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

Health, Social Care and Sport Committee - Fifth Senedd

23/05/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Caroline Jones AM
Dai Lloyd AM Cadeirydd y Pwyllgor
Committee Chair
David Melding AM Yn dirprwyo ar ran Angela Burns
Substitute for Angela Burns
Dawn Bowden AM
Jayne Bryant AM
Julie Morgan AM
Lynne Neagle AM
Rhun ap Iorwerth AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Angela Samata Llysgennad SOBS
Ambassador for SOBS
Avril Bracey Cadeirydd, Fforwm Rhanbarthol Canolbarth a De-orllewin Cymru
Chair, Mid and South West Wales Regional forum
Emma Harris Swyddog Polisi a Chyfathrebu, Y Samariaid
Policy and Communications Officer, Samaritans
Gwenllian Parry Cadeirydd, Gweithgor Hunanladdiad a Hunan-niweidio Gogledd Cymru
Chair, North Wales Suicide and Self-harm Working Group
Professor Keith Lloyd Cadeirydd, Coleg Brenhinol y Seiciatryddion yng Nghymru
Chair, Royal College of Psychiatrists in Wales
Sarah Stone Cyfarwyddwr Gweithredol y Samariaid yng Nghymru
Executive Director for Samaritans in Wales
Susan Francis Swyddog Prosiect Samariaid Cymoedd De Cymru
Project Officer for Samaritans South Wales Valleys Project

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Catherine Hunt Ail Glerc
Second Clerk
Philippa Watkins Ymchwilydd
Researcher
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 09:31.

The meeting began at 09:31.

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

Croeso i chi i gyd i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1, a allaf i estyn croeso i'm cyd-aelodau i'r pwyllgor iechyd yma? Ymhellach, egluraf fod y cyfarfod yma 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. Os bydd yna larwm tân, dylid dilyn cyfarwyddiadau'r tywyswyr, er mwyn gallu dianc oddi yma yn ddiogel. Rydym wedi derbyn ymddiheuriad oddi wrth Angela Burns, ac rydym yn anfon ein dymuniadau gorau iddi fel pwyllgor am adferiad buan. A gallaf yn bellach gyhoeddi bod David Melding yma yn dirprwyo? Ac, fel cyn Gadeirydd y pwyllgor hwn, rydym yn ymfalchïo yn ei arbenigedd e yn y maes hefyd.

Cyn inni symud ymlaen, mewn pythefnos, y cyfarfod nesaf o'r pwyllgor hwn, nid wyf yn gallu bod yn bresennol, felly mae angen ethol Cadeirydd dros dro. Felly, yn unol â Rheol Sefydlog 17.22, galwaf am enwebiadau ar gyfer Cadeirydd dros dro, ar gyfer cyfarfod y pwyllgor iechyd yma ar 7 Mehefin. Felly, a oes enwebiad? Lynne.

Welcome everybody to the latest meeting of the Health, Social Care and Sport Committee, here in the National Assembly for Wales. Under item 1, can I extend a welcome to my fellow members of the health committee? Can I further explain that this meeting will be bilingual, and you can use headphones to hear simultaneous translation on channel 1, or to hear contributions in the original language amplified on channel 2? If a fire alarm sounds, you should follow the instructions of the ushers in order to escape safely. We have received apologies from Angela Burns, and we send our best wishes to her as a committee for a quick recovery. Can I further explain that David Melding is here as a substitute? And, as a previous Chair of this committee, we are proud of his expertise in the area also.

Before we move on, in a fortnight, the next meeting of the health committee, I cannot attend, and therefore we need to elect a temporary Chair. And so, in accordance with Standing Order 17.22, I call for nominations for a temporary Chair for the duration of the meeting on 7 June. Can I therefore ask for a nomination? Lynne.

Mae enw Rhun ap Iorwerth wedi ei gynnig, ac wedi ei eilio gan Caroline Jones. Felly, Rhun, wyt ti'n barod i gymryd y baich o gadeirio'r pwyllgor yma ar y diwrnod arbennig yna? Rwy'n gallu gweld ei fod o, felly rwy'n datgan bod Rhun ap Iorwerth wedi cael ei benodi yn Gadeirydd dros dro ar gyfer y cyfarfod nesaf. Diolch yn fawr iawn i chi i gyd.

The name of Rhun ap Iorwerth has been proposed, and has been seconded by Caroline Jones. And so, is Rhun ready to take that responsibility of chairing that committee on that day? I see that he is, and therefore I declare that Rhun ap Iorwerth has been elected as a temporary Chair for the next meeting. Thank you very much to you all.

2. Atal hunanladdiad: Sesiwn dystiolaeth â'r Samariaid
2. Suicide Prevention: Evidence session with Samaritans

Symud ymlaen rŵan i eitem 2—parhad efo'n hymchwiliad i atal hunanladdiad, sesiwn dystiolaeth gyda'r Samariaid. Ac rwy'n falch iawn i groesawu i'n plith Sarah Stone, cyfarwyddwr gweithredol y Samariaid yng Nghymru; Emma Harris, swyddog polisi a chyfathrebu; a hefyd Susan Francis, swyddog prosiect Samariaid Cymoedd de Cymru. Rydym wedi derbyn eich tystiolaeth fendigedig ymlaen llaw, ac, yn ôl ein harfer rŵan, fe awn ni'n syth mewn i gwestiynau. A chwestiynau i ddechrau efo Lynne Neagle.

I move on now to item 2, which is a continuation of our inquiry into suicide prevention and an evidence session with the Samaritans. And I am very pleased to welcome Sarah Stone, who is the executive director for Samaritans in Wales; Emma Harris, a policy and communications officer; and Susan Francis, who is the project officer for the Samaritans' south Wales Valleys project. We have received your wonderful evidence beforehand, and, as usual now, we will go straight into questions. And the first questions are from Lynne Neagle.

Thank you, Chair. Good morning. Can I ask what further data we need in order to gain a better understanding of suicide, so that we can target action more effectively?

Okay. So, I think that you had a discussion with Professor Ann John on this subject when you talked earlier, and you talked about the time lag that there is between the Office for National Statistics statistics and looking at the actuality of what is happening this year, and looking at real-time data. So, I think that that is well worth examining, because we're always looking backwards at the suicide data, and we don't have statistics that tell us what's happening now—we don't have things that can raise concern and alarm bells in particular areas. So, there is an issue about data and the way it's reported, and I think there are ways in which we could do that better. So, there is a lot in that question, Lynne; I think that we could improve it, yes.

Could I actually come in? I'm a member of the Cwm Taf suicide and self-harm forum, and we're putting together the plan for that area. And it's very much a case of, you know, it's very early days for us, and we're pulling the information together, and we're trying to find information from what's available. But one of the problems for us is that, in Cwm Taf, it's about—. We've got about 10 per cent of the deaths across Wales, so when you start looking at those lower numbers, obviously you've got to be very sensitive about that. So, we can't actually access information—it's quite frustrating—in terms of whether we've got real issues, and taking on what Sarah's saying there about the time delay anyway. But, you know, have we got an issue that we don't know about? Are we targeting—and speaking from the project's point of view, are we targeting and best using our volunteer capacity in the right places and in the right way? So, it's almost as if, really, as forums, we should be able to ask questions that we need the answers to, and not necessarily—. We don't need to know the details and individuals, but we need to know whether we've got those sorts of issues.

And then a second point, really, on that is that we spend a lot of time looking at the data in terms of the number of deaths, but we also need to know about the number of people who are really struggling. I had a recent meeting with the Royal National Lifeboat Institution down in Port Talbot. For me to be shocked at a meeting, with the work that we do, is quite something, but I was. The number of people who the RNLI and the coastguard are dealing with who they call, 'despondent', is staggering. And those people, thankfully, are not going to show up on the stats for the number of losses, because they go out and they respond to them, but the number of people who are despondent is quite frightening.

09:35

Some people have given evidence to say that we need a real-time suicide surveillance system. How would you see that working?

Well, I think that we'd need to work out the details of that. It's not the whole solution either, because that wouldn't necessarily address the points that Susan's just made. So, I think that that could be worked out. I think you'd need to look at any unintended consequences of that, but, certainly, the expertise exists here to put together something that would be really effective.

Could I just add that, alongside that, I think we need to do that in conjunction with gathering better data on self-harm attempts and admissions to A&E, because that's such a high-risk factor for suicide? Once someone's been discharged after a suicide attempt or self-harm from A&E, they should be followed up within seven days, and they're often not. We don't have that data. That data needs to sit alongside real-time suicide data so that we can explore the two and work out any links.

Okay, thank you. We've also been told that one of the things that would help would be if the—. Currently, as you know, in an inquest, it has to be beyond reasonable doubt in order to give a suicide verdict, which is distorting the figures. So, we've had calls to press for a different system that would give a suicide verdict on the balance of probabilities. How do you feel about that?

Yes, I think that almost everyone involved in this field understands that what we have by way of formal data underestimates the numbers of suicides. So, the question really is how we deal with that. I think that we have this 'beyond reasonable doubt' standard of proof, which is very high. What we need to bear in mind is what we're trying to get out of this. What we're trying to achieve is a proper statistical picture of suicides. So, how we get there—whether we get there and how we code the narrative verdict—is the point really. I don't necessarily think there's a simple solution to it because the reason—. It can be quite complicated. So, we can do much better in terms of how we actually code suicides and how we commonsensically understand that this was most likely to be a suicide.

Ocê. Mae'r cwestiynau nesaf o dan ofal Jayne Bryant.

Okay. The next questions are from Jayne Bryant.

