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Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

07/06/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Angela Burns AM
Caroline Jones AM
Dawn Bowden AM
Julie Morgan AM
Lynne Neagle AM
Rhun ap Iorwerth AM Cadeirydd dros dro
Temporary Chair

Y rhai eraill a oedd yn bresennol

Others in Attendance

Alison Kibblewhite Gwasanaeth Tân ac Achub De Cymru
South Wales Fire and Rescue Service
Bleddyn Jones Gwasanaeth Tân ac Achub De Cymru
South Wales Fire and Rescue Service
Claire Bevan Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Welsh Ambulance Services NHS Trust
Ian Stevens Network Rail
Network Rail
Jonathan Drake Heddlu De Cymru
South Wales Police
Kenny Brown Gwasanaeth Carchardai a Phrofiannaeth EM
HM Prison and Probation Service
Mark Cleland Heddlu Trafnidiaeth Prydain
British Transport Police
Nadine Morgan Bwrdd Iechyd Lleol Hywel Dda
Hywel Dda Local Health Board
Nigel Rees Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Welsh Ambulance Services NHS Trust
Rhiannon Jones Bwrdd Iechyd Lleol Addysgu Powys
Powys Teaching Local Health Board
Sophie Lozano Gwasanaeth Carchardai a Phrofiannaeth EM
HM Prison and Probation Service
Stephen Clarke Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
Welsh Ambulance Services NHS Trust
Su Mably Iechyd Cyhoeddus Cymru
Public Health Wales NHS Trust
Will Beer Bwrdd Iechyd Lleol Aneurin Bevan
Aneurin Bevan Local Health Board

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 09:32.

The meeting began at 09:32.

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

Bore da i chi i gyd a chroeso i'r cyfarfod yma o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon. Mae'r cyfarfod yn ddwyieithog, fel bob amser. Mi allwch chi ddefnyddio'r 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. Nid ydym ni'n disgwyl clywed y larwm tân heddiw, ond os bydd y larwm yn canu, a gaf i ofyn i chi ddilyn cyfarwyddiadau'r tywyswyr wrth adael yr ystafell bwyllgor?

I wylwyr cyson y pwyllgor yma, mi fyddwch chi'n sylwi bod y Cadeirydd yn wahanol i'r arfer, ac mi nodaf i yn fan hyn fy mod i'n cadeirio dros dro heddiw, ac wedi fy ethol gan y pwyllgor i wneud hynny, yn absenoldeb y Cadeirydd arferol, Dr Dai Lloyd. Ac mi wnawn ni nodi yma fod Dai Lloyd yn un o ddau sydd wedi ymddiheuro ar gyfer y cyfarfod heddiw. Mae Jayne Bryant hefyd wedi ymddiheuro. Nid oes unrhyw ddirprwyon eraill, ond mi wnaf i hefyd nodi yn fan hyn fod Caroline Jones yn mynd i fod yn ein gadael ni ar ôl yr ail sesiwn heddiw, oherwydd gofynion eraill y tu allan i'r pwyllgor hwn. 

Good morning, everyone, and welcome to this meeting of the Health, Social Care and Sport Committee. This meeting is bilingual, as always. You can use the headphones to hear interpretation from Welsh to English on channel 1, or amplification on channel 2. We do not expect the fire alarm to sound today, but should that happen, may I ask you to follow the directions of the ushers in leaving this committee room?

For regular viewers of this committee, you will note that the Chair is different from the usual one, and I will note here that I am temporarily chairing today, and have been elected to do so by the committee, in the absence of the usual Chair, Dr Dai Lloyd. And we will also note here that Dai Lloyd is one of two Members who have apologised for absence for this meeting today. Jayne Bryant has also sent her apologies. There are no substitutions, but I will also note here that Caroline Jones will be leaving us after the second session today, due to other commitments outside the committee.

