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

Health, Social Care and Sport Committee - Fifth Senedd


Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns
Caroline Jones
Dai Lloyd Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden
Jayne Bryant
Julie Morgan
Lynne Neagle
Rhun ap Iorwerth

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alex Cotton Connecting with People
Connecting with People
Dr Alys Cole-King Connecting with People
Connecting with People
Ged Flynn Papyrus
Glenn Page Uwch Swyddog Polisi ac Ymgyrchoedd, Mind Cymru
Senior Policy and Campaigns Officer, Mind Cymru
Nicola Simms ProMo-Cymru
Professor Ann John Prifysgol Abertawe
Swansea University
Sara Mosely Mind Cymru
Mind Cymru
Stephanie Hoffman ProMo-Cymru

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Catherine Hunt Ail Glerc
Second Clerk
Philippa Watkins Ymchwilydd
Tanwen Summers Dirprwy Glerc
Deputy Clerk

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

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

Dechreuodd y cyfarfod am 09:30.

The meeting began at 09:30.

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

Bore da i chi gyd a chroeso i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1, a gaf i estyn croeso i'n cyd-Aelodau i'r cyfarfod yma, ac, yn bellach, egluro bod y cyfarfod yn ddwyieithog? Gellir defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well, ar sianel 2. Yn bellach, gallaf hysbysu pobl y dylid dilyn cyfarwyddiadau'r tywyswyr os bydd larwm tân yn canu, a hefyd bod y meicroffonau'n gweithio'n awtomatig, felly nid oes angen gwthio unrhyw fotymau. A oes unrhyw Aelod angen datgan diddordeb mewn rhywbeth? Nac oes.

Good morning to you all, and welcome to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. Under item 1, may I extend a welcome to my fellow Members to this meeting, and just remind you that this meeting is bilingual? Headsets are available to hear the interpretation from Welsh to English on channel 1, or to hear contributions in the original language amplified, on channel 2. May I remind people that they should follow the instructions of the ushers should an alarm sound, and also that the microphones work automatically so you don't need to touch them at all? Does any Member have any declaration of interest? No.

2. Atal Hunanladdiad: Sesiwn dystiolaeth gyda'r Grwp Cynghori Cenedlaethol ar Atal Hunanladdiad a Hunan-niwed
2. Suicide Prevention: Evidence session with National Advisory Group on suicide and self-harm prevention

Symudwn ni ymlaen i eitem 2, ac ein hymchwiliad ni i atal hunanladdiad, a'r sesiwn gyntaf y bore yma ydy tystiolaeth gan y Grŵp Cynghori Cenedlaethol ar Atal Hunanladdiad a Hunan-niwed. Fel y bydd Aelodau'n gwybod, dyma'r sesiwn dystiolaeth ffurfiol gyntaf ar gyfer ein hymchwiliad, ac rydw i'n falch iawn, felly, i groesawu'r Athro Ann John, cadeirydd y Grŵp Cynghori Cenedlaethol ar Atal Hunanladdiad a Hunan-niwed. Rydym ni wedi derbyn eich tystiolaeth ysgrifenedig, ac felly, yn ôl ein harfer, awn ni'n syth i mewn i gwestiynau gan fod amser ychydig bach yn gyfyngedig. Mae yna nifer fawr o gwestiynau gyda ni i'w gofyn, ond popeth mewn cefndir digon cysurus, rydw i’n siŵr. Caroline Jones i ddechrau.

We move on now, then, to the inquiry into suicide prevention, and this is the first evidence session this morning from the National Advisory Group on Suicide and Self-harm Prevention. As Members will know, this is the first formal session for the inquiry and I'm very happy to welcome Professor Ann John, who is the chair of the National Advisory Group on Suicide and Self-harm Prevention. We've received your written evidence and so, as is customary, we'll go straight into questions, since time is short this morning. There are many questions for us to ask, but everything is within a comfortable background. Caroline Jones begins.

Diolch, Cadeirydd. Good morning, Ann, how are you? My question is just one question and I'm asking: what further types of data do you think we need to get a better understanding of suicide and target interventions effectively? Is there a need for more qualitative data, for example, including from those who've been affected by suicide and self-harm?

I think there's a wealth of data; there are lots of qualitative studies. I think, in this area, things change, so there's always more need to understand in depth what's happening with people. But, if we're thinking about interventions, then, I guess if I was thinking about data, I'd say we need to think about whether we want real-time surveillance. So, the data that we get in Wales is based on Office for National Statistics data, which is always a year out of date. Then, there's a study that I lead based in Swansea that's based in what we call the secure anonymised information linkage databank, where we can look at long-term patterns. But what we don't have is something where we can respond very quickly if we think there are links between deaths.

So, there have been pilots of what we call real-time surveillance, and that can be based on police reporting or from coroners, and, with that, it would be about apparent or possible suicides, because, until there's an inquest, we can't say that it's an actual suicide. And then, I guess, the other thing that would be useful for us to know about is about self-harm and how self-harm is presenting to services, particularly emergency departments, and there are registers that run—three in England, one in Scotland, one in Ireland—and I think that's something we should also consider. That's because we know that the patterns in self-harm presentation are changing. We don't know whether that's because we've reduced stigma and increased awareness, so people are help-seeking more and staff are more aware so we're seeing people much more in line with guidance. So, if you look at the figures, you'll see an increase in admissions for young people, and that looks concerning. However, what we don't quite understand yet is that—you know, there's National Institute for Health and Care Excellence guidance that all under-16-year-olds should be admitted to have a formal assessment, and that increase could be that we're actually providing help in line with guidance. So, I think there's a change that we need to understand about whether it's better recording, better help-seeking or a genuine increase. I think we would benefit from being able to look at self-harm across Wales.


I find it a little concerning when you said about the age range up to 16, because does that mean then that when someone's 16 years and perhaps one week, they're excluded from this data? Because, effectively, they're still—

So, they're not excluded from the data, but I think, for self-harm, as in mental health services in general, that period of transition between 16 and 20 is an important period—

—where people can get lost to services. In this particular area, they are in the data, but the guidance doesn't talk about admission, because some of them can be seen for a psychosocial assessment by liaison teams and then can come back. I think I would like to understand more about that. So, at the moment, if we look at the research, we know that sometimes people turn up at emergency departments with self-harm, they register, some of them then leave before they're ever seen, and from the research evidence we know that's predominantly young men. It would be useful, I think, to be able to track much more clearly who's coming, who's seen, what happens when they're seen, who gets admitted, who gets offered to return to a crisis service, who does and who doesn't, and then what happens to them.

I think what's concerning me is: do they still have the level of support, if you like? When they've been identified as committing self-harm at the age of 16 and under, is that support ongoing when that person reaches 16 and over? When they're over 16, the support that they've had up to the age of 16—is that support still ongoing? That's what I'm asking.

I think, in terms of the actual event itself, what should happen is, up to the age of 16 they're admitted, so you can do a comprehensive psychosocial assessment. After 16, there is more leeway to either admit, if it's required, or to have someone return to see the crisis team—the liaison psychiatry team—to have an assessment. The reason—basically, there are usually lots of reasons why someone may self-harm. It may be precipitated by an acute event, but there are usually lots of reasons that you want to look at, and that's why we do what we call a comprehensive psychosocial assessment. What you want is that everything you identify in that, all the risks and things you can change, those are the things that you go away and do.

Okay. Time is a bit tight, and we'll come back to some of these issues in depth. Angela, you wanted a supplementary on this point.

A quick question, if I may, on data collection. There seems to be a real—coming from the evidence, there seems to be a feeling that, actually, people who die by suicide, those figures are under-reported or even misreported. I just wondered if you could give us an opinion on why you think that might be and what we might do to change that.

So, basically, if someone dies and there is a sudden, unexpected death where there is an inquest, in that inquest a coroner will come to a conclusion. For suicide, that conclusion needs to be beyond reasonable doubt. Now that level, that burden of proof doesn't really apply to any other conclusion that a coroner comes to in a coroner's court. So, because of that, there may be some under-reporting. 

Now, there are things called narrative verdicts, where the coroner tells the story of the death, and then that would go and be coded by someone, often with not that much training in making a decision. And it wasn't always very clear to people. So, sometimes suicides, for all the reasons associated with stigma, for all the reasons associated with the burden of proof, might be given a narrative verdict and miscoded as accidents, and that's why it can be under-reported. 

A few years ago, there was guidance and training issued to coroners and coders, and in Wales in particular we had a number of narrative verdicts that may have been miscoded. Because of that training, we've probably seen the slight increase in rates that we see, and you see that across the UK. But there are certain deaths—. So, we talk about suicides, which is an intentional act and it's very clear, and then we talk about probable suicides, where the intent was undetermined, and then we talk about possible suicides, and in possible suicides we would include things like single vehicle accidents. So, we can't say that they're suicides, but, in research, if there is a single vehicle collision—so, it doesn't involve anyone else—we would consider that as a possible suicide. And around all those different sorts of figures, there are boundaries of uncertainty.  


Bore da i chi. Mi fuaswn i'n licio edrych yn gyffredinol ar y strategaeth 'Siarad â fi 2', yn gyntaf, y syniad y dylai fo fod yn gweithio yn drawslywodraethol ar draws sectorau. A ydy hynny'n gweithio'n dda? Hynny ydy, a ydy'r strwythurau cywir mewn lle i alluogi'r strategaeth i fod yn wirioneddol aml-asiantaeth a chydlynol ar draws gwahanol asiantaethau? 

Good morning to you. I'd like to just look directly at the 'Talk to me 2' strategy, first of all, the idea that it should work cross-governmentally and cross-sectorally. Is it working very well? That is to say, are the structures and processes in place to enable an effective multi-agency co-ordinated approach to suicide prevention? 

I think there's been real progress in the last year and a half. So, I think there were issues. The way it's been set up is that there are three regional fora, and although they were working very well and they were multisectoral there were no statutory reporting responsibilities. And, because of that, enthusiastic, interested individuals working within organisations kept those going, but, every time someone retired or there was sickness, the sustainability of the regional fora was very problematic. On the national group, we stepped in quite a lot. I think, in the last year and a half, with the issuing of the local planning guidance, the issuing of a letter from Welsh Government saying that plans had to be developed by the end of February, the regional fora have developed local formal reporting structures.  

And has that happened? Has that improvement happened consistently in all parts of Wales?  

Some places better than others—'faster than others', I guess, would be more accurate. However, when we did the mid-point review, all areas across Wales at different geographical levels—so, some places have developed plans at a regional level, some places have developed plans at a local authority level, but everywhere is developing a plan and have either developed and endorsed, or are developing, formal local planning arrangements. So, I think there has been a huge change. And, because of those local formal arrangements, I think that change is going to be sustainable, whereas two years ago I would have been saying something very different.  

Are they adequately resourced? Or is the implementation of the strategy as a whole adequately resourced?


I would say that that's a big issue. So, at the moment, there is no specific funding for suicide prevention, and I think that goes across the board. I think we've made a lot of progress since the last mid-point review. There's no doubt. I think that was about getting structures in place, getting some local knowledge in place and people developing relationships. I think we achieve a lot in Wales through partnerships and relationships. But I think to progress from now, we do need to adequately resource, either at an area level or at an intervention-pathway level. And some of that funding may need to be cross-sectoral. So, to enable people to work together, the funding needs to be available, say, for police and health to work together.

Could you expand just a tiny bit more on that? More resource going into the interventional pathway level—what do you mean?