Good morning. In your paper, you say that the most effective means of achieving a local and collaborative approach is the creation and implementation of local suicide prevention plans. You say as well in your paper—you highlight some inconsistencies around the regional suicide prevention forums and local planning arrangements. Could you expand on that?

Yes, and I think that—. Obviously, Susan will have some things on this as well, but one of the issues for the last suicide prevention strategy, which was the original 'Talk to me', was the lack of effective local implementation. That's one of the big points that was made in that mid-point review. I think that we've done much better this time for a number of reasons. So, there is an improved picture. But when you think that we're two and half years into the second strategy and we've only just really got the functioning of those regional forums—and there has been quite a dependence, really, on local enthusiasm. There's quite a dependence on key individuals who are enthusiastic. When they're not there anymore then the impetus can fall a bit. So, I think that progress has been a bit slow. I think that it's happening now and I think that the fact this inquiry is happening and the fact that guidance has been issued by the national advisory group has galvanised people locally. So, it's not a bleak picture, progress is being made, but the engagement of local agencies in an energetic way is absolutely critical. The points are made in the evidence you've received; this is a complex issue. I think, Susan, you'll be able to comment on what's happening.

09:40

Yes. Speaking from the Cwm Taf experience, it was—they'd already tried to put a plan together and then the group dissolved for some reason. We've just restarted that, so it's still early stages for us. But there's a lot of frustration, as I said, about the statistics that we've got in the area, and then looking at the answer. But even the make-up of the group—we're still a small group and we're about to expand that, but where are the resources to do this? When we come to putting actions in place, finding the funding, the staff time, to put things in place, is going to be difficult for us. So, we're looking for answers, really.

That was my next question, about if you thought it was adequately resourced—

Absolutely not.

Yes, you've been clear on that. And where you thought it should be targeted.

I think there's so much scope here for resources. As you've said, it's such a complex issue, and we're talking about all the people who are struggling out there. I'm a Samaritans volunteer as well, and I can speak from that perspective as well, supporting people. I go out and I do a lot of awareness raising for the Samaritans, and I can guarantee that, wherever I go and speak about the work that we do and about suicide, I never leave without somebody coming and telling me a personal story. So, people want those opportunities to talk. So, how do we resource that? How do we give them that space? I think there's a real will for us—. I know Interlink in RCT are looking at this—how to create compassionate communities that can actually talk openly about well-being and suicide and give those spaces. But it will need development. It won't just happen. At the moment, it's all down to the good will. I agree with Sarah that there is a lot of enthusiasm, there is a lot of good will for this work, but there comes a point—. We need to hold a stakeholder meeting, so we'll be looking around the room for who's got a bit of money so we can actually hire a venue and have some tea and coffee so we can bring people together to have these conversations. 

We do see that a lot, where the will is there—we've had meetings with fire and rescue and police where they're doing great work on suicide prevention in their local area but they don't necessarily sit on the suicide prevention group, and that's because of a lack of resource in promoting it and holding it regularly and just getting some information out there about it.

Ocê, symud ymlaen rŵan i'r grwpiau hynny sydd â'r risg uchel o hunanladdiad, ac mae cwestiynau gyda David Melding.

Okay, moving on now to the high-risk groups, and David Melding has some questions.

I wonder if you could tell us your view of how the Welsh Government strategy, and then particularly the local plans, balance that issue of the preventative work with the whole population against the targeted interventions at the high-risk groups. Because most suicides still come from that part of the population that's not been in contact with mental health services, so it's obviously a difficult balance. So, how's it working out?

I think that the focus of 'Talk to me 2' is correct in that it does identify priority people and it has been aiming to narrow that focus on high-risk groups. Obviously, there's a powerful case for that because you can't do everything. But what we would be saying is that you've got to have a multi-level approach; it's not an either/or approach. The way I think about this is that suicide prevention can be seen as a competing priority for limited resources when you talk about the bigger picture. What I would say is, what we would say is, it's not actually a competing priority; it is so much of a piece with the preventative direction of travel that we need to take around mental health and well-being—so, it supports the wider aims of whole-population mental well-being. So, I think, yes, high-risk groups are really important to target. So, training for emergency services, A&E, you know, you're looking at men, particularly—obviously the vast majority, 81 per cent, of suicides in Wales are by men—and then you're looking at socioeconomic groups within that as well. But also we have this great opportunity for increasing understanding in the whole population of what helps emotional resilience. A lot of the things that we've done of late as Samaritans, including our work on socioeconomic disadvantage, including our work to promote emotional literacy in schools, is about that wider agenda. People really want to hear about that and I think it's because doing that meets a need that they have as well. So, I think we have a win-win situation, really, in the wider promotion across the whole population, because this is a public mental health issue.  

09:45

Following on a bit from that answer, I notice in the English strategy they are placing a new emphasis on reviewing suicides, particularly amongst those in high-risk groups, i.e. people that have been in contact with services, and then having a thorough review and obviously using that as a learning tool. Now, we've talked a lot about the data—is there enough reviewing going on within our strategy?   

Yes, I think—. So, you mean interrogating the data. We've got a—there's another trial—

Well, I think it's more looking at the actual case when, unfortunately, a suicide is completed. 

I think there's more that could be done around that to understand what's going on for particular groups. There was the child death review, which looked at suicide amongst young people, and that produced some very helpful recommendations. There's another one that is just starting, which looks at suicides and probable suicides amongst young people. So, I think there is a great deal to be gained by looking at the situation of older people, for example—there are other groups—and you can really delve into that, and in that understanding you can find things that would make a really big difference. So, there's area-level suicides, and I think that's a critical thing—we could do more there. 

Certainly, again coming back to Cwm Taf, the figures show us that people are taking their lives at a younger age in the Cwm Taf area, so to understand that better may help us to try and mitigate that. 

Also, we know up to 70 per cent of people who die by suicide aren't in contact with mental health services, therefore high-risk groups are still part of the whole population in terms of a community approach or a schools approach. There aren't necessarily specific settings that we can target. Men, who are the highest risk group, they would still benefit massively from targeting loneliness and isolation or improving community infrastructure and things like that. 

And then the final point from me—those that are in a situation of economic deprivation are both a higher risk group, but it's also a population factor, isn't it? Unfortunately, we have a lot of people in that category. How do you think the strategies are improving the response to that important part of the population that are at higher risk, but you're going to need more population approaches for, presumably? 

Yes. In our recent report, we set out 10 recommendations about that. Some of those things—. What we've done is to give that report to other organisations who are dealing with poverty in a much more whole way than we are, but—so, let this inform you. We can do things, and I think that one of the messages to keep giving, really, about this is that suicide is potentially preventable. There are things that we can do and it can feel too big, but actually you can do things like support work to increase community infrastructure—community centres, groups, things the third sector does that bring people together, things that mitigate the impact of unemployment on individuals. That's why we've called for a poverty strategy, because that's about a coherent approach to reducing the emotional distress and the isolation that economic disadvantage can bring to individuals.

09:50

Do you have any sharper observations, Sarah? I completely agree with what you've just said, but are there, other than we should give deprivation a higher priority in general in Government programmes—? I don't think there'd be anyone that would disagree with that. This morning, some of us attended the open fields trust, with the emphasis on green spaces. Are there some interventions in deprived neighbourhoods that seem to bear a lot of fruit in terms of building up resilience, like access to leisure spaces, that we might want to target with a more general approach?

One of the examples we give are things like Men's Sheds, where you've actually got projects that bring people together in a way that is acceptable to them. I don't know if there are other comments that you might have. 

I think, really, when we talk about a poverty strategy, for us it's about making sure that suicide is seen as a major link here and that the implications of not mitigating deprivation are that we're going to lose people—people are going to die. And we have the fact that there are a lot of people who are really isolated. So, with the closing of libraries at lunchtime or for certain days, and the community centres that we've lost, we've really lost a lifeline for people. Tea dances save lives, and it's as simple as that. So, I think, what I want personally is that that's in all your consciences, really, and that you're considering that when you're making decisions about funding—that, actually, these items that you might think are easy to cut actually make a massive difference in terms of people's well-being in those communities. 

Ocê. Mae hynny'n ein harwain ni ymlaen i'r adran nesaf, sef y gefnogaeth sydd ar gael, neu sydd ddim ar gael, i'r sawl sy'n galaru wedi hunanladdiad rhywun annwyl. Mae Rhun yn mynd i ofyn cwestiynau. 

Okay. That leads us on to our next section, which is bereavement support that may or may not be available for those who have been bereaved as a result of suicide. Rhun will ask these questions. 

Diolch, Gadeirydd. Mi fyddwn ni'n cymryd sesiwn yn nes ymlaen heddiw yn benodol yn edrych ar hyn. A allwch chi roi eich sylwadau chi ynglŷn â phwysigrwydd y gefnogaeth sy'n cael ei rhoi i bobl sydd yn cael profedigaeth oherwydd hunanladdiad rhywun annwyl, a sut yn benodol mae gwella'r mynediad i'r gwasanaethau cefnogaeth sydd ar gael?

Thank you, Chair. There will be a further session to look at this issue later on today. Could you give your comments on the importance of bereavement support following the suicide of a loved one, and how can access to support services be improved?

We know that being bereaved by suicide increases the likelihood of people dying by suicide themselves, and that, for every person who dies by suicide, about six people are going to be very closely affected by it. What we hear is that there are some really good advocates who have experienced suicide who talk about the lack of resources that they were made aware of. We're not where we need to be. So, resources like Help is at Hand are really important, and one of the simple things that we can do is just make people aware of what's available already, because that's an excellent resource and should be given to people. 

Access to bereavement counselling—there are waiting lists for that. It can be difficult to get hold of, so I think there's a lot more that could be done to make that available. 

What are the pathways that people are guided towards, and what are the common ways that people miss those pathways altogether and try to deal with things themselves?