2. Atal hunanladdiad: Sesiwn dystiolaeth â chynrychiolwyr Byrddau Iechyd Lleol a Iechyd Cyhoeddus Cymru
2. Suicide Prevention: Evidence session with representatives of Local Health Boards and Public Health Wales

Mi awn ni ymlaen at eitem 2 a'r sesiwn ddiweddaraf yn ein hymchwiliad ni i atal hunanladdiad: sesiwn dystiolaeth efo cynrychiolwyr byrddau iechyd lleol a Iechyd Cyhoeddus Cymru—y cyntaf mewn cyfres o gyfarfodydd tystiolaeth heddiw yma. Ond hon yw'r sesiwn dystiolaeth ffurfiol gyntaf heddiw. Mi wnawn ni groesawu'r tystion sydd o'n blaenau ni: Nadine Morgan, pennaeth nyrsio dros dro, Bwrdd Iechyd Lleol Hywel Dda; Rhiannon Jones, cyfarwyddwr gwasanaethau cymunedol ac iechyd meddwl, Bwrdd Iechyd Lleol Addysgu Powys; Will Beer, meddyg ymgynghorol maes iechyd cyhoeddus ym Mwrdd Iechyd Lleol Aneurin Bevan; a Su Mably, meddyg ymgynghorol ym maes iechyd cyhoeddus, Iechyd Cyhoeddus Cymru. Croeso i'r pedwar ohonoch chi. Nid oes eisiau i chi wneud unrhyw beth technolegol—mi ddaw'r meicroffon ymlaen yn awtomatig o'ch blaen chi, felly, nid oes angen pwyso unrhyw fotymau.

Awn ni ymlaen, os ydych chi'n hapus, yn syth i mewn i'r sesiwn gyntaf, a'r cwestiwn cyntaf. Un thema sydd wedi codi yn gyson yn ystod yr ymchwiliad hyd yma ydy'r anhawster yn aml i sicrhau cydraddoldeb—neu parity of esteem byddai'r term a fyddai'n cael ei ddefnyddio weithiau yn Saesneg—rhwng ein hagwedd ni a buddsoddiad, ac yn y blaen, rhwng iechyd meddwl ac iechyd corfforol. Faint o broblem ydy hynny yng nghyd-destun yr hyn rydym ni yn ei drafod yma? Pwy sydd am fynd yn gyntaf? Will Beer.

We will move on to item 2 and the latest evidence session in our inquiry into suicide prevention: an evidence session with representatives of local health boards and Public Health Wales—the first in a series of evidence sessions that we will be having today. But this is the first formal evidence session of the day. I welcome our witnesses: Nadine Morgan, the interim head of nursing, Hywel Dda Local Health Board; Rhiannon Jones, director of community care and mental health, Powys Teaching Local Health Board; Will Beer, a consultant in public health in Aneurin Bevan University Health Board; and Su Mably, a consultant in public health, from Public Health Wales. Welcome to all four of you. You don't need to do anything technical—the microphones before you will come on automatically, so there's no need for you to press any buttons.

We will move on, if you are happy to do so, straight to the first session, and the first question. One theme that has arisen constantly during this inquiry so far is the difficulty that often exists for there to be parity of esteem, which is the term that is often used, in our approach and in our investment between physical and mental health care. How much of a problem is that in the context of what we're discussing today? Who wants to go first? Will Beer.

09:35

Yes, I think one of the things is around how we define mental health. I think the term means lots of things to different people. I think some people think of mental health as maybe dementia; others will think of it as people who have more severe and enduring mental health problems, like schizophrenia, and others will relate it to more common mental health problems, like general anxiety disorder or depression. And there's a different perspective, which is about mental health being more related to mental well-being—so people being able to flourish and people being able to cope with adversity in life—so more mental capital: a resource that helps people cope with day-to-day living. So, I think one of the issues around parity of esteem is how we define it and the fact that it means lots of things to different people. I think that's not the case for physical health. I think there's much more definition in physical health. So, people understand what high blood pressure is and what diabetes is, and I think that's probably one of the issues.

I would agree with Will, but I think, over the years, the attention to mental health and the various national strategies and the allocation of funding has been really helpful in terms of presenting some parity. Definitions, as Will says, I think, is an issue and people have got different views about mental health, but I think probably one of the issues is more about short-term funding. So, this is why we welcome the mental health transformation fund in order that that can be used—very much using intelligence about how we can use it locally to address local issues.