So I guess, say if we decided to go forward and develop a pathway in Wales postvention, so that's about what happens to someone when someone close to them—there's a sudden unexpected death, where we suspect that there's suicide. Now there's been lots of work done in other nations about those pathways. So, that's ensuring that when the police inform families that there's adequate support for people after they lose someone. We have developed a Wales and Welsh 'Help is at hand' to give people an idea of the things that are coming, but in terms of giving people support, lots of people come and say, 'We didn't hear about "Help is at hand" until seven or eight months after', and people who lose someone through suicide are at risk themselves, so postvention is prevention really. If you have a pathway, even for the dissemination of 'Help is at hand' to ensure that there are people who, as part of their job descriptions, need to be taking these things forward, I think there need to be resources.

Yes, just swiftly. You said that people were at risk themselves after losing someone to suicide. Do we have data on that?

There is research data on that, yes.

There is. Could you tell us anything about it, just swiftly?

Basically, when someone dies through suicide—thoughts of taking your own life are quite common, but to go from thoughts to taking your own life, there are a whole set of circumstances and processes. One of those things is what we call, 'cognitive availability', so seeing that as a way out of a very distressing either long-term or short-term circumstance. Families, and particularly children in families, who are exposed to those behaviours, are much more likely to take their own lives.

Do you think that 'Talk to me 2' is striking the right balance between targeted interventions at those most at risk and a whole-population approach to suicide prevention?

That's an interesting question and it's partly about the story in Wales. So, the first strategy that we had, 'Talk to me', had 150 actions and worked from—. Building resilience and protective factors are really important. However, because of those 150 actions, lots of which were very clearly part of other strategies, like the mental health strategy, no-one was focusing on things that were very specific to suicide.

So, one of examples I often give is, we talk about mental health awareness and there is a lot of stigma associated with mental health conditions, however, the stigma associated with suicidal behaviours is associated with that but different. We have to have some quite targeted activities for suicide and self-harm. However, that said, I do think that there are very specific things that we can do that target whole populations in particular settings. There is a strong evidence base emerging about whole-school approaches to suicide prevention, and I am very keen for us to be looking at those sorts of activities. So, I think we can do whole-systems approaches.

I think we are doing quite well through Time to Change and other activities to raise awareness and knowledge. There is UK-wide work going on about developing the suicide and self-harm training competency framework, which I think is one thing that we should really take forward in Wales. One of the examples I often give is, as part of my role, I was invited to go on to applied suicide intervention skills training, which lasted two days. It took an awful long time for me to find two days spare, and the one I went on was with third-year healthcare professionals. So, these were young people who had been on the wards a lot. It took us the whole of the first morning for those young people to be able to say the word 'suicide'. I think sometimes when we work in these areas, we forget how difficult these issues are for people to talk about.

So, I do think that a whole-systems approach about raising awareness and competency is very important. But, I think we can do whole-systems approaches within settings that we know are vulnerable: so, prison settings; there's lots of work we do in in-patient facilities; and I think schools is an important area. Then, I think we just mustn't forget the high-risk groups who need more targeted interventions. And then, I guess one of the big things, and it's not just an issue for Wales, but for across the UK, is we need to find ways to develop systems that middle-aged men feel they can access.


Do you want to move on to your schools questions?

Yes, if that's okay. You gave written evidence to the children's committee's inquiry on emotional and mental health, which was very welcome, and that is something that's being followed up, the school approach; but, as part of that inquiry, we took evidence from the Samaritans who told us that they had some concerns about the lack of uniformity of approach in talking about suicide in schools. That involves not just preventative whole-school approaches, but also where there had been a suicide or a suspected suicide, we heard that some local authorities won't allow, for instance, the Samaritans' Step by Step programme in. Do you think it would be a useful thing for the Welsh Government to issue guidance to all schools and local authorities on the issue of allowing that postvention approach where there's been a suicide or a probable suicide?

Yes. I think that one of the pieces of work that would be really good to take forward would be that. So, for us to develop an all-Wales postvention pathway that would include what should happen for individuals, but also particular settings such as schools and then other more general settings like workplaces. I think that is a piece of work where there's an evidence base that we can draw on, on what needs to happen. There are pilots that have happened. I think it's something that we would definitely benefit from, because at the moment there is no consistent approach, not just for schools, but for anyone.


Thank you, Chair. You've already mentioned middle-aged men particularly being identified as an at-risk group, and your paper highlights that many men may not seek help in a traditional way or in traditional settings. What new approaches are needed for those men to support better mental health and well-being and resilience for those men? And what targeted approaches, as you mentioned, should be suited for those?

The evidence base is really emerging about how we can get particularly middle-aged men where, you know, traditional roles are changing, particularly I think for men from more deprived communities in terms of employment, circumstances are changing, relationships are changing. It's very complicated.

I think this is probably an area where I'll probably contradict myself a bit, where the work about protective factors and resilience and learning to talk may benefit. So, there are community programmes and voluntary sector programmes, such as Men in Sheds, that are getting people to talk. I think there are champions, from sports personalities to soap opera stars, and when you see them talk about their mental health, it becomes easier. We also have to understand how it might not necessarily be advantageous to brand these things as being about mental health, and maybe we need to go to the places where we know that men are going to be particularly vulnerable, like job centres or citizens advice bureaux, and have things available there.

If we're thinking more long term, I think there's something to be said for us reviewing the evidence base about how best to get men into accessing services. This isn't something that Wales is struggling with. If we look for self-harm in young men, if we look at suicide in men across the board, we have a pattern of help-seeking that we need to work to change, and some of that I think we need to target, you know, middle-aged men that we know are at risk, but then the other thing that we need to do is to change that for boys and young men in schools and universities, so that we have a much more—. I think what we've got to hope is that, through those sorts of interventions, we'll have much more emotionally articulate males growing up

Brilliant. Thank you. And what other at-risk groups do you think need further attention?

So, there are middle-aged men, and I think we need to look at children and young people. With children and young people, suicide is in the top-two causes of death, and the reason for that is partly because that they are not dying of other things that older people would die of, but it means that it's a really, really important thing for us to tackle for young people.

That said, one of the other things I'll often say is that, with self-harming behaviours, I think most people are surprised at how common they are. So, if we're looking at older adolescents, three people in a class of 30 will be self-harming. So, self-harm is relatively common; suicide is very rare in this age group, even though it is the commonest cause of death. So, most young people who self-harm will not go on to take their own lives, and the reason it's important to say that is that one of the things that sometimes happens, which we would hopefully change with a competency framework and training, is that people are scared when young people are self-harming.

So, what will sometimes happen is that schools will exclude people, and some of that is fear-based, and how do we manage people, because it is frightening. I think you can't underestimate how difficult it is for people who aren't trained and don't know when to hand people over. And for that reason, sometimes these young people get excluded, which compounds the risk factors that we know are there. So, I think within schools as a setting with young people there's a lot of work we can do. 

A quarter of those who die by suicide are known to mental health services in the year before they die, and I think that's an important area. We have various programmes that run, like the national confidential inquiry. So, a lot of work goes into that area but I think we can't underestimate that people in contact with mental health services are high risk. But that said, 75 per cent of people have not been in contact with mental health services. 


It's okay. I'm just going to ask on that particular point—the 75 per cent—because the 25 per cent are clearly in the system, so, in a sense, we ought to be able to see what's coming. The bigger problem seems to be the 75 per cent that are not in the system. I don't really know what my question is, but that just kind of struck me as a big figure. We've got 75 per cent of people who take their own lives that have never been known to the mental health system. 

In the year before they died.

So, in the project I was talking about earlier—SID-Cymru—what we've tried to do for Welsh data is anonymously link across services. The problem is that about 90 per cent of those who've taken their own lives have been to see their GP in the year before they die. However, so many people have been to see their GP and the risk factors that we talk about for suicide are so prevalent in the community that it's very difficult to pinpoint people. So, I think that whole-systems approach is how we reach out to that other 75 per cent. 

I wanted to ask in terms of high-risk groups and the thematic review of death of children and young people through probable suicide, which you've referred to in your written evidence. That had really good recommendations in it, one of which you've picked up in your written evidence in terms of increasing the school-leaving age. Did the Welsh Government really follow up on the recommendations, because it seems to me pointless to have a report and you then don't actually implement the recommendations? And they were also meant to complete another one. It's meant to be three yearly, but there doesn't seem to have been another one. Have you got any comments on that? 

So, we are doing another one, currently, and that should report in February of next year. So, we're beginning to gather the evidence for that now. A lot of the recommendations were taken up.

In terms of the school-leaving age, there's a system that operates in England. Basically, it goes back to the 16 to 18-year-olds. So, as far as I'm concerned, young people's brain and emotional development happen at very different rates for different people, and, until people are 24, in research we're still thinking of them as very young people, even though they're technically adults. But I think, with under-18s, we still have a responsibility because they are children, and I think one of the issues we have is that up until 16 someone is responsible. What we found in the last child death review is that between 16 and 18 a lot of these young people were lost, really. They can be living with another 17-year-old and that's fine. They don't have to be—. What would be useful I think is if they're in education, employment or training. So, we weren't saying that people should be in school or doing A-levels, but we should be somehow responsible for them. 

Okay. We need to be slightly fleet of foot now, as I'm looking towards Angela, who is going to discuss matters of media and social media very briefly.


Very briefly, on the media and the internet, neither of which are favourites with me, we hear an awful lot about, first of all, poor media reporting of death by suicide. We also hear reports of poor media reporting of just young people in particular and the social pressures on young people if they're deemed to be of a certain ilk. And also, social media—we hear a lot about bullying. We've read in this committee and in Lynne's committee, which is the Children, Young People and Education Committee, reports from all sorts of charities and third sector agencies about the effects of social media on young people, on their development, on their self-esteem, et cetera. We'd just like your take on it, on what you think we need to do. The one thing that your evidence I think said, which did strike me—because, as I say, they're not my favourite people—is that you also feel that social media could be used as a tool for good in trying to help people, whereas I just always see people being bullied online. So, I just wondered what you could tell us about the effects of social media and the media on people who are perhaps at risk of suicide and on whether you think the pressures that those organisations have do push people too far.

Starting off with the media and print media, I think we do a lot of good work in Wales. The Samaritans have issued guidance, and we've adopted and translated that. I work quite closely with the Samaritans, who run lots of training sessions with local journalists. There is definitely a balance between their needs and our needs, but it is a matter of working together. The issue with media reporting is about—. If you make it a very simple story, so, 'This person died because they were bullied'—and usually there's very rarely one single reason; there are usually a lot of complex reasons interacting—then lots of people out there will identify with that one—[Inaudible.]—struggling with mental health problems, when it becomes then about the individual. When you have that sort of identification, it makes young people in particular much more susceptible. One of the big risks is about putting details of the method, so, we work very closely. The Samaritans review all headlines, but things have to reach a certain level to hit their threshold at a national level. So, in the national advisory group, we do issue letters to editors if we feel there's been a breach. But I think it's very important for us to realise that we're working with the media and that they have very different objectives. In my experience, for the most part, people are people and they don't want to do harm. So, I think that's ongoing work. We know the evidence—. All the support—and people bring it up—is really important. 

Where social media is concerned, the team that I lead at Swansea does a lot of research into this area. So, whenever I talk about self-harm and suicide, the questions I get from the audience are very negative in relation to social media, and there are lots of negatives, but the thing to remember is that lots of the people who self-harm or take their own lives are often isolated or from marginal groups. So, LGBTQ people can find support and help online and feel less isolated. So, there are good points. I think we have to accept it's not going away and, for that reason, we need to—. One, it's not going away, and, two, it's very difficult for us to keep up with which platform they're using and what's going on. So, the way we can deal with it is twofold. If you take a YouTube video that could be negative, that could be shared—. We've found evidence of videos that were shared 200,000 times, with images that could trigger behaviours, normalise behaviours. I think we need to flip that and have things online that give people support and help in the same way. Now, I'm not saying that would replace face-to-face contact, but people need different things at different times. So, I think we can use social media. 