In Wales, there is no consistent approach to bereavement support and that's one of the problems. So, there isn't really a clear pathway. Help is at Hand is great and can help with that because it's very good for signposting. I think one of the major problems is stigma around talking about suicide, both for the person that's been bereaved and the person they may come in contact with, like their GP, or anyone actually in front-line services. So, that's why investment in that would be great—talking about suicide, and training, upskilling front-line staff. So, we really need a consistent approach because waiting lists are a major problem, and there's no clear guidance for people when they're bereaved.

09:55

Are you talking about investing in the services that we already have, which suggests to me that the building blocks are in place but somehow we need to build those up and guide more people towards those services?

I think so, and to make it an immediate response. I think there are some good models out there. 2 Wish Upon a Star, for instance, responds to a sudden child death. If we could have that response across Wales for people who are bereaved by suicide, again, that would just make such a massive difference, and, yes, if we can help people to tap into the resources that already exist and give them that helping hand at that very time when they're reeling from the absolute shock and horror of what's happened. 

These issues came up in the mid-point review of Talk to Me 2, calling for this all-Wales pathway, and calls also for support in settings such as schools specifically, targeting places where support should be highlighted. Is that something that you'd support?

We'd really welcome the issuing of guidance to schools on what to do following a suicide. So, we welcome the recommendations of the emotional health report. We've got a service called Step by Step, where volunteers go into a school and help them create a plan if there's been a suspected or attempted suicide, and that's proven really effective in enabling discussion between parents and pupils, pupils and teachers. The overall aim of that is to stop there being a copycat suicide or to stop imitative behaviour. 

We're coming on to questions like that. Lynne, did you have a supplementary before that?

On Help is at Hand, it's an excellent resource, but to what extent do you think it is uniformly being given to people who have lost someone to suicide? And, in terms of the resource issues, we know that it will be expensive to put in place better bereavement support, but, as your paper highlights, each suicide costs £1.6 million. So, do you think there's a really strong invest-to-save argument that we should be looking at here?

Can I just answer that? I think this really needs to be linked with the training that's required for front-line staff and volunteers. Again, in my experience of going around, I've spent a lot of time talking to front-line staff and hearing from them the struggles that they're having of not knowing where to signpost people and what to do and how to handle the situation when somebody approaches them. And there's the anxiety that that causes them as well. I think there's a massive impact on our front-line staff and their well-being, and I think there needs to be something put in place. We need to be encouraging more employers to put support in place. So, I think the two things need to be linked. The resource is good, but maybe we need it in different formats, and we certainly need front-line staff to understand it and know how to apply it. 

Okay, training figures in some questions later on. Caroline is on children and young people and university students. 

Diolch, Cadeirydd. Good morning, everyone. The emotional well-being and mental health of our children and young people must be a priority in schools. So, could you tell me what is the Samaritans' response to the recent recommendations and the Children, Young People and Education Committee regarding suicide prevention in schools?

Our response is a very positive one. We think it's a tremendous opportunity. The 27 recommendations in that report together form a menu that would help to transform the mental well-being of young people in our schools. I think it's incredibly important to do something about that, and all the time that goes by without putting in place that sort of emotional literacy, the support actions, is opportunity that is lost. We've got generations of young people growing up who need to have better tools at their disposal and better support to handle the world that they are in. So, we very much welcome it across the piece really. It's a good piece of work. 

Thank you. A record number of students died by suicide in 2015 and, indeed, there was an increase between 2007 and 2015 of 79 per cent. So, could you tell me the Samaritans' perspective on the increase in suicide among students in recent years, and in what ways could the suicide prevention agenda be strengthened in colleges and universities?

10:00

So, we know there's been an increase in colleges and universities, and we can see that's an increasing problem. We have been looking at developing some resources to support universities. One of the things that's really relevant with universities, much like I said earlier, is that a lot of students who are struggling are not necessarily in contact with mental health services. So, whilst it's vital that there's adequate mental health provision on campus or within the university, we need to assume that a lot of those students are not going to be going for formal support; they're going to be struggling in silence. And that, we think, is closely linked with loneliness and isolation, the stigma around thinking you're the only one having a bad time at university. So, a lot of it is increasing awareness about help seeking and just saying, 'It's okay to feel lonely and it's okay to feel isolated.' So, I think it's working with—. Each university needs clear guidance on how they can help the whole student population, through awareness campaigns and just better signposting and help seeking from the minute they get there. 

On this, is there any rigorous evidence that adolescents and young people are particularly vulnerable, just because, when they first get a significant episode of mental ill health, or even psychosis if it's very serious, they obviously have very little resilience if it's their first experience? Is that a particularly high-risk period for any individual in terms of suicide?

There is an increasing evidence base around this and the emotional vulnerability of young people and the effectiveness of interventions. There was, I think, a Public Health England report not so long ago that talked about the value of every pound invested in emotional literacy for young people and the repayment on that. So, there is growing evidence around vulnerability but also about some of the things that can help to mitigate that. 

Just on development, we had a talk, didn't we, at a recent conference about looking at the emotional development of young people and the recognition that, actually, we're sending young people off to university at a time when they're not emotionally developed, and we need to recognise that and prepare them better. So, I think, again, I would  definitely say we need to be bringing that education into schools and preparing them ready for going, but also to have that support there when they're in university. 

Okay. Time is going on in this session. It's all very interesting, but old father time and mother time is ticking onwards. We need some agility, and I'm looking at Dawn, who is the very epitome of agility, and is going to talk about media and the internet now. 

I am, yes. Sorry, I was looking at the later one. You talked about the potential harm from the internet. We've seen that in many reports that we've had in evidence presented to us. We've looked at harm from the internet. I'm just wondering if you could talk about how that could be mitigated and what scope there is for the internet and social media platforms to play a more positive role perhaps in raising awareness around the issues.

We know there's a lot of damaging information on the internet; of course, we all know that. We also know that a lot of young people and adults who are self-harming, or thinking of suicide, research on the internet. It's also really important to say that social media has many positive benefits for those who are struggling or lonely or isolated. But I think it's about working with a variety of agencies really. With the media, for every negative story, or just a story covering suicide, there should be a balanced piece that promotes help seeking or how you can improve your mental well-being. That's a really good way of dealing with that, and we've seen some good practice of that here in Wales. 

I think schools have got a big part to play. I think schools can actually work really well to dispel the myth that everything you see on social media is real, and that is weaved into some of our own emotional health lessons. So, I think, once again, targeting whole populations is really effective.

10:05

Any other comments on that one? One of the things I think we were talking about was whether social media, in particular, could use—you see some of these embedded adverts that can come in, and flash up: 'Do you need somebody to talk to?', that kind of thing. Have you seen any evidence of anything like that, not necessarily on social media, but in other parts of internet platforms, where something like that has been done?

I think, unfortunately, we see more of the other side of it—so, negative videos, or damaging videos, on YouTube. There was a very high-profile YouTube video, which depicted suicide, and if that was left to run, it goes to associated videos, all of which are negative, or associated, and we would want to see them linking to help-seeking videos. Obviously, that's a huge issue, and that would really involve targeting YouTube, Facebook, Twitter— 

Yes. Because we're clearly not going to stop young people, in particular, using the internet, and using social media, so it's about trying to use that for—

Yes. At Samaritans we have—we had a recent campaign, Small Talk Saves Lives, linked with Network Rail. And there's a lot of activity on that. So, I think the more that we can put out messages like that, to try and counter the negative—it's a positive thing to do.

Do you have any thoughts on some of the dramatic portrayals that we've seen of suicide? There's the recent one, which had a lot of plaudits—the Coronation Street storyline. Any thoughts or views on how that might impact?

One of the things about the portrayals of suicide is there's really good evidence that copycats can be caused by the wrong kind of reporting—by over-detailed reporting of a method, for example. So, we work with the media, usually behind the scenes, to encourage responsible reporting of suicide, which encourages help seeking. So, a good example was Coronation Street. Samaritans worked with the scriptwriters, worked with those producing that, so that that portrayal was responsible, that it encouraged talking, and it was something that I think was well done. And there are other examples that are really concerning, which we have been critical of, because of, again, portraying over-detailed method, just overexposure to the whole issue, and a simplistic assignment of cause and effect. So, you know, 'This happened, and therefore this person killed themselves.' That is something that is not responsible as a way of portraying suicide. It doesn't show the complexity, and it doesn't show the finality of suicide either. So, there is a bottom line here: there are ways of reporting that are really unacceptable and shouldn't happen. That does happen sometimes, and it's a constant need to be vigilant about that.

Okay. Moving on, Julie, you've got some questions on training, although training has been covered.

You've already mentioned training quite a few times, so it's obviously crucial. So, how would you suggest it was improved? I know, Susan, you were saying how inadequate it perhaps was.

Well, I think that people feel that they lack confidence in how to talk about suicide, or people's well-being, and how to respond to people who are emotional. I've heard some awful stories, really, that could have been dealt with in just a very human way, if someone had been given permission and the skills to just sit down and listen to what someone's saying, and—

You're saying there's the opportunity to talk to somebody, but people don't feel they have the confidence. 

Yes. I think, without naming any organisation, of course, I did hear an instance where somebody was dissatisfied with the service they were getting, and made a comment about ending their life, and the organisation went into lockdown, and the poor person was being chased by security, rather than somebody actually sitting down with them, and letting them talk about their situation, and giving them a compassionate response, and working out with them what needed to happen next. So, I think there's a lot of scope, really, for helping organisations that deal with the general public to make a more compassionate response, and to feel more confident in that response. And I think that links with what we were saying earlier about, 'Where would you refer people to? What is the right way to do that?' We certainly go out and make sure that we're giving as much publicity information as we can, but also helping people to refer to us in a way that would, hopefully, help that person to pick up the phone and make contact with us.