Mae yna gwestiwn, serch hynny, ynglŷn â'r gwahaniaeth rhwng yr arian sy'n cael ei glustnodi ar gyfer iechyd meddwl a faint sy'n cael ei wario ar iechyd meddwl. A fuasech yn cytuno fod hynny'n broblem?

There is a question, nonetheless, about the difference between the funding that is allocated for mental health and how much is spent on mental health. Would you agree that that is a problem?

I think it remains a bit of an issue, although I've recently taken up this new post in Powys, and one of the issues for me is, when we get an allocation of mental health funding, it's often viewed that that's about the mental health directorate, but actually it's much wider than funding allocated to the mental health directorate—it is about what we do in primary care; it's about the third sector. So, I think there's still some work to do to break some of that down.

Diolch, Cadeirydd. Regarding performance targets for mental health services, do you think that there's a case for the setting of them and the reporting on these performance targets to be more specifically aligned?

Do you want to start?

If I can start, I think that the whole approach to targets is something that is really important because it brings a highlight and focus to the performance. I think that one of the things that we'll consistently say is about the measures themselves and how you focus much more on outcome measures as opposed to processes and counting numbers. I am aware of the national work that's going on, particularly in mental health, to look at much more outcome-focused measures. Personally, I think those are important because targets are about patient experience.

Yes, they are, yes. Does anyone else having anything to say?

Yes, I think I would agree. There are process measures and there are outcome measures, aren't there, in the outcomes? And patient experience is what we're particularly interested in, I think. I think, certainly around psychological therapies now, there is a target for—

Okay, I'll wait for that then. [Laughter.]

Just in terms of—. The target is for at least 80 per cent of patients referred by their GP for psychological therapies to be assessed within 28 days. I think, certainly within our health board, that is now being met. But, it's then: what is the outcome beyond that? How do patients then receive sort of holistic support? And also, it's to address some of the underlying issues that may be to do with wider factors, like debt issues or unemployment or other things that are going on in people's lives. So, it's one part of a big picture, and I would agree that we probably need to focus more on the outcome and patient experience than on the process menus.

09:40

Nadine Morgan and Su Mably: do you have some general comments to make on that before Caroline continues?

Not specifically on that, no.

I would agree with Will, actually. In our health board we have recently achieved that target as well; so, from referral to assessment is 28 days, and then from assessment to intervention is 28 days as well. I think that one of the challenges for us is having that—. One of the things that we've addressed recently is to scope what interventions we are actually able to deliver from within our health board. We do have the National Institute for Health and Care Excellence guidance to guide us around what therapies we should be delivering, and we've got a core group of staff who would be delivering, for example, cognitive behavioural therapy and other therapies, but actually thinking about providing a wider range, so that there is increased patient choice around that as well.

I think that one of the other things for me is that most of the targets are around patients coming through primary care and then being referred on, and what I would like to see is more intervention that can have a population reach. So, for example, we're trying to develop our foundation tier mental health support services in the community that are universally accessible. So, if someone wants to learn more about CBT, they can now attend one of our psycho-educational classes. We run stress-control ACTivate Your Life classes in community venues, which are non-stigmatising, people can just turn up. They could be a carer. They could be a professional. They could be a member of the public who wants to learn more about how to cope better with everyday stresses in life. So, if you're thinking about population health, scaling up some of those universal self-help approaches, where you don't need to be referred by your GP, is probably going to have a bigger impact.  

And also, training the workforce, so that when they are actually faced with some of the challenges that the person may be dealing with, they are actually able to not necessarily have to refer on, but they can actually manage some of that themselves. 

I wanted to add something, probably complementing what both colleagues have said, in relation to not just the statutory sectors. Some of the most significant interventions that I have seen, for example, are with Mums Matter, around our perinatal mental health agenda and what the third sector, the voluntary sector, can bring to this as well. So, it isn't just about the statutory sector, but I'm sure you're aware of that.