Where cyber bulling is concerned—and these are areas where we're actually doing some research in Wales, but I think we could develop this type of work in Wales. We're also just about to publish a piece of work on cyber bullying. There is no positive about cyber bullying in relation to suicide and self-harm. However, one of the things we did find was that those—. The difficulty with cyber bullying now is that, in terms of traditional bullying, you would go home and you would have some respite. The thing about cyber bullying is there's no end to it. Particularly teenagers, while they want to be different, they're also highly sensitive to social exclusion. It's part of a developmental thing. So, it's very well recognised. Now, the potential level of exposure and humiliation online is much bigger than it was with traditional bullying. However, what we did find was that bullies and perpetrators are often the same people, and while those who are being victimised are at very high risk of—they're twice as likely to self-harm as those who aren't cyber bullied. There are also increased risks for those who are bullying.

The conclusion we've come to from that—and this paper should be out in the next month or so—is that when we come across cyber bullying, we often take a very dichotomous view of the bully and the victim. And what we probably need to do is change that a bit and see that what we've got are vulnerable young people, and instead of taking a strictly disciplinary view—if people do criminal things, it's different—but instead of taking a strictly disciplinary view, we actually need to be supporting victims and perpetrators through this. Because the thing that I'm always strongly aware of is that when we go down disciplinary routes solely, then we're further isolating young people. So, I think it's a really complex area. I don't think we'll ever be able to keep up, so we need to teach our young people to be good citizens online, and we need to find ways to teach them what we call 'bystander intervention'. So, that thing when you see that something's not happening, people aren't behaving well towards each other, that we empower young people to be able to say something, and that we teach them—which we are doing through Digital Heroes and things in primary schools—about how you behave online. If you want to share something with someone in it, you need to ask their permission. So, I think there's a lot of work we can do that I think we need to do through schools.


Can I just very quickly ask, but I suspect we all know the answer to this, is there any way of policing social media and, for example, sites that tell people how to do things to themselves?

I think there is a way of policing them. I think that comes through UK Government processes, which the Wales Internet Safety Partnership—. You know, they feed into those processes. However, I think we have to accept that as fast as we take something down—

—something else pops up.

Okay. We're nearly out of time. Two final questions: one from Julie and one from Dawn. Most issues have been covered, I have to say—some very comprehensive answers. So, Julie, have you got anything else that hasn't been covered?

We did have a lot of evidence talking about the importance of early intervention. Do you think the access to mental health services is adequate in Wales?


We have a counselling service that is accessible to children from year 6, however, currently, the counselling services are delivering really supportive things as opposed to therapies and interventions. I know there's lots of work about—we have primary mental health care workers in general practices, but we don't yet have a system like the access to psychological therapies, and I really think that, across the board, that's something that's important, both in this field, but in mental health in general.

Yes, very briefly, Chair, because you have covered the importance of training. Specifically, do you think that (a) the training that we have is adequate, and, if not, what needs to be improved? But secondly, do you think that there is a case for compulsory or mandatory training around suicide prevention for all health professionals? So, I'm thinking about GPs, where they currently do CPR—they have mandatory CPR training, for instance—to do something like this.

Yes. Up until recently, there have been a million different training programmes: some online, some developed ad hoc, some provided really well by voluntary sector services, some provided by not-for-profit organisations. They all last for different times and they all cost different amounts of money. I think it's very difficult for people and organisations to make choices. I think the work that will come out from the national collaborating centre and the Royal College of Psychiatrists, which will give competency frameworks, means that there will be some guidance for the type of training that organisations should have. We've developed a framework at the national advisory groups: so, there's stuff that the public should know, and there's stuff that people working in the YMCA—people who come across people who might be vulnerable—should know, and then healthcare professionals. Different organisations and royal colleges have developed training. I think that I would definitely support it being—. We do manual-handling training—it's mandatory, so I think—. And that works not just for the people that organisations come into contact with, but also the people that they work with.

Okay. Angela has discovered a question—two unasked ones.

A very quick one on the training is about the fear element. So, if I'm trained in manual handling or if I'm trained in CPR, there's a finite sense of the responsibility that is upon me. So, how far do you envisage training going down into the general public or ordinary people—perhaps people around the Assembly should be trained, because if you don't pick up, despite your training, on issues, then the outcome is terminal? So, I just wondered about, you know, when we go out there and we say that we want to have more awareness and training with the general public, and perhaps more in schools, we're putting an awful lot of pressure, perhaps, on teachers or people whose normal day to day, to be frank, isn't in the saving-life business. How do they feel, and how can they cope with that pressure?

You see, I think training will help with that. So, one of the things that people often say to me—I really remember talking to a young girl who had lost her mother, and was having all sorts of difficulties in her life as a teenager and she started self-harming. She talks about it really clearly, and she changed how she dressed: she was going into school with big, baggy jumpers on, and she was bandaging her wrists and the bandages were poking out, so she was very ambivalent about whether she wanted people to know or not. And one of things she says now is, 'Nobody ever asked me about—', and I think the reasons people don't ask is fear. And that's about holding all that difficulty and what you do with it. One of the things that proper training does—. I don't think we should expect everyone to be a trained professional, but you can make people feel comfortable with having that conversation, knowing that that conversation isn't going to make someone go out and feel worse. Really, people want to have these conversations, and then part of that training would be knowing where you send people to or what you do with that, and what the limits are. The thing about training is that they show you what you can do, but proper training also shows you when you reach the limits of what you should do. 


Diolch yn fawr iawn. Rydym wedi mynd ychydig funudau dros amser, nid fy mod yn edrych yn gyhuddgar ar unrhyw Aelod yn benodol. Diolch yn fawr iawn i chi am y dystiolaeth raenus ymlaen llaw a hefyd am fod yn dyst mor fendigedig y bore yma. Diolch yn fawr iawn i chi. Gallaf, bellach, gyhoeddi y byddwch chi'n derbyn trawsgrifiad o'r trafodion yma er mwyn ichi allu cadarnhau eu bod nhw'n ffeithiol gywir. Gyda hynny, diolch yn fawr iawn i chi. 

Fe gawn ni doriad am ddau funud rŵan er mwyn i'r tystion nesaf ddod gerbron. Diolch yn fawr iawn i chi. 

Thank you very much. We have run a few minutes over time, not that I am looking very accusatory at any Member specifically. Thank you very much for your polished written evidence and also for being such a wonderful witness this morning. Thank you very much. I can now announce that you will receive a transcript of these proceedings in order for you to check for factual accuracy. With that, thank you very much. 

We'll have a two-minute break now in order for the next witnesses to come before us. Thank you very much. 

Gohiriwyd y cyfarfod rhwng 10:20 a 10:25.

The meeting adjourned between 10:20 and 10:25.

3. Atal Hunanladdiad: Sesiwn dystiolaeth gyda Mind Cymru a Connecting with People
3. Suicide Prevention: Evidence session with Mind Cymru and Connecting with People

Croeso nôl i sesiwn ddiweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym wedi symud ymlaen rŵan at eitem 3—parhad efo ein hymchwiliad i atal hunanladdiad. Yn y sesiwn yma, rydym yn derbyn tystiolaeth gan Mind Cymru a Chysylltu â Phobl. Croeso i'r pedwar ohonoch chi. Rydym wedi derbyn tystiolaeth ysgrifenedig bendigedig ymlaen llaw, felly diolch i chi am hynny. Mae'n bleser gen i groesawu i'r bwrdd Sara Moseley, cyfarwyddwr Mind Cymru; Glenn Page, uwch-swyddog polisi ac ymgyrchoedd Mind Cymru; Dr Alys Cole-King, Cysylltu â Phobl; a hefyd Alex Cotton, Cysylltu â Phobl. Diolch yn fawr am eich presenoldeb.

Fel sy'n arferol, fe awn ni'n syth i mewn i gwestiynau. Nid oes angen cyffwrdd â'r meicroffonau; maen nhw'n gweithio'n awtomatig. Felly, awn ni'n syth i mewn i'r cwestiwn cyntaf sydd o dan ofal Caroline Jones.

Welcome back to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We have moved on now to item 3, which is a continuation of our inquiry into suicide prevention. In this session, we will receive evidence from Mind Cymru and Connecting with People. I'd like to welcome the four of you. We have received your wonderful written evidence beforehand, so thank you very much for that. I'm pleased to welcome to the table Sara Moseley, the director of Mind Cymru; Glenn Page, senior policy and campaigns officer, Mind Cymru; Dr Alys Cole-King, Connecting with People; and also Alex Cotton, Connecting with People. Thank you very much for your attendance.

As is customary, we'll go straight into questions. You don't need to touch the microphones; they work automatically. So, we'll go straight into the first question, which Caroline Jones will ask.

Diolch, Cadeirydd. Good morning, everyone. I wonder if you could tell me, in your view, how effectively is the cross-governmental, cross-sectoral and collaborative approach, as described in 'Talk to me 2', working across Wales? And is the role of the third sector in the suicide prevention strategy and planning, and in the delivery of actions, being maximised, please?

I'll start. We heard Ann John's evidence earlier, and we sit on her national steering group, so the third sector has made a considerable contribution to developing that plan. I would echo her sentiments in that it's taken a while for those cross-sectoral and cross-geographic structures to come into place, and that they are much improved. We know, for instance, that a number of local Mind groups are very involved on the ground. The group in Torfaen and in Merthyr is chaired by a local Mind, but I think that there's a way to go in terms of linking that work with other elements of improving mental health care. I think that's reflected in some of the views that were shared with us in preparing a response to this consultation. We had people from all over Wales, many of whom, it was very clear from what they told us, had had thoughts of suicide or had lost loved ones through suicide and were sharing some very personal experiences with us. What came through very clearly is that suicide prevention obviously sits within a much bigger picture in terms of networking improvement of mental health care generally. I think there are a number of things, related to 'Talk to me 2', which are excellent, but which could really be embedded in a wider view of how we are providing support for people with mental health problems, whether or not they’re known to mental health services.

Okay, thank you. My second question is: Mind Cymru's paper highlights that the third sector organisations are often the first point of contact for people seeking help, but the lack of a clear process and pathway between the third sector and the NHS mental health services often means that individuals at risk of suicide do not receive timely and appropriate support. So, I wonder if you could elaborate on this point and tell me what sort of arrangements that you would like to see differently, or something more effective as a way forward.

Thank you. I think that it's absolutely crucial that we have an integrated approach and I think that the ethos that you promote is absolutely spot-on, because suicide prevention is everybody's business. It is absolutely not the preserve of specialist services. We need to democratise suicide prevention, in that everybody has the right to know how to keep themselves safe and to know how to keep those around them safe. I think the problem we have now is that there is often a lack of integration, there can be a lack of consistency of approach, and I suppose the vision that we need to look towards is very much—. If I was the person in distress, wherever I went anywhere in the system—whether it's third sector or statutory services—I would want to have a compassionate approach, a timely response, and I would want the person I approach to validate my feelings, to be able to respond themselves safely or to know exactly how to signpost me in a timely way. And in the same way as, perhaps, somebody with cancer care, they don't always know who is delivering that care, they wouldn't necessarily realise if it's the NHS, if it's primary care or if it's third sector. They just know they're having good care, and surely that must be the vision for our way forward. 


Can we just talk more generally about mental health services, particularly those with a role in prevention and early intervention? Mind Cymru's paper raises some concerns about access to talking therapies, which is becoming a bit of a theme across committees. Can you expand on what you think the issues are, and also maybe pick up on any concerns you've got about people accessing primary mental health care services as well? 