10:10

In the bigger, all-Wales picture on training, it's a key part of 'Talk to me 2'. This is a complex issue, so, when you land on something that is really sharp and achievable, that's a very good thing; that sits in that box. Achieving much more consistent training for people on the front line, who are likely to encounter people who are suicidal, is something that we can make some real progress on. We know what that really ought to look like, and the emergency services are calling out for it. I've had conversations with the police, with the fire service, with others, who are very keen on getting that training. And it comes down to this question of resource. One of the things that would be a good thing would be to put more resource into achieving 'Talk to me 2', because there are some very specific, achievable aims in there, which need to be supported better, in order for us to really make progress, nationally and locally.

Excellent. Sounds like a cast-iron recommendation—that's what we're about in this committee, Sarah. Always my heroine, from that point of view.

And what about GPs? Do you think GPs need to have more training on this?

Yes, absolutely.

They are the front line. I mean, 90 per cent of people who die by suicide have been to see their GP in the preceding year. They're an incredibly important point of contact, so every tool that they can have—and knowing where to refer as well. So, there's a lot that could be done with GPs.

Do you want to deal with the stigma question as well, Julie?

Yes. In earlier evidence, there was a call for a public awareness campaign aimed at encouraging everyone to reach out and help when they're aware that somebody is struggling, rather than targeting specific people at risk. So, what are the witnesses' views on whether a suicide prevention public awareness campaign is needed, and who should this be aimed at?

I think a public awareness campaign is a tremendous idea. As we've already said, we've done that sort of thing, talking about the importance of talking and listening, and skilling people up. So, it would be fantastic to be a nation of good listeners, wouldn't it? Brilliant. And I think that what people don't necessarily understand, and people don't understand until they become Samaritans, or they come and do the Samaritans training, is the power of listening. And it really is a life skill; it's not trying to fix everything for people, but actually being an empathetic listener. And there are all sorts of ways in which that can be portrayed to people: through training, through work—which is a great opportunity—through school, and through population awareness campaigns as well. So, I think there is great merit in that.

It would also be brilliant if a campaign could focus on breaking that stigma that mental illness is something that happens to someone else, or mental ill health. Quite often, if we speak to people who are bereaved by suicide, the comment that usually comes is, 'Oh, you never would have thought that they were suicidal.' And I think there's some work to do in myth busting around the fact that it's the case for one in three of us. So, I think that's also really important.

Okay. Rhun, you've got one minute on the access to mental health services.

Have I, now? Okay. I'll just try to be quick. What impact would the introduction of waiting times measures for psychological therapies, which you're calling for in your evidence paper, have, do you think, on suicide prevention?

I don't think we mention waiting times measures specifically, but we did talk about access, and I think it's a huge issue, this. People who are waiting for therapies for months and months, or maybe years, they will call our service while they're waiting. Mental health problems are one of the major reasons that people call Samaritans, and it makes us very aware, as a service, of the distress that that sort of waiting causes. So, I think measures that would be effective in reducing those waiting times would be very important—

10:15

Well, I think reducing the waiting times, basically. How do you achieve it? The availability of talking therapies is not there; it's not there sufficiently quickly. So, yes, reducing that.

And when you consider the strength that it takes for somebody to approach their GP—we've just talked about that, and the stigma, haven't we, and the number of people who are just not doing that. So, when somebody actually makes that approach, and then they've got to wait, and wait, and wait, it is cruel, and we need to make that—it needs to be an instant appointment for them, to get that specialist help that they need.

And also, you can look at intervention as being one intervention, or you can look at it in terms of the ongoing support that somebody would need as well. What work needs to be done on that?

I would just make a final comment there that, actually, this is another example where emotional health provision in schools would massively impact on waiting times. Because many young people are pushed into mental health services, and on waiting lists, where they have a low-grade mental health problem that could have been dealt with through increasing resilience, and emotional health lessons in schools. So, I would just really like to add that, because I think that's really important.

Can we have a final question from Lynne about confidentiality issues?

Yes. Thank you, Chair. We've been told that there's a problem with information sharing between health professionals and families and friends of patients who are identified as being a potential risk for suicide. And we've been told that it would be better for that to be looked at, to take away some of those barriers. What is your view about that?

Obviously, for Samaritans, confidentiality is a critical thing for our own service. And what's really important for us as a service is that people feel able to speak freely, and have a safe space in which they can communicate whatever it is that they are feeling, without concern that that's going to be passed on, unless they want it to be. So, we understand the importance of that, and I think that's important to state straight away. In relation to information sharing, I think it's a complicated issue, really. You need to respect people's right to control their own data and their own information, unless there's a major safeguarding issue, unless there are other issues. So, again, I think that you need to respect the rights of the individual, and I think that there may be some unintended consequences from that, which would need to be looked at. But that's the major stance that we would have, I think. Any other thoughts from colleagues?

I think, as you say, we've just got to be really careful. It might be worth looking at why are people frustrated about that sharing of information, and if it's about that person actually getting the help that they need, what were the barriers to that. And again, it's about that stigma again, isn't it, and it's about making those services as accessible and open as possible, and the appointments as instant as possible. And I think then that would reduce that frustration in terms of sharing of information.

Ocê. Diolch yn fawr iawn. Rydym allan o amser. A allaf i ddiolch i'r dair ohonoch chi am eich tystiolaeth ysgrifenedig fendigedig ymlaen llaw, a hefyd am fod yma y bore yma, eich presenoldeb, a hefyd am ateb y cwestiynau mewn ffordd mor aeddfed, a fydd o gymorth mawr i ni lunio adroddiad cynhwysfawr ar y mater? Diolch yn fawr iawn i chi. A allaf i, ymhellach, gyhoeddi y byddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma, er mwyn i chi allu gwirio eu bod nhw'n ffeithiol gywir? A gyda hynny, diolch yn fawr iawn. Fe wnawn ni symud ymlaen nawr at ein tystion nesaf ni—neu at y tyst nesaf. Diolch yn fawr iawn.

Okay. Thank you very much. We are out of time. Can I thank all three of you for your excellent written evidence beforehand, and also for being here this morning, for your attendance, and also for answering our questions in such a mature way? It's been of great support to us in drawing up a report on the issue. Can I further explain that you will receive a transcript of these discussions, so that you can ensure that they're factually correct? And with that, thank you very much. We'll move on to our next witnesses—to the next witness. Thank you.

10:20
3. Atal hunanladdiad: Tystiolaeth gan Goleg Brenhinol y Seiciatryddion yng Nghymru
3. Suicide Prevention: Evidence with Royal College of Psychiatrists in Wales

Dyma ni yn symud ymlaen yn hollol ddidrafferth i eitem 3 a pharhad efo'n hymchwiliad i atal hunanladdiad: sesiwn dystiolaeth rŵan gyda Choleg Brenhinol y Seiciatryddion. Rydw i'n falch iawn i groesawu hen ffrind i'r pwyllgor yma o'n blaenau ni, yr Athro Keith Lloyd, o Abertawe, cadeirydd Coleg Brenhinol y Seiciatryddion yng Nghymru. Dyna'r het rydych yn ei gwisgo heddiw. Rydych yn gwybod, yn ôl ein harfer, y byddwn ni wedi darllen eich tystiolaeth ymlaen llaw, ac felly, yn ôl ein traddodiad ni, mi awn ni'n syth mewn i gwestiynau ar y mater pwysig yma, ac mae'r cwestiwn cyntaf gan Rhun ap Iorwerth.  

There we go, moving on seamlessly to the third item and the continuation of our inquiry into suicide prevention: an evidence session now with the Royal College of Psychiatrists. I am very pleased to welcome an old friend of this committee before us, Professor Keith Lloyd, who is the chair of the Royal College of Psychiatrists in Wales. That's the hat you are wearing today. You know that, as usual, we will have read your written evidence beforehand, and so, as usual, we'll go straight into questions on this important issue, and the first question is from Rhun ap Iorwerth. 

Bore da. Cwestiwn eithaf cyffredinol: rydych chi'n gefnogol iawn o 'Siarad â fi 2', rydych chi'n gwneud hynny yn glir, ond rydych yn teimlo eich bod chi eto i weld ymrwymiad cryf gan rai grwpiau gweithredol lleol. A allwch chi ehangu ar eich pryderon chi ynglŷn â sut mae strategaeth atal hunanladdiad Llywodraeth Cymru yn cael ei gweithredu a'r mathau o gamau y gallai gael eu cymryd i gyflymu neu wella'r broses o weithredu? 

Good morning. I have quite a general question: you're very supportive of 'Talk to me 2', you make that very clear, but you feel that you've yet to see a strong commitment by some local implementation groups. Could you just expand on your concerns as to how the Welsh Government's suicide prevention strategy is being implemented and the kind of steps that could be taken to hasten or improve the process of implementation?

Thank you very much. The Royal College of Psychiatrists particularly welcomes the committee's in-depth look at this particular area, because, as we said in our report, more can and must be done to prevent deaths and the impact that suicide has on families, friends and communities. So, in relation to 'Talk to me 2', which we commend, and we also commend the leadership of Professor Ann John in respect of 'Talk to me 2' and the advice she gives to the Welsh Government—.

In our earlier evidence, we said that we were unsure whether the local implementation groups actually were empowered or committed to deliver suicide prevention at a community level. There seems to have been some movement on that since, but I think it's an area that bears ongoing attention. I know—I believe the committee is seeing later today people from a local implementation group in north Wales, I think. So, I think that would be a very good question to put to them about whether they feel things are changing and whether they feel things are empowered to help out at local level.