From my point of view, the area of work that I focus on primarily is very much: how do we talk about mental health in society, and how do we work with our children and young people in schools? There's a huge amount of work and activity happening in schools and, indeed, in workplaces as well. So, it is very much, while we need to measure performance and referrals, it's actually that wider perspective and population base that is important too.

Thank you. Going back to the psychological therapies, at the end of the day, it does come down to investment, doesn't it, and the quality of service that you can provide? So, can you tell me what actions are being taken to improve access to psychological therapies across Wales, and how we can ensure that the services provided are going to be sustainable?

Shall I start? Thank you. Within Powys, we have been working on online CBT and improving access to psychological therapies, but also looking at skill mix, so that we use highly skilled people for more people with greater needs. We have recently launched our new SilverCloud online CBT, and we've been working with the schools. So, we've got XenZone, which is online CBT and intervention for children in schools, which links in with what Su was saying. 

It is about looking at local intelligence, in terms of what the impact is. So, Powys and rurality, it's really important in terms of looking at our issues. While a lot of our data does chime with the national statistics around suicide and self-harm, there is a local picture that is very different to what Cardiff and the Vale or Betsi Cadwaladr might do. So, it's having the local intelligence to target investment and really promote early intervention, which is the element that Su will probably wish to come in on, and ensuring that that allocation is identified, is supported and really demonstrating impact, which I think, rather than measures, is about patient experience and patient story-telling. And, really, that goes along with the reducing of stigma. I think the significant amount of work that's been done by the royals, by the media, to reduce the stigma is really important for people, to encourage access.

09:45

And I think, building on from that, is the stepped model of care. The need is so great that you can't have a one size that fits all, a single service; it's a whole network of services. Certainly what we're looking to do in the Aneurin Bevan health board is develop that stepped model, which starts with that universal self-help provision and front-line professionals, generalists, being able to hold that individual and deliver a brief intervention if that's what's needed, and then offering some low-intensity intervention for people who need it, as well as the more intensive support like direct one-to-one CBT or counselling. It's prudent really, isn't it? It's about getting the right intervention to the right person, depending on their level of need at that time.

Yes. I'm going, actually, slightly back to the question that Rhun asked at the very, very beginning, and building on the answers you've given to Caroline, about whether there is a real difference, do you think, in the way we treat mental health and physical health. Because, I'll be honest, I think there is from the casework and people I've talked to. I was just trying to get to the core of it and I wonder if you can just give us some guidance. Is it because a lot of mental health issues are the kinds of things that can be helped by the third sector and, therefore, they're not seen as a health priority? Because they are the kinds of things that might start off on a very low level, like someone smoking too much or being too overweight, so it's perceived as a lifestyle thing about getting someone straight, building emotional resilience, helping them with their external factors, and it's only when they go into absolute crisis and start threatening to self-harm or have an incident of some sort that then we start looking around and thinking, 'Gosh, the specialist isn't there'. I remember reading in all this weight of paper yesterday that, for example, if a hospital lost a chemotherapy consultant, they wouldn't get the person waiting for the chemotherapy to wait 10 months. Whereas, if a hospital loses a mental health professional, then those people are very often waiting 10 months. So, I just wondered if there's—. Because I'm trying to get to why we treat the two so differently, or if we have this cultural thing towards it and what we can do to bridge it. Because I think you're right, there's so many great things out there, but there's still that gap, isn't there, no matter what we say? 

I think, unfortunately, the reality of what we're dealing with is that that stigma and discrimination still remains. It remains in different guises within mental health services—maybe towards substance misuse and so on, maybe not—but also when we're working from a health perspective, when we're working with our general health colleagues, if somebody presents at A&E having self-harmed or having taken an overdose or whatever it might be that they're presenting with, unfortunately, there does remain, in some instances, that stigma and discrimination. Whether that's stigma because of fear in the individual, whether it's about confidence in being able to receive that information and then not knowing, maybe, what to do with that. It may be around training, knowledge, understanding—it's multifactorial, I think. And there's a lot of work that we still need to be doing to work together, collaboratively, between mental health and general health services and across first responders—it's everybody's business, but we need to be working together to really think about how we can tackle this issue. And I don't think it's going to happen overnight—it hasn't happened overnight. I know that people have been aware of this for a number of years, but it's a big challenge for us all. 