Yes, certainly. If we maybe start with primary care, the vast majority of people who take their own lives have been to see their GP to start to express a concern. They know that they need help. We've been calling for a mandatory element of training for GPs. So, when you are a young doctor preparing to be a GP, you don't have to train in mental health, even though that is a really big part of what you're seeing. Around about a third of the people coming to see you are going to have a component relating to mental health. And once you are qualified, there's no requirement on you to have continual professional development in mental health. It's also the case that the other staff within the GP service—the primary care service—are also not required to train. So, it's actually incredibly difficult when you're really busy, you're seeing lots of different people, and you haven't been trained in this area, to understand fully perhaps where you might need to refer people on or where there might be a greater cause for concern. So, that is something that I think is incredibly important, because, of course, the focus in Wales is primarily on primary care. 

Then, the second thing is that although there are improvements in terms of access to talking therapies and so on, time and time and time again people are telling us, 'I have to wait and I can't wait, because if I wait I just get more and more sick and more and more desperate, and perhaps get to the point where it's too late for me to have got that help, which would have supported me'. 

I think the third thing is that when you're at the point of crisis, somebody needs to be there 24/7 to respond to that. What people are telling us and what we're seeing is that all too often that's the police, because if you look at some of the freedom of information requests we've put to health boards, very, very few of them have got that provision that's available 24/7 where you know where to go if you are in desperate need and you're in crisis. 

I'm Alex Cotton. I'm a team manager and also a front-line clinician for street triage in Coventry, and I can share with you that this has been a real positive intervention where it's been not a partnership on paper, but a partnership in working. We've really felt the benefits and also the service users, the people we are offering our service to. We're offering assessment at the right place at the right time, and decriminalising people who may be in severe distress. We've seen, with the use of the training written by Alys, an increase in compassion in the police—that when we're going to incidents that involve knives, people aren't seeing the knives. The police just used to see the knife, now they're seeing the person and what is behind—what is happening with that person. So, we are able to offer an intervention, not only to that person, but also educate the police on how to respond appropriately. We see the reduction in our detentions, in our admissions to A&E and in the use of ambulances. So, I think it's a win-win for everyone. So, I can suggest street triage teams. 


It's just on that point about crisis intervention, actually. You've highlighted some of the concerns. What do you think specifically we need to do to ensure that those crisis services are actually in place and are there and able to respond in the way that we would want them to?

One of the things that came through really, really clearly in the survey that we put out to our own supporters across Wales was that need for 24-hour access to crisis provision. And I think it links back to your question earlier around those clear pathways between third sector organisations and NHS mental health providers or providers more generally—that, outside of the nine-to-five hours, there's not a clear idea of where people should be supported to go. Something that came through clearly in the survey was that people are left with nowhere to turn but perhaps the police or presenting at A&E, and so what we really need is 24-hour provision, or certainly that's what people want—is to be able to access those services at any time.

Another point that I would make as well is around discharge and follow-up. So, perhaps you're in a mental health crisis or you've been admitted into an in-patient unit—that when you leave that unit there is a proper procedure in place to ensure that you get good follow-up care and good ongoing support. The 'Together for Mental Health' strategy says that all health boards should be ensuring that patients who leave in-patient units will be followed up within five days. We conducted a number of FOIs last year, and only one of the health boards was actually recording that information, so we can't be certain that this follow-up is happening.

It's also worth mentioning that, last year, Mind conducted another survey. It was 850 people across England and Wales, and what we found is—. It was a survey of those who had spent time in an in-patient unit and we wanted to find out more about what happened when they left hospital. What we found was that for those people who were effectively followed up within seven days, which is the NICE guidelines, they were half as likely to attempt suicide following that discharge. So, this is a really important point here: that crisis services are effective and that they're available when people need them, but also that when you leave those services, people are able to have effective, ongoing support.

That was going to be my second question. Can I just ask you specifically, though, about the integrated approach that you were talking about? With reference to crisis, do you have information about the way in which, say, local authority housing departments deal with that, for instance homelessness? If someone's presenting with a serious mental health crisis, and they're homeless, their first port of call is they go to the council to present as homeless, and they don't meet the criteria. Did you get a sense that the housing teams know where to refer people in those circumstances?

The crisis care concordat has been signed up to by all the local authorities and all the health bodies—over 40 organisations. So, the understanding and the infrastructure is there. There are regional criminal justice and mental health groups, which are co-ordinating the work locally, but I think that within the plan that we've got, it's really important to review every case. So, it's really important to have an inter-agency approach that is focused on the individual and the person, as opposed to the organisation, the agency and the department. In a direct answer to your question, I would say that that is probably very patchy, and I think we're seeing more co-ordination perhaps between the police and health, and we're seeing some good examples of that happening, for instance mental health nurses in the police control room in Gwent responding, but there's a way to go before the agency response is around the human being, as opposed to which department you're in.

One of the things that I think is holding that up is that we haven't got this data set yet across Wales—this mental health data set—that will tell you what is happening to the individual and that you can then review, and I think it's really, really important. That's due to be delivered next year, in 2019, and I think it's really important that it is and that it includes this element, which is about the outcomes for the person. So, for instance, do they have somewhere to live that's safe? Do they have meaningful employment? Do they have social networks? Then, if you can look at things from an individual perspective, it helps you transcend these organisational barriers, and I think we're a way off that at the moment. 


Symudwn ni ymlaen at faterion hyfforddiant. Mae'r cwestiynau'n rhannol wedi cael eu hateb, ond mae Rhun yn mynd i ofyn rhywbeth. 

We'll move on to training issues. These questions have partly been answered, but Rhun is going to ask something. 

Mi wnaethoch chi sôn am ofal sylfaenol a'r diffyg hyfforddiant yn y fan honno weithiau. Wrth gwrs, mae 'Siarad â fi 2' yn nodi bod yna elfennau eraill o ddarparwyr gofal blaenoriaeth sy'n cael eu hadnabod, sef yr heddlu, diffoddwyr tân, staff ambiwlans a staff adran achosion brys hefyd, yn ogystal â staff gofal syflaenol. A yw'r rhestr yna'n gyflawn? A yw pawb wedi cael eu hadnabod sydd angen cael eu hadnabod fel darparwyr gofal blaenoriaeth? Ac a ydy'r un issue yn wir ar draws y grwpiau yna wnaethoch chi grybwyll yn nhermau gofal sylfaenol, sef bod yna, yn gyffredinol, jest diffyg yn yr hyfforddiant sy'n cael ei roi i alluogi pobl i ddelio â'r hyn sydd o'u blaenau nhw? 

You talked about primary care and the lack of training in that area sometimes. Of course, 'Talk to me 2' does identify that there are other elements of priority care providers who are identified, namely police, firefighters, ambulance staff and emergency department staff, as well as primary care staff. Is that list comprehensive? Has everyone been identified who needs to be identified as priority care providers? And is the same issue true across those groups—the issue that you mentioned in terms of primary care—namely that there is generally a lack of training that's provided in order to enable people to deal with what's in front of them? 

Efallai y buasai Alys yn hoffi ateb y cwestiwn yna hefyd.  

Perhaps Alys would also like to answer this question.

I think the analogy I would give is that if I collapsed in the street, I would want the closest first aider to come to my assistance, but I would want to then get an ambulance, I would want to go to the emergency department and it may be that I would want to go to coronary care. All of those people would have contributed to saving my life, but the training requirements for each would be different. So, we need to think in a more sophisticated way about training and think about competencies. It has to be proportionate to your job role, to your experience, to your expertise.

If we come back to GPs, they see about 95 per cent of people in primary care. Some GPs are incredibly well trained and they provide extraordinary care. However, they are generalists. We expect them to be generalists and it's not fair to expect them to be specialists in everything. But I suppose what we would hope is they would have a compassionate approach, they would be able to triage effectively and safely, and to know when and how to refer, to know the language of referral. But even at that first point, you can actually make a difference and intervene. Anybody can offer compassion, can offer validation and make an immediate safety plan. We need to think in a more sophisticated way about training. I know that Alex has delivered training to a lot of different professional groups. 

Buaswn yn cytuno â hynny. Buaswn hefyd yn dweud mai'r rheswm roeddem ni'n sôn am feddygon teulu ydy mai dyna lle mae'r Mesur yn anfon pobl yn gyntaf, ac yng nghyd-destun y sgwrs yma fan hyn, bod 90 y cant o bobl a gymerodd eu bywydau yng Nghymru wedi bod i weld y meddyg teulu. Ond o ran a ydy'r rhestr yna'n gynhwysfawr, buaswn yn cytuno bod angen efallai meddwl yn fwy eang ynglŷn â hyfforddiant iechyd meddwl, gwaith gwrth-stigma, er enghraiffft, ac efallai meddwl ynglŷn â sut mae pecynnu hynny mewn ffordd effeithlon i grŵp mwy eang.  

I would agree with that. I would also say that the reason that we talked about GPs is because that is where the Measure sends people first, and, in the context of this discussion here, that 90 per cent of the people who took their own lives in Wales had been to see the GP. But in terms of whether the list is comprehensive, I would agree that perhaps there is a need to think more broadly about mental health training, anti-stigma work, for example, and perhaps think about how to package that in an efficieint way for a more broad-ranging group.  

Rydych chi eto wedi dod yn ôl at y diffyg hyfforddiant, o bosib, ym maes gofal sylfaenol. Generalists ydy pobl fel Cadeirydd y pwyllgor yma fel meddygon teulu. Ond a ydy'r un peth yn wir, ac a ddylai fod ein disgwyliadau ni yr un fath ar gyfer yr heddlu a diffoddwyr tân a staff ambiwlans—bod ganddyn nhw hefyd ddigon o wybodaeth a hyfforddiant i allu cymryd y cam cyntaf yna pan fydd rhywun mewn trafferth yn cael ei cyflwyno iddyn nhw?

You come back to the lack of training, possibly, in the primary care sector. As GPs, people such as the Chair of this committee are generalists. But is the same thing true, and should our own expectations be the same, for the police, firefighters and ambulance staff—that they have enough information and training to be able to take that first step when somebody is in trouble?


Certainly, in the University of Wolverhampton, which is in the submission, we deliver training across the group, from the vice-chancellor, the cleaners, the academics, the security staff, NUS staff, HR staff. And it meant that those people could intervene at the time in a compassionate and proportionate way, so that crises, it appears—. It's an observational study, so clearly we have to be careful in how we interpret that, but it shows promise that you can train people from different areas to intervene in a safe way so that that person is—you can help prevent the crisis.

Your using fire and ambulance is a bit uncanny because I'm due to train with the Warwickshire fire service, using Alys's material again, but they are now offering—they're taking over from the ambulance service taking people home, and they are going to do not just home checks but, using the skills that we teach them, do a person check so they, hopefully, won't have to re-present at A&E because they'll have the teas, the coffees, they'll have food in; the fire service will check that. There'll also check for the slips, trips and falls. And how many people go home from a life-changing event when you've been in hospital and have the means to take your own life because you've been discharged with a load of painkillers—those firemen are going to look after and share their knowledge of what we've taught them when they take those people home.

Just out of interest, what is that programme? Who's running that?

Connecting with People. The organisation’s 4Mental Health, but it's called Connecting with People. 

Yes, the one with the crossover between the fire service and the ambulance—

That's happening in Warwickshire—Warwickshire fire service. Coventry and Warwickshire. Ian Tonner is the man with more pips than a pomegranate. [Laughter.]

Okay. Thank you. SAFETool: could you just tell me little bit about SAFETool—how effective it is, how widespread its use is?