What are the sort of signs that you're seeing that perhaps things are moving slightly forward? 

The committee's just heard from the Samaritans. They work closely with the local implementation teams in some areas. I guess what I'd be looking for is evidence that local government buys into the need to address this as a priority area. It goes into the area about parity of esteem and stigma, which I think is the underlying issue, and people recognising the need to—. It's very difficult for a hard-pressed local authority with very little money to see this as a priority area. Yet, if you think about the years lost of life, particularly for young people, then it's a very real issue that we need to see them addressing. So, I'd expect to see local authorities buying into initiatives to raise awareness about suicide prevention, working with schools on building resilience and wellness in young people, much as the Children, Young People and Education Committee has recommended in their report, 'Mind over matter', for example. It's what the role at the local level is about doing each of those things.  

I wonder if you could give us an update on recent trends and in particular groups that seem more vulnerable than we realised, of course, in the past. I think you mention the issue of young women, which is not something I've heard before, as being a particular group, and this remarkable shaming statistic, really, that men in the lower social class, inevitably living in deprived areas, are at 10 times a greater risk of suicide. It's absolutely astonishing. 

They are astonishing figures. If you look at the attention that's given to deaths through road traffic incidents compared to the attention that's given to deaths of people by suicide, you can see that there's a difference in the way that's perceived and addressed. So, you're right.

One of the recent concerns over the last few years has been the rise in suicide amongst middle-aged men. It's linked to depression, it's linked to socioeconomic factors, it's linked to deprivation, it's linked to isolation and loneliness. Young women are much more likely to self-harm than they are to complete suicide. That's because, traditionally, young women have used less lethal means. So, an overdose, unless it's undetected and people don't seek help, is less likely to lead to death than hanging or violent means, for example. So, what we're seeing now is an increase in the use of more violent methods by young women. It's as if some young women are adopting more traditionally male patterns of risk taking—that is what I'm suggesting. 

And, of course, the other group in whom there's a lot of attention at the moment is students. Now, if we go back to the men for a minute, it goes back to this thing about parity, help-seeking and stigma. So, men have been—. We are very bad at seeking help for our mental health problems. We're very bad about seeking help for any kind of health problem generally speaking; we're just not very good at it. And you'd need a broad range of initiatives to enable men to seek help. So, for example, there are some wonderful community-based initiatives to get men to talk more about these things. There was a programme, a documentary, on Radio Wales recently, 'Trust me, I'm your Barber'—great, fantastic. That is about socialising, talking about mental health and self-harm. Fantastic. So, that sort of thing is happening for men now. There's another group that works through sport. They originally started out in the north of England, in rugby league, but they've now spread out across the UK. So, we've got different groups now starting to self-harm more and use more lethal means—we've got young women and we've got students—so we're going to need to work the same sorts of initiatives through in those groups now.

The other issue that that then touches on is about confidentiality and information sharing, if I may speak to that. Doctors have very clear guidance—GPs, all of us—from the General Medical Council about when we can breach confidentiality. We know that if somebody is very dangerous or a risk to other people, there is clear guidance around how we breach confidentiality. Medical practitioners are much less confident about doing that where issues around self-harm and suicide are at play. One of the big issues for families is, 'Nobody told us he felt like this.' You hear that time and time again, and it's something that the committee may wish to think about in terms of its recommendations about pointing to the guidance that currently exists around confidentiality and talking about self-harm. It's a difficult one, because there is no single answer, but the Chair will know that you do this on a person-by-person basis when you're with somebody. So, those are the sorts of issues that we need to think about, and it might be worth developing that a bit more, if we may. 

10:25

Can I just return to—? There's so much that one could follow up, but what you said about young women is interesting. We've known for a long time that young men are a very vulnerable group and we're also talking about students more, and obviously that cohort are often students. And I asked this question of the Samaritans: is there a growing body of evidence that we have to take special care of that group, because their resilience and points of reference are often absent? And the effect of a significant mental health episode for the first time can itself be a factor beyond the actual event itself. Is this an issue? And therefore, should we be doing much more in terms of looking at well-being factors and information in school and in the universities? 

The Samaritans would have spoken about the developing emotional awareness and listening programme, I think. As a result of 'Mind over matter', the Welsh Government has put investment into building resilience in children and young people. So, if we're seriously investing in the health and well-being of future generations, then that has to be a major priority. Why do young people lack that resilience, or appear to? I don't know. But it's clearly something that we can—. If we're serious about investing in the future of Wales, then we have to invest in our young people. So, that seems to me to be a priority area for any kind of recommendation from this committee. 

10:30

Then the final area I just wanted to touch on is that we know a lot of people who have a substance problem or misuse have a higher suicide risk. Where's our understanding on the interplay of that? Is there still evidence that people in the health service are seeing that predominantly as a substance problem and therefore not fully considering, perhaps, the mental health issues? Where is the balance, because they're not coterminous. They may overlap, but they are quite distinct also, aren't they? I think, when you see someone who clearly has these issues in terms of substance misuse, some people can be quite dismissive, potentially, or take a very moralistic view of that. 

Yes. Substance misuse is a significant risk factor. Alcohol is a particular risk factor. When people are drunk or under the influence of other drugs, it can change the threshold that they're actually going on to act something, they're not inhibited and can go on to act and take their life.

In terms of service provision, I think one of the key questions that we probably need to get to at some point is the relationship between the budget that's allocated to mental health services and the actual spend that goes into mental health services, and where that spend goes. I think that might be something that would be worth exploring. Substance misuse services in England have fallen apart, because they've almost moved out of the statutory sector completely. We're in much better shape here and could do something quite radically different that would maintain and preserve them. The voluntary sector has a huge role to play in those kinds of services, but so does the statutory sector too. 

And presumably—. I take what you've said about if you're consuming large quantities of say, alcohol, then your susceptibility to a mental health episode increases, but presumably the other thing that happens is that mental ill health can then start a drinking problem. 

Yes. People who are anxious might start drinking more and then that spirals out of control. They drink and—. So, yes, it's a two-way street. 

Okay. Turning now to a separate issue, although linked—people discharged from in-patient care. Jayne. 

Thank you, Chair. In your paper, you suggest that a first follow-up for people discharged from in-patient care should occur within three working days, as opposed to the five that are in the mental health delivery plan. Can you explain why you feel that? 

Okay. So, one of the things that 'Talk to me 2' draws out is the difference between things that can reduce suicide for the whole population and things that can work for high-risk groups. People who have just been discharged from psychiatric hospital are of a high-risk group. We know that. They're at much higher risk of death by suicide in the year following discharge. At the moment, 'Together for Mental Health' recommends a five-day follow-up, I think. This is what we're committed to as services. There's a clear case to be made, I think, that if we could bring that follow-up forwards it would be helpful. 

You can imagine what it's like for people who are discharged from—. In fact, I was going to give an example of somebody I saw recently in exactly that situation. They had just come out of hospital having been very unwell and were just left to their own devices. So, the sooner services follow-up people with severe enduring mental illness who've been in hospital the better. Now, I've got to say that my colleagues who work in community mental health teams work very hard. There's a question of the resourcing for them to be able to do that. So, that is our ideal. That's the standard I think we should aspire to. That will not happen without greater investment in the delivery of services—not the budget for services but the spend for services. 

And you mentioned—. We've talked about 'at risk' groups, but perhaps you could identify where further attention could be focused, such as people with eating disorders or dementia? 

People with a range of mental health problems are more likely than the general population to die by suicide. In fact, people with severe mental illnesses like schizophrenia and bipolar disorder die much younger than the general population—about 20 per cent die through suicide. The risk in eating disorders is very high, and the risk—. Suicide in more advanced dementia is less of a problem. There's carer burden for the people looking after the people with dementia, which is a huge issue. In a sense, we were talking earlier about young people needing to build resilience. You've got a generation of older people who are caring for people with dementia who maybe haven't got the tradition of seeking help for their own needs. So, particularly with dementia, I think the issue is supporting carers.

10:35

Okay. Moving on now to the access to services. I think we're starting off with primary care to secondary care in its various forms. We've had a lot of evidence. Julie.

Yes. Concern has been expressed to us about the interface between primary and secondary care and how easily GPs are able to get access to secondary care support for their patients. So, what is your view on that?

Primary care does a fantastic job of dealing with 95 per cent of all mental health problems. Of the people in whom primary care services identify a problem, they still only refer on about one in 20 of those to secondary healthcare services. So, the vast majority of the workload does fall on primary care and, by and large, they do a really good job of it. If they referred many more to secondary care services, secondary care services wouldn't be able to cope with it. So, of the people who are referred, there are delays in the availability of various treatments—particularly I would identify psychological therapies. So, in the area where I work, it's easier for a GP to refer somebody to psychological therapies than it is for me as a consultant psychiatrist. And I do know that if I do refer somebody, the wait is in the order of 18 months currently. That's simply not acceptable, and that comes down to investment in services.

I have a 12-week target within which I will see people who are referred to me by a GP. We're monitored on that and we try to keep to that.

Right. And just as you referred to the psychological therapies, are those very significant in terms of suicide prevention?

Particularly for young people, yes—well, for everybody, but particularly for young people. I think it's possible slightly better—. I think there's been a big investment in child and adolescent mental health services, as there has been in eating disorder services, so I think that's going to help there. If we're building resilience, we're also building help-seeking, which means that more young people are going to want the services that we have. It's a pipeline: if you're teaching people to be more emotionally intelligent and to recognise when they have problems and seek help for them, the services have got to be there for them when they talk about it.

Is not acceptable, but it's where we are at the moment.

Lynne, you've got a supplementary. We'll come back to you, Julie.

