's there, they can access it, but until that happens, until they're in that situation, it's not a priority.

Mandatory training and protected time are what we need. 

Exactly. We have mandatory training, but—

But you need the time to do it properly.

Yes. The mental health training around students isn't mandatory.

Yes, it's research, money and not mental health.

Diolch yn fawr. Diolch, Gadeirydd

Diolch. Buffy Williams now.

Thank you, Chair. Thank you for joining us this morning. How well do we understand the extent of mental health challenges among the student population? And how could our data and wider intelligence with regard to student mental health and well-being be improved?

As we've discussed, there are some well-known factors that we know contribute to student health—we've talked about finance, social support networks. We know what many of the common mental health problems are that our students face and we know what some of the other more specific mental health issues are that students face. So, we've got good data on that. I think what we know less about, as we've discussed as well, is the impact of COVID and how we can best support students in relation to that moving forward and what the long-term impacts are going to be. We do know as well, and we've got data, about specific groups of students who may have a higher risk of mental health issues and would benefit from additional support.

I think in terms of data and intelligence, there are data collections going on in Wales and the UK, but actually, I think that we need to be working together to improve that and make sure that we've got robust data. A lot of data around student mental health tends to be asking students whether they think something's been effective and getting their kind of perspective, which I'm not saying is not valuable—it is—but we need better outcome measures. We need to be looking at longer term outcome measures as well as short-term measures. So, rather than just asking students whether they think an intervention has been effective after they've engaged with it, we need to be looking in the long term and we need to be having more robust outcome measures of whether something is effective or not, so that we've got an evidence base and we actually know how to deliver effective interventions in university and clinical settings.

Julie.

I think it's also very helpful to know what's actually happening in each university. I don't think we know—I certainly don't know—what happens in every university in Wales, never mind universities across the border where people will move to. And I think it's important to have that as a basis, and have a kind of standard data set, if you like, of expectations as to what should be available in each area, and that will hopefully be a good start to look at that.

Kim, did you want to add anything?