So, SAFETool is the assessment framework. It's been developed with a combination of clinical practice, looking at the best available research, and it's been designed so that the person using the framework has the latest evidence at their fingertips. The SAFETool itself is the electronic version and the thing with GPs is in order for them to be able to practise in a more effective way, to record their clinical decisions, and, perhaps as an aide-mémoire, if a GP perhaps doesn't see many people, it sits on their desktop, because we have to make it easy for busy GPs. The key thing is that it promotes a compassionate assessment, it promotes a collaborative assessment, but it's—we've developed a triage version, because we recognise that GPs are bound by time pressures, and it means that they cover the most important points. They can then make their own clinical decision on whether this person needs to be referred or not, but the key thing—the absolutely key thing—is that every patient has a co-produced safety plan. This is a move away—we have to move away from characterising and quantifying risk, because we cannot predict risk. It takes time away from the clinical encounter. If anything, it doesn't promote a compassionate approach because the person is focused on characterising the risk. The majority of people who die by suicide were judged as low risk or absent risk in the last encounter. It's far safer to co-produce a safety plan with everyone, and there are key elements.

So, the first thing is to work with that person to help them identify reasons for living, to make explicit reference to either removal of means for suicide—but obviously you wouldn't use those words with a patient—and if you cannot remove means then you mitigate it; you know, can you make it safer, can you put in a protective factor? And then the other thing is that you build on that person's own assets. So, you look at are there things they can do for themselves: are there things they can do to lift their mood, to self-soothe? And even if it's just distraction—if that person's distracting themselves, they cannot be ending their life. And then the person agrees who is acceptable to them that they will seek help from, because let's not forget the impact of stigma. I'm afraid that stigma kills people. It stops them admitting to themselves that they're suffering, it stops them asking for help, and I think that, sometimes, it stops professionals asking. So, that's a huge thing.

So, the person decides what help that they will access, and then they actually make a commitment that they will contact these people. Then there may be healthcare contacts that they include, and it may be then that they include some key third sector. This is the beautiful way you integrate. So, in Northamptonshire, they've been trialling this for a year and they pre-populate the safety plan so that everybody gets the Samaritans' number, everybody would have the local Mind Association. There'd be no reason you wouldn't want that. Then somebody then commits to, 'Yes, that is my plan and I will follow it'.

So, in terms of effectiveness—you know, these are early days, because you'll know that conducting this sort of research is challenging. We have just started a national project in Ireland, called Connecting 4 Life. It's a patient safety initiative that's funded by the Irish Government in collaboration with the Irish College of General Practitioners and the Irish Government's National Office for Suicide Prevention, but that allows for a proper evaluation where you can evaluate at the start. By the very nature of a larger project, some people will engage sooner than others, so that gives us the chance, but almost like an intention to train analysis.


Presumably, you're saying—I won't be a second—that these kinds of tools aren't being used enough at the moment and we need to roll them out, and presumably you would like us as a committee perhaps to consider putting an emphasis on the roll-out of that kind of model as a priority.

I think, historically, we measured risk like a survey, 'Do you think you're going to commit suicide?', and doing like a Victoria Wood sketch. It's more than that. It's about not how likely, 'What is it we can do to reduce that risk?'—and everyone has a role within that. So, it's been about being forward-facing and not facing in, I think.

Building on the stigma issues, Lynne, a couple of questions.

Is there any further work you think should be done to reduce stigma around suicide and mental health more generally in any particular settings, such as schools, et cetera?

Time to Change Wales is about to go into its third phase, and we've done a lot of very careful analysis of what worked, but also what's still to be done. It's very clear to us that it's been more difficult to engage men in talking about mental health, in anti-stigma messages, and we've done quite a bit of digging into that. I was listening to a group of men in Newport, and it was really salutary to hear the kind of catastrophic thinking there is around, 'If I talk about my mental health problem, my work will find out, I'll lose my job, I won't be able to look after my family, and then I'll completely lose my identity'. You can see that it's very linked into insecurity around work, conditions of employment and so on. So, the next phase of Time to Change will focus on reaching men, and working with men, and it'll also focus on working with employers. We particularly want to work with employers that are, you know, large and important employers, but they also have an impact on others. So, for instance, if you work with the health service, the health service is an audience for that kind of campaign, but also we want them to be a partner. Because breaking down those kinds of barriers will help reduce some of the defensive behaviour that can lead to stigma within the health service and with very vulnerable groups. So, we certainly think that that is very important.

We also think it's very important to be reaching rural communities and some parts of Wales that we haven't reached before, and we know that, very often, rural communities have access to the means, and those professions where you have an access to the means are more likely to have completed suicide attempts. We also think that there should be more work in schools. So, Time to Change, for instance, has a lottery grant to do some pilot work in schools, which has been tremendous, but, again, it's lottery-funded, it's pilot work, it's going to come to an end in 18 months. And the interim—we haven't published this yet, but the interim evaluation from that is showing really high levels of children who either themselves are experiencing mental health difficulties or who know people who have mental health difficulties. And the three-month post evaluation is showing that the intervention is actually having—. They don't necessarily remember all the facts about mental health, but what's changed is the level of compassion, and that is just incredibly important in terms of compassion towards self and compassion towards others.

So, I think baking that into what we're going to be seeing in the new curriculum, baking that into learning what we're doing from Time to Change—I think that's absolutely crucial.


I know it's not Dragons' Den, however, this is also—. I'm the founder of this, so it's part of me. If you're having me, you're having It Takes Balls to Talk. A bit of origami. I'll pass these around. I didn't think there'd be this many. It Takes Balls to Talk was an idea of mine, following working with the police and finding out that the majority of men who've taken their lives have had no contact with mental health services. When you're in the services, you don't see the people you don't see. So, seeing the people who we don't see made me think. And then I was at a football match—we'd got 8,000 people, we were at the Ricoh, so—. It was then 30,000 for the rugby for the Wasps the next day, mostly men. We train up volunteers—we have volunteers from Mind, Time to Change, the Samaritans are involved and Unite, the union. We train using Alys's Connecting with People training. So, people go to that and they, hopefully—in 10 years' time, I hope that, on World Mental Health Day, people will expect to see It Takes Balls to Talk at a sporting event. These cards, they fold, which then attracts the men because they want to work out how the card works, firstly. 

Yes, it's looking a bit complicated, I've got to say. [Laughter.]

So, when you've been shown that, it's then—. We find very few of these cards on the floor—very few.

Yes, very useful, because it must be tough being a Coventry City supporter. [Laughter.] Moving forward to media and social media issues—Angela.

I know that neither of you directly reference social media and the media in your evidence papers, but I would like to just get a quick overview of your take, because, for me, social media is one of the great drivers of isolation, of bullying, of loss of self-confidence and self-worth. I guess it can also go the other way and be used as a useful tool. So, I particularly wanted just to first of all get your take on social media, what we may or may not be able to do about it, but also in terms of your training programme that you've developed, and I saw all your different categories—naive, et cetera—and the way you're trying to train organisations. But do you take account, also, of the fact that social media does everything—from making you feel so dreadful about yourself you might contemplate taking your own life through to how to do it. And the saving of it. So, just generally, a take, please.

That's very pertinent you say that because I've just—. I'm not sure what the word is—I felt rather brave doing it, but I actually put an open poll on my Twitter feed, asking people to rate the helpfulness or not of my tweets. Because I think if you're working in social media and you're working in a very transparent way, how better to actually evaluate if it makes any difference than to ask people. I actually had, I think, over 850 responses. But what was interesting is some of the qualitative responses, where people were coming back saying that, following seeing those tweets, they then had the confidence to intervene when somebody was suicidal.

There's a huge positive impact, and I know that you mentioned some of the negative, but, if we focus on the positive for a while, there is no stigma to accessing good-quality, safe information online; we can all do that, and especially now we've got—. Most of our areas are very good in broadband, and, particularly in a rural community, it means you can target—whatever your interest is, whatever your age group, there will be an organisation, which is very good and supportive for that. Particularly in Wales, I absolutely believe that you need good-quality, safe information in your mother tongue. I know I'm not speaking Welsh now, but absolutely. Connecting with People, 4Mental Health, we've developed a lot of free self-help resources and I'm delighted that three of them, the first language they were translated into was Welsh, and they're actually available in Welsh. Because I think if you're struggling emotionally, you need your support in your language, because otherwise, you can't really—. I know that Alex said 'commit suicide' earlier, but she was playing a part. The key thing with the Connecting with People approach is that we believe that languages are building blocks, and, absolutely, stigma is a social construct, which means that we have the power to change it, and that starts with words.


Can I just very quickly ask you on that, though? Your training programme about training organisations and individuals, whether they're GPs or teachers or whatever they might be, and the kind of things that you run, when you try to train people about how to look out for signs, how to pick up issues, do you have an element of understanding that a lot of the pressure in society comes from social media and that that might be the cause of somebody's despair?

Absolutely, and, in fact, in SAFETool, we have actually put in explicit reference. This is a patient safety thing here. We need to make sure that everybody working especially in healthcare, but actually in any front-line service, they know which questions to ask, which are pertinent, and we need to understand that our young people are digital natives, and unfortunately, at the moment, some of the people delivering the care are not. They need to know the importance of asking about certain sites and other sites—absolutely.

I think if you are feeling unwell, if you are having thoughts of suicide, that's a very lonely and scary place to be, and the availability of information is incredibly important. We just had a quick look before we came, and 1,800 people looked at our support information in Wales over the last three months on suicide. I think it's very important that the information is varied, so you'll see, both on Mind's website and Time to Change and the work that we do with the blue-light services in particular, that it's about human beings who are like you, who are talking about their own experiences in a very direct and open way. You may not have the energy or the bandwidth to read stuff, but you can see and share experiences. And we also, as do other organisations, run online support groups for people. Elefriends, for instance, you can go on there 24 hours a day and chat to somebody who's feeling just like you are, and that element of peer support and joint support is really, really important.

So, I think having content through digital and social media, which is the first thing you see and it is helpful, compassionate and directly speaks to you, is reflective of your own experiences, it makes you feel part of a community, that is incredibly important and we have to engage with that. On the negative side, although we didn't ask about this, generally in terms of well-being, staying connected, giving and being part of a community, there is lots of evidence that that is really good for your well-being, and the reverse is true as well. So, withdrawing into a digital world that becomes overwhelming is also extremely negative. We didn't ask about that, but I think, in general terms, that clearly is the case.

Working with the press on how they report a suicide, because, obviously, we have a thing called contagion that can be dangerous and can highlight hotspots, if you like, and it's about the wording and teaching the press how to word a compassionate article if they have to report it. I think that's important.

Okay. That well-known phrase 'fleet of foot' raises its head now, because we're coming to running out of time. Julie, a couple of questions and then Jayne.


Yes, it's really the debate between targeting intervention and looking at the whole population. How do you think 'Talk to me 2' does strike that balance?

I think 'Talk to me 2' has got a very specific purpose, which is to look at the evidence around where this is most of an issue, and it's learned the lesson of having to be more focused around groups who are most at risk and who are most likely to take their own lives. So, in my view, that is the correct approach, because I think if we try and boil the ocean, then the general programmes are clearly not reaching those groups—they're not reaching middle-aged men, they're not reaching older people with long-term conditions, and we need to make a very specific and determined effort to be sure that they are not left out by whole-population programmes in order to be effective. But this sits within a much wider environment, where I think mental health literacy, reduction of stigma, access to the right support quickly—those are all things that absolutely need to be included in a much wider view of how we look at improving mental health and preventing suicide.

Okay. Jayne,  do you want to wrap up the session?

Yes, thank you, Chair. I think you mentioned middle-aged men being at particular risk. Are there any other risk groups? You've mentioned also rural communities and more work to be done in schools.

Well, I think certainly people who are known to mental health services and who are being discharged from care, and the need for discharge planning there. I think that is incredibly important. There's certainly something that's very clearly the case for older people who are experiencing big life changes. So, maybe they're illnesses, bereavement, loneliness. We've seen an increase in the number of suicides amongst older people, and sometimes much older people. I think that, alongside the focus on dementia for older people, we also need to bear in mind that older people are experiencing mental health problems that are not dementia and that there are social issues linked into that as well.