Yes. It's on the issue of the waiting times really, because although there are challenges in waiting times in physical health, there is nothing approaching the consistently difficult waiting times that you see for psychological therapies. Ann John has given an interview to the BBC today, highlighting the fact that we need to have parity between physical and mental health and then we wouldn't get this problem. Is that something that you would support?

The Royal College of Psychiatrists has consistently argued for parity of esteem around mental health and physical health. You see that in terms of psychological therapies and it comes back to investment and spend—not just having a ring-fenced budget, but actually spending the money that's allocated to mental health, and that comes back to the things that are actually monitored by health boards, by Welsh Government for health boards to meet their targets. If you had to wait that long to be seen in an emergency department, you can imagine what would happen.

So, the parity of esteem thing also comes into play in terms of accident and emergency departments. So, there's a huge need for training and awareness raising amongst emergency department staff, some of whom still have a rather negative attitude towards people who self-harm. That can lead to people not subsequently seeking help. If someone consistently turns up with abdominal pain, they'll probably get taken fairly seriously, but if somebody continually turns up having cut themselves, they won't be. That's a real parity of esteem issue, so Professor John is correct to raise that.

10:40

Okay. Rhun, you've got a supplementary before we come back to Julie.

Just delving a bit deeper into the 12-week referral time: what if there is a concern that a patient is at risk of suicide? We've heard concerns raised during our evidence sessions of the lack of contact between the GP and yourself directly being something that slows down the system, where it's identified in primary care that there is something that needs attention far quicker than within 12 weeks.

Yes. So, I work as part of a team. I work as a general adult psychiatrist in a community mental health team, so there's a large team of people who are all very committed—a community psychiatric nurse, social workers, occupational therapists and psychologists—and we have a system, which is in place across Wales, whereby if somebody needs to be seen that day, they can be. We have a duty system where, in office hours, effectively, people can be seen much more quickly. What there is to offer them on from that is another issue. So, yes, we can see people, but if we're honest, seeing people and identifying the problem does really sometimes help, but the challenge is: what do we then go on to offer people, if the psychological therapies aren't there for 18 months? The third sector has been absolutely brilliant about picking up some of the slack there. I often refer people to the Samaritans, saying, 'This is an organisation you can contact in confidence and they will offer you support, non-judgmentally.' If people need more than that, it can be challenging. There aren't the services there to offer that type of care for people.

One of my questions was going to be about the crisis care services, so have you any more comments on that?

Yes. I don't think we have invested in those to the extent that we should. It comes back to the parity of esteem thing. If we were talking about cancer services, this would be a national scandal, but because it's mental health, we don't think about in the same way. If we were talking about paediatrics or child health, it would be a national scandal, but it's mental health. So, in terms of crisis services, they are very busy; they are under-resourced. If we are increasing emotional resilience and if we are encouraging people to talk to us—'Talk to Me 2'—then we have to have the services behind that to give them the service. Mental health services only deal with a very small proportion of the people with mental health problems. Primary care deals with far more, so we need more investment in psychological therapies in primary care, for example. The demand is such that there's always going to have to be some sort of triage, but we're going to get a better result the further back up the stream we offer the support.

Okay, thank you, Julie. Moving on to another aspect of awareness and training and such things. Dawn.

Thank you. It's important, when anybody presents with self-harm or attempted suicide or whatever that might be, to have a compassionate response, and yet your report and your paper talk about how people in distress, who self-harm or are threatening suicide, are often considered a nuisance. I don't know whether you mean that they are considered a nuisance sometimes by clinicians, or whether you're talking about more generally in public services. What do we need to do then to change the way that self-harm and suicidal tendencies are viewed by clinicians?

It's not just clinicians—it's everybody's business. So, it's about public attitudes to suicide and suicidal behaviour. So, there's a public education task, and as I mentioned earlier, the Trust Me, I'm Your Barber programme was absolutely brilliant, because it's really taking it out to people and delivering it in a non-stigmatising way. So, talking about it and normalising it and it being okay, just as it is to have chest pain—people don't have a problem with seeking help if they have a pain in their chest or think they have a bad cold. If they feel depressed or are self-harming, they should be able to feel equally able to seek help. So, people are reluctant to seek help in the first place.

How do clinicians respond, which was your question? I think it's particularly a problem in emergency department settings. Emergency departments have been under tremendous pressure over the winter. A colleague, who works in the emergency department in Morriston, told me recently that he could tell spring had arrived because the demand had gone back. But in amongst all that, it's about how those staff recognise that they need to treat equally the people with mental health problems as they do people with physical health problems.

We were looking at the BBC news before coming here and we saw a story from Sweden about mental health ambulances, but it's about a different way of thinking about how you provide services for people with mental health problems. Many emergency departments now have primary care physicians—GPs who work alongside them; we should see a parallel investment in mental health workers in that setting.

10:45

Yes. So, do you think that there is scope for mental health awareness training being the norm in terms of all of our public services and actually the general public? I'm thinking more in terms of the way that we do first aid training, CPR training—

That's a brilliant example.

Yes. That's the comparison. If you think of the number of people now who know how to do CPR and how it's become part of what everybody thinks they would know, or have some idea, what to do and the provision of external automated defibrillators everywhere, we need the same kind of training around it being okay to talk to people. I had, recently, somebody approach me to say that somebody they knew—a doctor—had approached them, saying that they felt suicidal, and this person had approached me and said, 'What should I do?' He'd actually felt able to (a) let that person say it to him, and (b) to then ask what else he should do. So, it's about having that confidence to do that.

Schools is another very good example. Teachers and classroom assistants have got to feel comfortable and have the skillset to allow children to talk about emotional distress. We would be failing people if we, as a society, didn't also equip people to have the skills to respond to mental health distress, once we've told people to raise it. So, I think you're absolutely right: I think mental-health-first-aid-type training is a really good idea and we should all do it, just as we—. I'm sure many of you have probably had some sort of training in CPR, for example, and the same thing could be done for mental health first aid, and why not?

That moves us seamlessly on to issues that Lynne would want to raise anyway.

Thanks, Chair. You referred to the importance of educational settings. What do you think the key things are that we need to have in place in our schools to ensure that children are emotionally resilient and also that we prevent suicide?

I think schools and the education system have a key role to play in building emotional resilience: space in the curriculum to do it and space in the school day; school counsellors—that's already been agreed as an initiative. Developing Emotional Awareness and Listening, which you've heard about from the Samaritans, that will be rolled out. So, I think it's about skilling up staff, and that's everybody actually—that could be from the receptionist through to everybody. Everybody needs to be able to be a mental health first responder.

10:50

I'm hoping that DEAL will be rolled out; that's one of our recommendations. We're waiting for the Government to respond on that. We've also made recommendations that I think Welsh Government might think are quite challenging around issuing guidance to schools to empower them to talk about suicide and self-harm, particularly prioritising schools where there's been a suicide or a suspected suicide. What's your view on that? How achievable is that for Welsh Government to do quickly?

I think that is very achievable. You've actually touched on another issue there, which is not only how we build resilience to help people not get into trouble in the first place but actually having something ready—the term is 'postvention'—after something bad has happened, what support can be offered to schools to move on from that. So, I think both are essential.

Okay, thank you. You've already touched on the problem of students, and we've seen a big increase in suicides in higher education. Is there anything particular that you think this committee ought to be recommending in terms of, you know, we know this is a key pressure point because it's a transition point for young people?

Yes. Yes, I think Professor John raised that very point that it's a key transition for young people. So, I think that universities are really good at looking after the physical health of their students. I know that all universities in Wales have student counselling services. If something bad happens, it can be quite difficult for them to scale up their response, so I think that the task for universities is to be able to scale up their response when something happens and to have sufficient investment in counselling and student support services that they are there to help. Traditionally, secondary mental health services deal with only a very small proportion of the people who come from universities, and often the students will go back to their home, if they can, for that kind of support. I have been the psychiatrist to a university, and it does seem to come down to the amount of investment in those services in universities. I think they've got it, but it's actually following through on it now is the recommendation I think the committee could very usefully make.

Okay, thank you. We've heard for many months, really, the potential dangers that there are for young people on social media, and the Samaritans referred to that in their evidence earlier, but what scope is there, do you think, to use social media as a force for good in protecting young people's mental health and particularly protecting them from suicide?

Social media is a two-edged thing. We know that there's been a lot of concern expressed about online bullying. However, it can be a huge force for good, so making available apps and ways of accessing help and just assessing your own mental health can be very helpful. There's a raft of online resources that are available to people to, for example, provide online cognitive therapy, which actually works very well. So, there's a range of things like that, but you can't get away from the need for core investment in those services in universities and further education as well. We've talked about universities; further education is another pressure point as well. 

We're going to be hearing from Angela Samata later from Survivors of Bereavement by Suicide, and I think that one of the things that she's very keen on is that they've developed an online app to train the public in how to respond if they're worried about someone. Is that something that you think is particularly useful?

I'm not familiar with that particular app. I'm familiar with Survivors of Bereavement by Suicide, and I think they're a great organisation. So, if people can develop apps that are safe and are evidence-based then I think that's a fantastic thing.

Can we nail this thing about talking about suicide makes it more likely that suicide will happen? When you're out there sometimes, talking, people need that reassurance that—because, sometimes, the fear of talking about it, it's because of that thinking that actually talking about it makes it more likely that somehow it's going to happen.

No it doesn't. That's the same kind of myth as everyone saying, 'Oh, my grandad used to smoke 80 a day and he lived to be 100.' It's not true.

10:55

That's great. We just needed that on the record. Great. Any other questions? Great. Diolch yn fawr. That brings us to the end of that evidence session. Thank you very much indeed, Keith, once again, for the wonderful evidence beforehand and, obviously, for answering the questions now. You'll receive a transcript of this just to make sure that it's factually correct.

We'll break now for a few minutes. We'll have a break until 11.10 a.m. Thank you very much. Diolch yn fawr.

Gohiriwyd y cyfarfod rhwng 10:55 a 11:10.

The meeting adjourned between 10:55 and 11:10.

11:10
4. Atal hunanladdiad: Sesiwn dystiolaeth â fforymau hunanladdiad aml-asiantaeth rhanbarthol
4. Suicide Prevention: Evidence session with regional multi-agency suicide forums

[Torri ar draws.] Diolch yn fawr am y cychwyniad dramatig yna gan y clerc, ac felly croeso nôl i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Rydym ni wedi cyrraedd eitem 4 erbyn rŵan, a pharhad o’n hymchwiliad i atal hunanladdiad. Y sesiwn dystiolaeth nesaf rŵan o’n blaenau ni ydy gyda fforymau hunanladdiad aml-asiantaeth rhanbarthol. Rwy’n falch nid ydw i'n gorfod dweud hynny bod dydd, ond, serch hynny, croeso twymgalon i Dr Gwenllian Parry, cadeirydd gweithgor hunanladdiad a hunan-niweidio gogledd Cymru, a hefyd Avril Bracey, cadeirydd fforwm rhanbarthol canolbarth a de-orllewin Cymru.

Croeso i chi’ch dwy. Rydym ni wedi derbyn eich tystiolaeth ysgrifenedig ymlaen llaw, yn naturiol, ac, yn seiliedig ar honno, mi fydd yna res o gwestiynau rŵan dros yr hanner awr nesaf. A allaf i bellach gyhoeddi, oherwydd pwysau gwaith amgen, mae’n rhaid i Rhun ap Iorwerth adael yng nghanol y drafodaeth yn fan hyn? Ond rydw i’n siŵr mi allem ni drio palu ymlaen yn dy absenoldeb, felly, yn ddigon dewr, Rhun. Ond gyda chymaint â hynny o ragymadrodd, awn ni'n syth mewn i’r cwestiynau cyntaf—Lynne Neagle.

[Interruption.] Thank you very much for that dramatic start from the clerk, and therefore welcome back to the latest meeting of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We have reached item 4 now and the continuation of our inquiry into suicide prevention. The next evidence session is with the multi-agency suicide forums. I'm pleased that I don't have to say that every day, but a warm welcome to Dr Gwenllian Parry, who is the chair of the north Wales suicide and self-harm working group, and also Avril Bracey, who's the chair of mid and south-west Wales regional forum.

Welcome, both. We have received your written evidence and, based on that, we will have a series of questions over the next half an hour. Can I further announce that, due to workload pressures, Rhun ap Iorwerth will have to leave during the discussion? But I'm sure we can try and bravely carry on in your absence, Rhun. But, with that much of an introduction, we will go straight into the first questions—Lynne Neagle.

Can you just, as an opening, tell us a little about the make-up and operation of the regional fora, including leadership and accountability structures, please?

Do you want to—?

Shall I start? I think the structures are quite different in the two areas. In north Wales, we take our lead from the national advisory group—the 'Talk to me 2' national advisory group—as all the fora do, but we report to the regional delivery group, which, in turn, reports back then to the 'Together for Mental Health' partnership board. And it's the local implementation teams who then put the 'Together for Mental Health' strategy, or the mental health strategy for north Wales—they implement that strategy. So, we are making close links with the local implementation teams.

In terms of structure, we are multi agency, we have good representation, although I think we could do better. There was a group set up in north Wales prior to the new guidance in terms of developing the plan for 2018 to 2021, and I think, since we've received that guidance, we have built up momentum. And, I think, as well as a lot of goodwill in terms of putting the strategy together and delivering the strategy, we've also seen there's been good attendance overall at the suicide and self-harm prevention groups.

It does. I think we could improve in that area because we do work with six local authorities, and some local authorities are represented better than others, but it's something that we are working on and the group is actually going to make contact directly with local authorities.

Yes. A slightly different structure in the mid and south-west Wales—we do have a large footprint, so, in terms of structure, it's quite a complex structure because our region covers seven local authorities, three health boards and two police forces. So, that is quite a complex structure, going from the north of Powys right through to the tip of Pembrokeshire and across to touching on the Vale of Glamorgan. So, that's been quite complicated, I think, in terms of governance.

It's fair to say that our region has been inactive for a while. I took over as chair last November, so it's about six months that I've been chairing the group. Prior to that, the group hadn't met that often, and, really, that was because of some committed and inspired individuals who moved on to different positions.

I work for a local authority as a head of service, so I think one of the reasons for asking me to chair was to raise the profile of this subject in local authorities. I am the Association of Directors of Social Services Cymru lead for mental health, so I do have a link in with all the heads of service in all the local authorities, and I've been able to raise this on that agenda to make sure that all local authorities are engaged.

In terms of reporting, I think that is also a little complicated, because we have the regional group, we report quarterly into the national advisory group, but we have slightly different reporting mechanisms as a region. So, we have a sub-regional delivery group in the west—Pembrokeshire, Ceredigion and Carmarthen. We report into the Together for Mental Health partnership, but that’s not the same in other local authorities. So, personally, I think some central co-ordination or a steer on reporting mechanisms for Wales would help us with that.

The other thing that I’ve done in our region is I’ve made a link with the regional safeguarding boards. Whilst we don’t officially report into regional safeguarding boards, I think that is a useful thing to do, because those boards have the most senior people from our organisations—police, health and social care—and what we’ve done is introduced suicide and self-harm as a cross-cutting agenda between children and adults on those boards. And we’re trying to do that in other parts of Wales. I think, in terms of reporting, that’s a good place for sustainability as well.

11:15

Thank you. The recently published mid-point review of Talk to Me 2 said that continued high-level engagement and sustainable resourcing is necessary in order for things to progress. Are you confident, then, based on what you’ve just told us, that you’ve got the right structures in place to deliver on that, and have you got the resources that you need to do the job?

Shall I go first? Suicide and self-harm prevention is a priority for mental health and for public health, as well as being a priority for other agencies, such as the police and Network Rail, for example. It’s still early days in terms of our structures, but we’re hopeful, I guess, and, I think, confident that they will work, but what my concern is is that we’re so different across Wales, and it would be really useful to have a central steer.

In terms of resources, we don’t have any specific resources, and I think that we could do more if we did have those resources.

So, when you say a central steer, are you saying that you’d like to have a steer from Welsh Government on what the structure should be?

Yes, either from Welsh Government or from the national advisory group, or maybe, I guess, working together.

Okay. And, in terms of reporting, you said that it might be useful if we were to look at recommending a sort of different reporting structure.

Or an additional one, working with the regional safeguarding boards.

An additional one. What would you see that looking like?

I think, if I look at sustainability first, for me, the regional safeguarding board structure comes from the social services and well-being Act, and that’s where, in my view, it sits. Because, if you look at the social services and well-being Act, we have a legislative framework that requires all of us, as organisations, to work in partnership and deliver on things like early intervention, prevention, community resilience. That is the essence of that Act, and suicide and self-harm fits with that agenda. It is about building individual and community resilience. It is about looking at asset-based approaches and, as I said, it is about early intervention, prevention and access to information and support. So, I think that’s a good place to start.

And, also, if I look at the analogy with domestic violence—we’ve got this push from Welsh Government on domestic violence—we have a structure for reporting, we have targets for training. Training is a big issue in suicide and self-harm, and, for domestic violence, we have a steer from Welsh Government that says 100 per cent of our front-line staff have to do that basic awareness. I think suicide and self-harm are as important. So, when I talk about a central steer, that’s the sort of thing I’m talking about.

Resource is always helpful. So, I think some central and local resource would help us, because even the smallest projects that we’re starting in communities need a resource. So, in all honesty, some resource would help us deliver on this agenda, for sure.

Yes, thanks, Chair. I understand that, of the local suicide prevention plans, the north Wales one has been published, but I’m not sure that any others have. Could we have an update—if any have been published, and, those that haven't, when they might be?

11:20

Yes. Ours hasn't been. As I said, when I took over as chair last autumn the group hadn't met, and our first task was to produce a draft plan by February to comply with the mid-point review. So, those first four months were at a pace, really, to try and produce a draft plan. What we did was we had a few stakeholder workshops to produce an outline plan, which is still very draft. What we're doing in July is we're going to launch that with stakeholders and present it to them and say, 'Are these the priorities? Are these the right objectives?' with a view to publishing it then in the autumn.

So, as I said, the group had been inactive, but we are going at a pace now to get it published.

And is it your understanding that the other local plans are going to be published probably by the autumn? I appreciate you may not know, but if you do—.

I'm not sure. I suppose there are a number of different plans because, within our region, we have some local, some sub-regional. Bridgend has a plan, which I'm sure is about to be published—specific issues in that area that you'll be aware of. So, I'm not sure of when the others are going to be published.

It might be better if they were called regional plans or something, because I think the language is a little confusing. I suppose I am talking about 'regional', really, if we talk north Wales and your large area.

So, yes, autumn for us.

That's fine. Then, I just wonder—this is a question for both of you—what's the practical purpose of these plans, in that they're presumably just not delivery plans for the national strategy, but they're meant to give you some sort of local flexibility, perhaps responding to particular datasets you may have developed, and understanding some of the more local—you mentioned Bridgend—priorities like that. So, could you give us an idea of how they're meant to work, and be multifaceted, I suppose, if that's the intention?