Can I just say also self-harm? People who self-harm are at a much greater risk of suicide. We need to take self-harm more seriously. We need to look at the person, not the self-harm, because people change method or people may get worse, and that early intervention—. Also, we don't know the size of the problem. We know that many people do go and see their GP, and I think the thing with our experience with GPs is that we encourage them to take opportunistic interventions, in the same way they do with physical health and to ask the question, because, actually, more people have died by suicide who've been discharged from a general hospital than who've been discharged from a psychiatric hospital, and a lot of that is to do with visits to ED and, perhaps, other painful conditions or physical health. And the whole thing about self-harm is you do not have to be an expert in mental health to compassionately help somebody to look at the way that they're currently dealing with the distress and, perhaps, find less harmful ways. That's the key thing about safety planning, that anybody can engage in that. You don't have to be an expert if you've got the competencies.

It went. Sorry. [Laughter.]

The final group—

Just to echo the comments of Ann in your previous session, a whole-school and targeted approach around young people is really important.

I think that, when we talk about mental health, it's important to remember, of course, not everybody who has experienced a mental health problem will feel suicidal. Indeed, lots of people at some point in their life will experience suicidal feelings, but where somebody is in contact with a mental health service and can be identified as experiencing those suicidal feelings, those comments that we spoke about earlier in terms of discharge and follow-up planning really become quite crucial at that point. 


A campaign for everybody. Obviously, It Takes Balls to Talk is targeting men, it's targeting the issue of the stigma with men, and getting men to talk to men. I've done a couple of films with some rugby players and put them out there. It's actually barrier breaking that is the fundamental bit, and it's creating the awareness to create change, I think, is the point we're at at the moment.

Grêt. Diolch yn fawr. Rydym ni allan o amser ac wedi amseru pethau'n berffaith. Diolch yn fawr iawn i'r pedwar ohonoch chi am ateb y cwestiynau mewn ffordd mor raenus ac aeddfed, a diolch am y dystiolaeth ysgrifenedig ymlaen llaw. Byddwch chi'n derbyn trawsgrifiad o'r trafodaethau i gadarnhau bod popeth yn ffeithiol gywir. Gyda chymaint â hynny o ragymadrodd, a gaf i ddiolch i chi unwaith eto? I'm cyd-Aelodau, rydym ni'n torri am ddau funud arall er mwyn newid pethau rownd cyn y sesiwn nesaf. Diolch yn fawr.

Thank you very much. We're out of time and we've timed this perfectly. Thank you very much to the four of you for answering our questions in such a mature and polished way, and thank you also for your written submissions. You will receive a transcript of the proceedings to check for factual accuracy. With those concluding remarks, I'd like to thank you once again. To my fellow Members, we will take a break for two minutes and change things round before the next session. Thank you very much.

Gohiriwyd y cyfarfod rhwng 11:11 ac 11:16.

The meeting adjourned between 11:11 and 11:16.

4. Atal Hunanladdiad: Sesiwn dystiolaeth gyda ProMo-Cymru a Papyrus
4. Suicide Prevention: Evidence session with ProMo-Cymru and Papyrus

Croeso nôl i sesiwn ddiweddaraf cyfarfod y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym wedi cyrraedd eitem 4 ar yr agenda y bore yma, a pharhad efo'n hymchwiliad i atal hunanladdiad. Rydym wedi cyrraedd y tystion diwethaf am y bore. Rwy'n falch iawn o groesawu, felly, Stephanie Hoffman, pennaeth gweithredu cymdeithasol ProMo-Cymru, Nicola Simms, arweinydd arferion gwaith, ansawdd a gweithrediadau llinell gymorth ProMo-Cymru, ac hefyd Ged Flynn, prif weithredwr Papyrus. Croeso i'r tri ohonoch chi. Diolch yn fawr iawn am y papurau ysgrifenedig ymlaen llaw. Mae pob Aelod wedi eu darllen nhw mewn manylder brawychus. Felly, fe awn yn syth i mewn i gwestiynau, a'r cwestiwn cyntaf gan Caroline.   

Welcome back to the latest session of the Health, Social Care and Sport Committee here in the National Assembly for Wales. We have reached item 4 on the agenda this morning, which is a continuation of our inquiry into suicide prevention, and we have reached the final set of witnesses this morning. Therefore, I'm very pleased to welcome Stephanie Hoffman, who is the head of social action at ProMo-Cymru, Nicola Simms, the lead for helpline practice, quality and operations, ProMo-Cymru, and also Ged Flynn, who is the chief executive of Papyrus. Welcome to all three of you. Thank you very much for the papers that you sent beforehand. Every Member has read them in careful detail. So, we'll go straight into questions, and Caroline goes first.   

Diolch, Cadeirydd. Good morning. Bore da, everyone. My first question is on the collation of data. So, what does data tell us about the trends in self-harm and suicide in children and young people? How much do we understand about the reasons for self-harm and suicide in young people and children? Is there further intelligence that we need to identify the trends and to go forward with assisting children and young people in this area? Thank you. 

Thank you for the invitation to come here today, firstly, and the question. I represent a national charity founded by parents who had lost a child, so we have, without apology, a particular lens on this, and a personal one. We think the data is, at best, a best guess. I often say in our training sessions, 'Write this down, I'm going to tell you now how many children and young people die by suicide' or 'I'm going to tell you now how many children engage in self-harm. Are you ready?', and everybody gets their pen ready, and I say, 'We don't have a clue'. And that's for a number of reasons. I think, putting away my cynicism for a moment, the good news is over the last 150 years for which we've got data in the UK, suicide has come down in huge number and rate, largely because of reducing access to the means of suicide. 

In children and young people, that's similarly a trend, that it has come down, in spite of what people—. When they engage with us when they lose a child to suicide, they think it's suddenly, alarmingly going up, and that's not true; it's coming down generally. But I think more locally, so the age profile you're looking at—children and young people—we do know at the moment that there is a plateauing of that downward spiral in general terms, in terms of self-harm and death by suicide. And worryingly, whilst we're always very cautious about making policy on the hoof because of a little blip in the graph, there is clearly a plateauing in general terms around suicide and self-harm because of the recession. So, in the last 10 years that downward curve has stalled a little. 

My understanding, though, is that the proxy indicator for the numbers of young people who engage in self-harm is how many access an emergency service, how many present to the health services, and it is said that for every one person who presents, there may be up to 20 others who are engaging. So, anecdotally, I would share a story where one of our team was in a local, small shop and was reaching for the cornflakes or something and got into a conversation about what she does for a living—suicide prevention. And there were 14 staff in that shop, and 13 of them had shared stories of their children engaging in self-harm currently. So, anecdotally, there is a sense that this is a much bigger problem than the statistics would tell us. 


Following on from that, then, is it your view that there's not enough focus given to children and young people around suicide prevention? Would that be your view?

I think in general across the UK—. I sit on the national advisory group here in Wales, and I think we've done well in Wales to foreground children and people and their parents in 'Talk to me 2', the national strategy. I think there can always be more done in general. I think, speaking very generally, nobody wants to talk about suicide, and the focus is always on the person who's struggling with the thoughts of suicide. So, for example, we often put a poster up that says 'If you're thinking about suicide, or if you're struggling with your mental health, contact this organisation.' And I always say we should turn those posters around, and the focus of those posters should be the rest of us: 'If you can see that somebody is struggling, you reach in and help them.' So, children and young people must be our focus, not because the numbers are high in relative terms, but in terms of the impact and the future that we're wasting, really. That suicide is the leading cause of death—unequivocally, by far, the leading cause of death in children and young people, up to the age of 35—is a national scandal that we're not talking about. If this was Ebola or HIV or any other disease, we would be throwing millions at it. And the funding for suicide prevention, although it has improved since the inception of Public Health England and similar bodies, is risible, I think. 

If I could just come in from Meic's perspective. I'm making an assumption that people will be familiar with Meic, the universal information, advice and advocacy service for young people in Wales, up to the age of 25. So, I'd reinforce a lot of the messages and points that Ged has already made. But, from our perspective, particularly around trends and data, clearly, we're not a specialist organisation dealing with particular issues or target groups. Ours is very much generic, universal. But mental health generally features very high up in the issues that are presented to us. And it's increasing. However, of that proportion, the prevalence in terms of suicide and self-harm—although the volume is increasing, the proportion is actually remaining steadily the same. So, from our point of view, in terms of children and young people contacting us because they have suicidal thoughts, or have actually an intention or a plan to commit suicide, or are sharing and disclosing certain behaviours, that's kind of the trend that we're picking up.

I think, again, to reiterate the point, within Wales we've got things like the Social Services and Well-being (Wales) Act 2014, and the emphasis on things like voice, choice, early prevention, intervention et cetera. These are all key principles within the children's rights agenda that we work to, and what we would want to stress very much is that when children and young people contact us—and I think the youngest was a nine-year-old—this is a very significant step along a very turbulent journey for a child or young person. And while I think that's probably a no-brainer, and probably that's very clear and obvious, it's worth reminding ourselves of that. 

So, before children and young people come to us, as well as afterwards, they are still on a journey. And it's absolutely crucial in that context that people are able to pick up on those issues and deal with them, so that children feel that they're able to express themselves, that they are heard, and that they are met with the appropriate and timely response whenever and wherever they are. So, this is a big issue for all of us. It's not just professionals within CAMHS or us as a low threshold, universal service. We all have a part to play, whether that's parents, carers, dinner ladies in school—you know, whoever it is. So I think, as regards that, and reinforcing Ged's point, this is a matter for all of us, and we need to somehow get cleverer, perhaps, in how we get those messages across, particularly because of the stigma and the difficulty that's associated with the issue and being able to talk about it.


Okay. Caroline, you've got a supplementary. I'll come back to you then, Dawn.

It was just the final part of my question, which was: what sort of further intelligence do we need to identify issues and so on? I didn't quite have that answer.

I could speak at length on something I wrote about in my written evidence here about the standard of proof. If we change the use of the standard of proof, which is only used for homicide, regicide and suicide—namely beyond all reasonable doubt—what we will then do is enable coroners to say, 'Given the evidence before me, it is more likely that this child has died by suicide than not.' Then we'll get a much truer picture. But more impactful, perhaps, over time, we will do to suicide what we've done in this country to homosexuality—we'll free people up to speak about it. It's always going to be there and people are living as homosexuals more freely than they ever did. Sadly, people remain isolated because the state compounds the silence around suicide.

Yes, it's really to follow on from my first question about whether organisations that represent children and young people are playing an active enough role in suicide prevention strategies, and also to pick up on something that I think the Papyrus paper talks about, which is using the lived experience of those who have attempted and survived suicide or those who've had suicidal thoughts and not followed through—it's those kind of lived experiences. So, it's the involvement of children's and young people's organisations and the use of the lived experience—are we making enough of that, really?

If I'm cynical, again, when I go to a suicide prevention conference, I can bank on who's going to be there from the third sector, and it's unusual to get some of the major children's charities there. You would expect—and you could probably list them with me—Samaritans, CALM, Papyrus et cetera, so I'm always pleased when we reach out to the unusual suspects at conferences and events. One of the things Papyrus is doing just now is pushing children's suicide prevention, looking at children under 18. Two hundred children at least die every year to suicide under the age of 18, but that can't be left, as you said, to the usual suspects, even within the third sector. We need to reach out to partners across the piece who engage daily with children and young people and their caregivers and parents.