I think, in terms of delivery, one of the important things that comes out of the plan is that we all work together. So, all the agencies are working together with the same aim of reducing and preventing suicide and self-harm. In north Wales we do have priorities, and at the moment we're looking at reducing the access to means. So, we are working, again, as a multi-agency to look at the frequently used sites for suicide in north Wales. So, there are two specific sites, and in the period between 2006 and 2015 there've been eight possible suicides at both these sites. So, at the moment, we're looking at making adjustments to those sites with the aim of reducing the figures.

In terms of the other areas we're going to be monitoring, we'll be monitoring the amount of cases that come into accident and emergency following self-harm, and the amount of acts of self-harm on NHS property as well as the actual suicide rates.

Yes. It is obviously about reducing the numbers and reducing the incidence of self-harm, but I think it's about a much wider agenda than that, and it's about improving the health and emotional well-being of the population. So, I think, when we're trying to address it, we need to think of it in those terms. So, when we're looking at population needs assessment as part of it—again, I refer to the Act—we're including this in there. When we're going into schools or we're going into some targeted areas, like middle-aged men, for example—we have plans to go into sports clubs and places where men are, but to talk about emotional well-being and general population health as well as suicide. So, I think it's part of a bigger health and social care agenda.

Ocê. Rhun, a oes gennyt ti gwestiwn atodol, cyn inni symud ymlaen?

Okay. Rhun, do you have a supplementary question, before we move on?

Jest yn sydyn, mae yna gwestiynau, rydw i'n meddwl, i ddod ar rannu arfer da, ond, yn y broses o lunio'r cynllunio, fel rydych chi'n ei wneud ar hyn o bryd—rydych chi wedi gorffen yn y gogledd—sut mae yna gydweithio i sicrhau eich bod chi i gyd yn symud i'r un cyfeiriad ac yn rhannu arfer da, ar y stêj yma felly?

Just briefly, there are questions to come on sharing good practice, but, in the process of developing the planning, as you're doing at present—you've finished in the north—how do you work collaboratively to ensure that you all move in the same direction and share good practice, at this stage?

O ran cydweithio ar draws Cymru?

In terms of pan-Wales collaboration?

Mi ydym ni'n cyfarfod bob chwarter efo'r national advisory group, a dyna lle rydym ni, fel arfer, yn rhannu ymarfer da. Fel arall, rwy'n meddwl efallai ein bod ni hyd yn oed yn dysgu o heddiw, fel mae Avril a minnau wedi treulio bore yma efo'n gilydd, ac rwy'n meddwl y buasai'n fuddiol iawn i ni gyfarfod yn fwy rheolaidd er mwyn—

We do meet on a quarterly basis with the national advisory group, and that is usually the forum where we do share good practice. Otherwise, I think we may be even learning from today because Avril and I have spent the morning together, and I think it would be most beneficial for us to meet more regularly in order to— 

11:25

A ydych chi'n rhannu drafts o'ch cynlluniau wrth i chi fynd, ac ati? 

Doo you share drafts of your schemes as you go forward, and so on? 

Ydym. Ac wrth gwrs, wedyn mae gennym ni 'Siarad â fi 2' hefyd, sydd yn rhoi arweiniad i ni. 

Yes, we do. And of course, we have 'Talk to me 2', which also provides us with some guidance. 

Yes, the final question has been touched upon, actually, when you identified middle-aged men as a particular group risk. We've heard very strong evidence that social deprivation is a big issue or is a big risk factor, and men in the lower socioeconomic group are 10 times more likely to commit suicide than men in the general population, or the general population—I'm not quite sure whether it was men or the general population. But anyway, their risk factor is hugely larger than other groups. So, are you looking at something as specific as that? Do you have any—?

Yes, we are, and that's about inequalities between men and women as well, isn't it? But we are. It's a huge issue, isn't it, social deprivation, and we're talking about major programmes—anti-poverty, regeneration—but I think, on a regional, local level, there are things that we can do. I can give some examples where we've looked at, as I said, resilient communities and we've looked at what the community can do. So, even though suicide is highest in those most deprived areas, my experience as a social worker for many years is that often those deprived areas have a sense of community.

So, across Wales, there are examples where we've actually had programmes to reduce loneliness. We in the west now have just set up a mental health and running project; you may have seen it on BBC Wales last week. We set it up in conjunction with Run Wales and our leisure services. We're training a group of individuals to run a half marathon, and one of those individuals lost a son to suicide, and he is saying that if you look at the therapies and everything else he was offered, it's this running project that has actually made the biggest difference; he doesn't feel so isolated. Men's Sheds is another example. So, I think what we need to do is target those areas of social deprivation and look at how we can work with communities, and help communities with the infrastructure for that, and the third sector, to address the issue. That is our plan. 

Okay. Jayne, you've got the next couple of questions. 

Thank you, Chair. Just following on from that, really, are all key statutory agencies and voluntary sector organisations participating in the three regional forums? 

Shall I start off? We do have very good representation, and, with the new guidance, we've increased the membership of the group as well. We're very, very pleased that we have Caniad, who attend regularly and give a voice for those with lived experience. I am aware that we don't actually formally have somebody representing those who have been bereaved by suicide, although I'm sure that there are members of the group who actually have been bereaved through suicide. I think we could do better in some areas. For example, with youth justice and probation services, I think we need to invite them into our services, and other services as well. We're very pleased that recently we've had representation from the perinatal mental health service, as well as the coroner—the coroner now joins us—and chronic health difficulties as well.  

I don't think we're quite there yet. That's a priority for us this year. As I said, I think local authority representation has improved, and if I look even where we were six months ago, we are getting more representation. We have probation, we have the Samaritans as vice-chair of the group, and so we have third sector, we have people with lived experience on the group. We have health boards. So, I think we do definitely need to extend that representation, and that's a priority for us. I feel I'm repeating myself, but by getting it on the agenda of the regional safeguarding boards, that's helped, because what I'm finding is when I took the last report to the regional safeguarding board, the police came back to me and said, 'We need to be on that group', and that's how it's developing. So, that's a priority—that we will have all the stakeholders round the table. 

11:30

So, what arrangements are in place to monitor and evaluate the effectiveness of local suicide prevention activities, and what indicators are used?

That is an area that I would say we are most behind in. So, in terms of gathering data, we started in the region, and also in the local and sub-regional groups, looking at what's out there, because we realised, collaboratively, we didn't even know what services were out there for people, and that, also, we're not publishing them, so people don't know. So, we've said that we need to focus on what's already out there and making people aware where to get help, how to get help. 

The other thing that we've said is a priority this year for us is qualitative data, because the numbers are one thing, but the numbers tell part of the story. We're very keen that we talk to people, survivors of suicide, families affected by suicide, to ask them, 'What's worked for you? What hasn't worked? Were you able to get help when you needed it? Where do you go for help?' So, we do need to—. As I said, we're prioritising the data gathering of what's already out there so that we can publish that, because we think that's important, and we want to prioritise the quantitative data as well as the number crunching. 

And in terms of north Wales, in terms of monitoring, we've set ourselves three targets, which, as I've said before, are: looking at the number of cases that come into A&E due to self-harm, the cases of self-harm occurring on NHS property, and the actual suicide rates. We've set ourselves a target of reducing suicide by 10 per cent, although I'm also really aware that, because there's a wide time frame between implementation of any interventions and, actually, the impact, it's going to take a long time for us actually to see the effect of any strategies we've put in place. 

Diolch, Gadeirydd. Good morning. In terms of meeting the objectives of the national strategy, 'Talk to me 2', and of local suicide prevention plans, what are the key challenges in going forward, and what are the priority areas for you to action?

I think I've mentioned previously our priorities in terms of looking at access to means. But we're also looking at interventions that we can carry out in schools, for example, universal interventions, which we hope will reach everybody. So, we've got projects going on in schools. We're also aware that young men are going to grow up to be older men, so we're hoping that by educating them and by reducing the stigma around mental health—. For example, we've got Mental Health Matters, which is a programme going into all the schools in north-west Wales to look at talking about mental health and reducing the stigma. We also have the self-harm pathway programmes within schools. So, in terms of meeting the objectives, I think the challenge is to continue to have the resources to be pooled together in order that all the agencies can deliver on their part. 

So, I think the agencies are now providing their services, their time, and I think it's about keeping up momentum in that. So, what we're going to do is, we had our launch in February, and from the launch we've—. Actually, at the launch, we had stakeholders looking at the objectives, and looking at ways of improving what we'd already set about—the draft objectives, if you like. We're going to produce a document following on from that, and we hope to have an annual report. 

So, what sort of timescale are you looking at to meeting your objectives?

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We've set a target of 2021.

Right. Okay. Thanks. And do you think that target is achievable? Obviously, you've set the target, so you must think that you've got a good chance of hitting that target.

I think it's really, really difficult to—

Because of the resources, but also in terms of—you know, it does take a long time, from any intervention, to see what the impact of that is going to be, and we are working across the age range. So, I just think that it's not straightforward, if you like, in terms of monitoring.

I think the biggest challenge is about sustainability, and I think the other challenge is that central and local investment that I talked about, if we're going to deliver on these challenges. We haven't been so specific with targets yet, but we have got specific priority areas, and some of those are linked to the 'Talk to me 2' strategy, like training, like information, advice and assistance, access and pathways. Because what we would like is to have a national postvention pathway for those affected by suicide. That would be good, but also access and pathways in, and management of people who are surviving. You know, proper pathways from A&E—those kinds of things. Then we have particular regional challenges, in that we have two prisons in our region, and we know they're a high-risk area. We also have two universities, and a number of further education colleges, and on the news again this morning, that's another area—children and young people, education and schools, and then the challenge of the rural, agricultural community, which is another. So, I think we have some bigger challenges around sustainability, and some smaller ones based on having a number of high-risk groups in our region.