In terms of your other question—remind me. It was about—

—lived experience. I think there's lots of ink spilt about lived experience and service user involvement and all those tags. I think it's essential for us as Papyrus to say that anybody could run a helpline, anybody can run training programmes, anybody can run community engagement education packages, like we do. What makes us unique, perhaps, is that we don't take on a service user involvement mantle. That is us. We are, sadly, a club that nobody wants to join. You come to know about Papyrus because you've lost your child, and it's heartbreaking, to say the least. So, service user involvement has to be everybody's business. Lived experience needs to be at the forefront of our strategic thinking and our planning. So, I'm pleased to say that Papyrus and others under the National Suicide Prevention Alliance, a UK-based organisation, have been able to bring together some of the more unusual partners, but critically, we have—and on the national advisory group at Westminster; less so here, I think, in Wales—really reached out to ensure that, avoiding tokenism, people who have had lived experience of having suicidal thoughts and behaviours and those who have been bereaved and touched personally by the death of a loved one are actually at the highest table, organising, planning and helping to implement suicide prevention.

Can I just ask you how much involvement you have in Wales? Your bases are all in England, aren't they?

We have three bases geographically—London, Birmingham and in the north-west, where our headquarters is—but we've always been UK-wide. So, who we are is a membership organisation for people who've lost children and those who want to share our mission—so, very much part of your work in Wales.


Yes. It's just a supplementary on what you said about 'less so in Wales', you said. I think you were referring to the use of lived experience.

In a sense. I have to say—and I'm not looking for brownie points here—I think Wales is really doing well in terms of its size. I have to be very careful here, in this hallowed place, don't I? [Laughter.] I've just watched the session you had with Dr Ann John, who I take my hat off to—she's an incredibly powerful—that's not the word I want—incredibly generous and resourceful woman and gives more than her paid time to this, I know. And, under her leadership, the advisory group does some exemplary stuff and challenges you as an Assembly and Government. But one thing we could do better, perhaps, is to reach out further at that table, to include in our leadership team those who have been touched personally by suicide. I represent, at one lens into that, those who have been bereaved, but there are others who have had suicide behaviours and have survived and would have a lot to offer to that.

Thank you, Chair. Lack of timely access to mental health services and support was a significant concern in the written evidence. What are the key issues that you think are faced by young people and their families in accessing mental health services in Wales?

My own service, HOPELineUK, we run from 10 o'clock in the morning until 10 at night and, frankly, we're buckling with the demand. Remember, we're a very niche service. Meic is a very more general service, and I'm not sure what your capacity is like, but we put paid professionals online for 12 hours a day—text, e-mail and telephone—and we are absolutely buckling. Remember that we're a niche market here; this is for suicide-specific need in children and young people, and we're really buckling. And I suspect that's true of most services, statutory and third sector, at the moment.

I think we've done something that, probably, we could have anticipated. The more we talk about mental health, the more people will put their hand up and say, 'Me too'. Therefore, services are going to get—. The thresholds of need are going to get higher. One worrying trend is that I hear anecdotally that some people are saying, 'Do I need to pretend to be really poorly before I get in?' So, people feigning suicidality, almost, in order to get into a service, which skews the statistic completely. But, anecdotally, I'm sure we could spend all day sharing stories about people who, postmortem, have been let down by services that, frankly, were under-resourced and sometimes not trained for that specific need. And, pre-death, we hear daily from people who often use helplines like ours and, I'm sure, yours in lieu of a service that would better meet their need.

If I could just give a bit of, again, a Welsh picture from Meic's perspective, but what I'll do is I'll hand over to Nic, who can provide some of the more anecdotal information.

Yes, in terms of the messages that you were just putting across there, Ged, in relation to 'in lieu of other services', we find that a lot of young people come through to the service to speak to us because they can't access appropriate services that they may be involved with or that they're aware of at the time that they need it and in a format that's accessible to them as well. So, examples of that are that we've regularly had young people coming through who've tried to access the Samaritans, the Community Advice and Listening Line helpline, and other counselling provision, the sporadic counselling provision for young people in the format of Kooth throughout Wales, but only in three local authority areas. So, when they're trying to access those services, they're either waiting in sort of holding rooms or the service is engaged, we're told. We've had anecdotal evidence that, quite often, when they're calling the Samaritans, it's increasingly happening that they're engaged and they can't get through. And we've actually had adults coming through as well to to our service saying, 'We know you're for children, but we're desperate and we can't get through to anybody else.' Obviously, with suicide, it's not an issue that you can leave and refer; it's something that you have to deal with there and then.

How do you think access to appropriate bereavement services in Wales could be improved?

I think I'll start with a story, if I may. A woman told me that she mislaid her laptop and it became clear that it had been stolen on the tube, and after that event, within three days, she'd received two 90-minute phone calls from victim support. Seven months later, her daughter died by suicide, and she's still waiting for a phone call from anyone. She had to reach out. I think it's a powerful story. The Support After Suicide Partnership was set up three or four years ago, across the UK, for individuals and organisations who wanted to coalesce around the belief that it should be a right that you get access to a service having lost someone to suicide. At best, it's a postcode lottery just now, right across these islands.


And I suppose there are different times when people who have experienced a family member they've lost to suicide—there are different times when they want to access those services. It might be at the start, they might not be ready to access them, but when they need to do that at a later point.

Indeed. Grief is a funny thing, isn't it? It doesn't go in a line. We're always up and down. I would always throw into the mix that some people don't need a service as well. Some people come, for example, to Papyrus and say, even within two weeks after the death of a child, 'I don't want this death to be in vain. I won't be able to do anything for my child now, but I might be able to help yours.' So, they come along to Papyrus and they fundraise and they engage in our work and they sit on local authority groups around this, and that, in a way, is a healing part of their own recovery. But I still think a large majority of people who probably will need some intervention after that, beyond their GP, should be given that by right, and again that comes down to a choice of resourcing that.

And just finally, Chair, just to go on to training: how do you think suicide prevention training for front-line staff could be improved in Wales, and what sort of settings do you think would be most beneficial?

In terms of children and young people, I would start with those who most readily come into contact with children and young people. If I were to ask each of you to name two of those, schools would be on everyone's list, but also parents. So, we've just done a schools' guide—I'll leave these with you—which equips schools to talk about, not mental health, but talk about suicide—to children, with children, and for children. We did a YouGov poll that asked, 'Is your school doing everything it can to prevent suicide?', and most people found that a really difficult question. The more difficult question is: 'Did you do everything you could?' So, I think schools are on our radar list for training.

I listened in to Ann's evidence earlier on the tv. She shared the importance of getting competency frameworks right so that we know what we're expecting from people. Not every lollipop lady needs the same as your local psychiatric liaison officer, but there needs to be some gradation. She and others have given evidence to say, 'This is everyone's business. We can't leave it to people in white coats and people whose vehicles have blue lights. Your child may only have one chance to speak to somebody and that may be you.' We need to translate that message right across the country.

If I may, there are two points that I'd like to make, specifically with regard to the training aspect of things. One would be about content. The ASIST model—applied suicide intervention skills training—young mental health first aid—those are the key training programmes that are really useful. But what we find on the helpline, and this is based on our experience, our knowledge, our expertise and research, is that people are also in desperate need of other resources that they are then empowered themselves to use, implement, research et cetera. So, there is something about more informational content around resources, strategies et cetera that can be included within that training model, taking on Ged's point about that being graduated depending on who your audience is.

And then on that point in terms of audience, and again thinking about models and target audiences and the co-productive approach and it being everyone's business, I see a lot of benefit when there is training that actually brings different people from different sectors and professions together, who all have perhaps a different but important perspective. It can provide significant added value, including the lived experience et cetera. So, there's something very rich when you bring very different people together to engage in the same kind of information and training.

I think that was probably all I wanted—. There is perhaps an example. I don't know whether it's a bit tenuous, but I'm aware that recently Welsh Government have rolled out something that's referred to as the Working Together for Children programme, which was a specific CAFCASS contact activity programme, but it was commissioned to deliver it to Families First, Flying Start professionals et cetera, to equip them with skills and information to be able to engage with a much wider audience of families who are in conflict. So, again, there are models, perhaps, of how training can be cascaded to wider and more different audiences.


Mae'r cwestiynau nesaf o dan ofal Julie Morgan. 

The next questions are from Julie Morgan.

Diolch. I wanted to ask your views about the issue of confidentiality in relation to the young person against information sharing and the fact that carers or parents often aren't aware of a risk that may be there. So, I really wanted to ask your views about that.  

I always start this subject by sharing a story, with his permission, of a father of a 17-year-old boy who went to make sense of a very recent death of his son, which looked like suicide, and within a couple of days the GP said to him, 'Now, I can tell you this is his third attempt.' Incredulously, the father said, 'Why couldn't you tell me before?', and the GP, rather apologetically, just simply said, 'Confidentiality.' How can that be the case when the General Medical Council guidelines, which have been in place at least since 2003, state quite unequivocally that life comes before data protection, and that data belongs to the child and the child is a minor and therefore the primary care giver should be part of the care pathway? 

I think one of the things that we can do to break the impasse here is something that we've led on recently. I'll describe the impasse first. Three years ago, I think, we worked across the national advisory group level in the UK with all the royal colleges and we created a consensus statement, which was basically three sides of A4, which documented why all those key professional bodies agreed that there were limits to confidentiality where life was in danger. Broadly, the principle was that we can all usually share information to protect life within certain parameters. And that very simple document just got parked on a shelf. I used to say every time I went to my GP, 'Do you know about the consensus statement?', and she'd say, 'I've no idea what you're talking about.' And the impasse was we were getting nowhere with this.

So, recently I've written to 154 NHS trust chief executives, because I believe that nurses, doctors and others would say, 'One of the reasons why I don't share information is because if I do, I'll get in trouble and I might get struck off and I won't be able to pay my bills.' So, we heard of I think it was Berkshire. The chief executive wrote to all his colleagues and said, 'If you make a best interest decision, where life is in danger, you document that, you share it with your line manager as to why you've done it. If in doing so you get into trouble, I will back you in court. I will have your back. I will support that decision.' We felt that was a jolly good idea. So, I've just written to every chief exec of every NHS trust in the UK and said, 'Why don't you copy that?' I only sent it 12 days ago, and thus far, I've had six people saying, 'We'll do that too. What a jolly good idea.' Part of me thinks this is common sense, but it's just breaking down a big problem into little bite-size chunks and saying, 'If this is just "I need permission", then give them the permission and it will save lives.'

So, would there be general agreement that this is the way to go?

Well, I think there are discussions being had at NHS board level now about, 'Why haven't we done it?', and I will press now the other 140 if they can do it. Is this another postcode lottery? 

And what about situations where it's maybe not in the child's interest—presumably those do exist?


Of course. It's not ubiquitous law that we should go down the route of, 'Everything's out there.' I always start by saying there are certain things I go to the doctors with I wouldn't want my Mum and Dad to know about, whatever my age, but when my life is in danger, I think, usually, it's possible to share.

I think it's important to add to this that this can be thought through in increments—it's not that the child is always unwilling, as the patient, for that information to be shared. When a person is thinking about suicide, it takes an awful lot of courage—somebody in an earlier session used a different word, but I won't go there—a lot of courage to talk about mental health. If you pluck up the courage to talk to one person, i.e. your GP, that major battle has been won. And all the GP will need to say is, 'What has it been like to talk to me? Why don't we build on the safety that you've found with me to others?' That may include others and the child will usually say, 'Well, yes, I could talk to others. Will you help me?' But further than that, I've seen several cases where the child has given explicit permission to share that information and the doctor hasn't, or has forgotten to, or thought he had. So, we really need to hone those skills and attitudinal issues in GPs. I'm not castigating them as a group of criminals here—I'm not. I'm just saying there are little things we can do to get better at improving practice. 

Thanks, Chair. Is there evidence that talking more openly about suicide and self-harm in schools reduces the risk of suicide and self-harm and actually increases help-seeking behaviour?

My understanding is that there isn't evidence that says that about schools. There is strong evidence to say that talking about suicide does increase safety, regardless of age. I think we just need to acknowledge deep down in each one of us that there is a resistance to talk about suicide. At a committee like this we're all going to nod along and say, 'Oh, yes, it wouldn't be me', but actually, deep down in me, we don't want to talk about suicide and that's what we need to overcome.

I always tell the tale, when I got this job, my friend asked me round for tea and her little girl said to me, 'What do you do now? Do you still work with poor children like you used to with my Mummy?' And I said, 'Well, no' and at that point the cloud of unknowing came down—I wanted to pretend I was a butcher, or a baker or a candlestick maker. And the mum came in and said, 'What are you doing?' and this child was six or seven, and mum, quite matter-of-factly, said, 'Some children don't want to be here anymore and they try to kill themselves and Ged's trying to stop them', and the little girl said, 'Well, that's cool. Do you want a sandwich?' I think that's probably true of all our children.

The problem is, the rest of us have grown up with this air, unevidenced, that if we talk about it we'll create a problem. That's evidence—. We did this survey of teachers. A lot of them were saying, 'We're presented with suicidality quite explicitly every day, every day, and we want to do something, we just don't know how.' The children are already talking about this, so we just need to wake up and smell the coffee and get over ourselves and do something about it.

If I can just add some things again from what young people come to us with. So, very much in line with what Ged has already said, I think there is evidence to show, generally, that the way we communicate with our children and young people is really important. A lot of that is about naming feelings and emotions, which is linked into the whole agenda around resilience and being able to have difficult conversations that are age/maturity appropriate rather than ignoring it, belittling it, distracting from it, because it's just too uncomfortable, awkward or embarrassing to be able to talk to children and young people about those difficult issues. And a lot of children and young people who do come to us will say very often that they're isolated, they can't talk to friends. Friends don't understand. They can't talk to family, because they don't want to disappoint them or alarm them. So, a lot of responsibility being taken on, and being very guarded about what they say, how they say it, who they say it to. So, that step, as Ged said, is really important.

Whoever it is, at that point in time really needs to grasp the nettle and seize that opportunity. But likewise, being on the receiving end, whether it's as a parent, a professional, again the GP example, it's about knowing how to respond in that situation that will encourage that trust and openness in order to be able to take that next step. So, again, very much what children and young people come to us with and what we try and encourage—coming back to the confidentiality point—is to talk to someone that they trust, whether that's a parent, a school counsellor, whoever is perhaps a trusted adult, whether that's a relative. But whoever, just to be able to continue that conversation.


At the moment, it's down to individual schools and individual LEAs in Wales how they approach any discussions about suicide, and that includes where there has been a suicide or a possible suicide in a school. Do you think that Welsh Government needs to take action to make it clear to schools and LEAs that there needs to be more discussion of this kind of thing, especially when there's been a suicide or a possible suicide?

I imagine that—. I may be wrong, but you don't allow schools to decide whether to teach maths and English and Welsh. Am I right?

No further questions after that. [Laughter.]

This is killing our kids more than anything. What's more important to parents? I wrote to Theresa May recently, and I had lots of things I said to her. One question: what can you think of that is more important than protecting children from suicide?

I think the other point that I would make again within the Welsh context is, clearly, there's an ongoing review and development of the curriculum, so whether or not there are opportunities to be looking, yes, at suicide, but alongside all sorts of other difficult issues—you know, mental health and well-being issues—within the context of the new curriculum, so it becomes normal and routine to talk about difficult things, rather than, 'Let's blitz the school and bombard them with all these resources at one particular crisis point,' and then that blows over, and it's kind of all gone away again.

Mathematics is difficult, from what I remember, but they still kept telling me about it. It's done me some good.

If I could just interject as well. In terms of that awareness raising with young people at the earlier stages, then obviously that provides an opportunity for them to be made aware that there is support for whatever issue is going on in their life. There are support mechanisms out there, whatever they may be, to be able to help them address that, and that suicide is not the only solution—that it's out there.

Exactly. Angela is going to deal with social media in an agile fashion

Ged, you actually said, 'Children are already talking about this—they're already talking about suicide,' and of course, social media is utterly prevalent. Our children are now very social media orientated; it's their way of communication these days. And not just social media, but television and the media and press reporting of death by suicide, and I just wanted to get your take on a couple of things. One is your views on how television portrays death by suicide in films and in plays and in soaps and everything that our kids watch. Secondly, where you think social media's responsibilities, and our ability to curtail the negative impact of social media, might lie, and also our ability to use any positives from social media in terms of how we can communicate positive messages. I say all of that because, over the last few years, some of us have produced and read report after report from all sorts of third sector organisations, and it's always about the negative impact. I very seldom read a positive impact, but the negative impact of social media on our children's health, well-being, self-confidence, self-belief, sense of self-worth. 

If I take the television and film bit first, I think, often, I'm watching a rather compelling drama and I think, 'How is this—usually a bloke—how is this bloke going to get away with this?' He ends his life, usually chased up a high building by a group of police, and you think, 'There's no way out of this.' Now, subliminally but explicitly, the message that comes across is: suicide is a valid way out. So, that's dangerous. I would charge every editor and author of such dramas to think, 'That's just a lazy plot line'. You should at least, then, have the second programme showing the devastation for everybody, not just the local people who are the loved ones, but the whole community, the police, the third sector, organisations that have to rally round to support, and all of that. The impact of that is cataclysmic. One of my colleagues often says, 'You can't imagine what it's like to lose someone to suicide, so don't try, because it's too painful.' And that's never shared in films. 

In terms of media, I know that other colleagues have shared the general response around safe reporting of suicide, so I won't repeat that, but in terms of social media, we've done a lengthy piece of research with the University of Bristol and Samaritans, as a partnership piece of research, which showed us some surprises.

So, we're 20 years old at Papyrus—21, actually, now—and we have, for most of that time, held an 'internet equals bad' agenda—a ban the bomb agenda. We've learned through that research and others that people who are suicidal actively search for validity, for 'Is this real? Do I really need to do this? Am I really thinking this? Are there others out there?' Without making a judgment on that reality, that's a complex mix of emotions, thoughts and behaviours going on, and nowadays it's as normal to explore that reality online as it is outside the online environment. What we've discovered is that, in simplistic terms, people needed the good and the bad, and weighing those up was keeping them alive quite often, more often than it was putting them at risk of suicide. That was coming from the people who were suicidal online, one of whom was a GP who said that she often thinks about suicide herself, and it was valuable to her to be able to access some of the recipe sites.

However, I've written to the Attorney General, last week, the week before, to say that Wikipedia still, if you search online, shows you how to kill yourself. I think that's heinous. The problem for the Attorney General and the Crown Prosecution Service is that it's very difficult to get a case study. It's very difficult to demonstrate that this information led to this death. I read one story recently—I'll anonymise it—a young person died, and after the event they researched through that young person's history. You would expect me to say now that there were some bad sites and some good sites, and there were, but the more compelling, heart-rending thing is that that person had not slept for half of the last 78 days before his death. That leads me to think it's not just the content of social media that we need to dwell upon in committees like this, it's our behaviours. Coming down here on the train yesterday I probably passed 200 people. I only saw three of them because most of the time I was looking at my phone. That's what we need to think about. Have we created a monster around the behaviours we engage in around social media? I was in a school in Belfast two weeks ago and I said, at the end of my little lecture, 'Like Papyrus on Facebook. Somebody may see us because of that and you may save a life', and the teacher said, at the end of the lesson, 'You're not allowed your phones.' So, we got chatting, and he said he'd confiscated a phone because a girl had been on YouTube consistently for 14 days. We're probably all engaging with social media much more than we would like to admit.

Two more points. The principal life-saving factor for young people is the sense that they are connected, and social media does at least purport to connect us. Whether that connection is legitimate and wholesome is another matter, because my second point is this: we shared in our evidence a picture of a campaign we did—'Behind the brave face, someone could be dying for help'. The young person who says, 'Everything's wonderful, my life is great. I've been to Cardiff today, I sat in a committee and it was lovely', but I don't tell you all the bad things that are happening. So, we often say that encouraging young people to use social media in a moderate way, and also challenging them, because they may be the protagonists of the cyber bullying stuff as well, it's not always—. As somebody earlier said, bully and victim are not always different people. Young people are vulnerable and we need to encourage young people to be safe online, to behave well online and to share not just the good bits, which brings me back to my first point, doesn't it? Suicide is a disaster and we shouldn't portray it as an easy way out.


Okay. We're about to run out of time, so Rhun can wrap things up and Stephanie can comment as well. 

Yes. It's literally wrapping it up, really. I've listened with a huge amount of interest, not just to this session, but the other sessions this morning. Are there other elements of fighting the stigma that you think we should be concentrating on and making recommendations on as a committee? Because that's been the theme that has come up time and time again this morning—our unwillingness to talk about it, the silence around suicide.

I'd just make one point if I may. There's a lot of talk about mental health; there's very little talk about suicide. So, if I had a dream, it would be a public information film about suicide prevention, like we would have about AIDS.

We're all at risk. We're all at risk. 

Sorry, yes, I understand.

Yes, I meant at immediate risk. Or all of us who could be helping somebody?

The latter. The latter, definitely. We've heard for decades about, 'If you're at risk, ring this number'. We need to change that around.

I think probably just a couple of points to add to that and link to social media. It's about being much cleverer, I think, again, about content and campaigning and bringing together the lived-in experience—all those elements where, actually, people who've experienced it are sharing information and connecting and communicating and engaging and reaching out to a much bigger audience and being able to cascade information, videos, et cetera, et cetera. 

The other point I would make, linking back to the earlier point about resilience, the curriculum, is it's teaching children, but also engaging with their parents and families from a very young age—you know, appropriate behaviours, resilience, how to cope with adversity, difficult conversations and how to do that, whether that's within the family setting, within a community setting, with peers; what's acceptable, what isn't, et cetera. So, again, those face-to-face and online conversations are very key and the curriculum, schools, et cetera, could be a force for good and a focus for change as far as that's concerned.

I think what Stephanie was saying there is that that often happens now after the event with parents and with children within the school setting—that that information giving is there when that's happened in a setting, but there's no preventative in terms of, 'This is what you should be looking out for to prevent that happening'.

Ocê. Diolch yn fawr. Rydym ni allan o amser. Diolch yn fawr iawn i chi am ateb y cwestiynau mewn ffordd mor raenus ac aeddfed, a hefyd am y papurau y gwnaethoch chi gyflwyno ymlaen llaw— mae'n safon fendigedig o dystiolaeth. Diolch yn fawr iawn i chi. Byddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma er mwyn gallu gwirio eu bod nhw'n ffeithiol gywir, hefyd. Felly, diolch yn fawr iawn i chi.

Okay. Thank you very much. We've run out of time. Thank you very much for responding to our questions so well, and thank you also for the papers that you submitted beforehand—they were of a great standard of evidence. Thank you very much. You will receive a transcript of these discussions so that you can make sure that they're factually correct. So, thank you very much.

5. Papurau i’w nodi
5. Paper(s) to note

I'm cyd-Aelodau, rŷm ni’n symud ymlaen i eitem 5 a phapurau i’w nodi. Byddwch chi’n gweld papur gan yr Athro Ann John ar y Gronfa Ddata Gwybodaeth am Hunanladdiad—Cymru. Mae yna lythyr arall ynglŷn â chaffael contract y fframwaith systemau gwasanaethau meddygol cyffredinol a rhestr cyflawnwyr meddygol Cymru gyfan hefyd, yn ogystal â llythyr ar gaffael contract y fframwaith systemau gwasanaethau meddygol cyffredinol oddi wrth Ysgrifennydd y Cabinet dros Iechyd a Gwasanaethau Cymdeithasol i chi nodi. Unrhyw sylw? Dim sylw.

To my fellow Members, we move on now to item 5, which is papers to note. You will see a paper from Professor Ann John on the Suicide Information Database—Wales. There is another paper on the general medical services systems