Rydw i'n gwybod eich bod chi eisiau dod i mewn, ond rydym ni angen symud ymlaen rhywfaint yn fan hyn, os y cawn ni, ac efo'ch caniatâd chi, Caroline, mi hoffwn i symud at gwpwl o gwestiynau, jest yn sydyn, cyn i ni ei agor o allan i Aelodau eraill. A oes yna broblem yn y cyswllt rhwng gofal sylfaenol a gofal eilaidd, yn gyntaf? Pwy sydd am ateb hynny? A oes yna broblem yn y continwwm ac ati rhwng gofal sylfaenol a gofal eilaidd?

I know that you want to come in, but we do need to move on a little here, if we may, and with your permission, Caroline, I'd like to move on to a few quick questions, before we open it up to other Members. Is there a problem in the interface between primary and secondary care, first of all? Who wants to answer that? I want to know if there's a problem in the continuum, and so forth, between primary and secondary care.

Personally, I don't think that's an easy question to answer. And I think there isn't one answer that is right. I think there's some excellent examples of good collaboration between primary care and secondary care, and then there are other areas where it isn't so good. I think the focus for mental health—maybe picking up on what Caroline said earlier, but to answer this question—whilst there has been really good collaborative working and, I think, it's an exemplar, mental health, in terms of that multi-agency, multifaceted approach, is that it's always been on the crisis and the escalated interventions as opposed to early health and well-being, and the early intervention and self-help, as we described earlier. GPs have got a key role to play, and I think, through the evidence, we've demonstrated that, in a lot of areas, GPs are fulfilling that role.

09:50

We hear of GPs, though, saying that physically they find it difficult to refer.

To which—? For people who are in crisis, or just generally?

Within Hywel Dda—I can just speak for Hywel Dda, really—where GPs can refer, they can have a very prompt response, within a period of four hours, if the level of need is great. I think one of the key drivers, really, for access to services, which has driven the transformational work—the transformation of mental health that we've been working on—has been through a consultation process recently, out with the public, which has provided the public with a suite of options around how mental health services are now going to be delivered and provided in the coming years. We now have received board approval for that, so we're moving towards the implementation phase of it. The model, actually, allows a single point of referral. So, it doesn't necessarily mean that another practitioner or another clinician needs to make that referral, and people will be able to go in on a walk-in basis and have that 24 hours, seven days a week.

I think, picking up on something that was mentioned earlier on in relation to psychological therapies, we do have fantastic psychological therapies and support that we can be delivering as practitioners, but also I think what will be the added benefit of the single-point-of-contact centres will be that the other aspects that might be triggers or might be stressors in a person's life that might be impacting upon their mental health or emotional well-being can actually be dealt with at that point as well. So, it may be around finances or housing, which are certainly considered as part of the care and treatment plan currently. But I think what will happen is that will happen quicker, at that point of need, and we'll be able to address those needs that that person's presenting with at any time of the day, any time of the week, really.

Thank you. I think that, historically, there probably have been issues, because the focus has been on referral and access criteria, but many health boards have moved away from that approach, and it is about 'no wrong door'. So, if GPs are citing that they're still finding that difficult, I think that's for us to pick up and to explore that locally.

We're in a similar position in Aneurin Bevan health board in that we've just gone through a 12-month action learning set, not just within the mental health division, but with partners. So, the police have been involved. We've had service users, carers, and the local authority involved in that to develop the new crisis model, and we will be moving to a new single point of access, 24/7, and options to in-patient admissions. So, we're looking at sanctuary provision, we're looking at crisis housing, we're looking at host families, and modernising the crisis resolution home treatment service. That's currently available until 10 o'clock, but that will be extended. So, that's happening.

I think the other issue is about this 'no bounce' policy. I'm the lead for the neighbourhood care network in Newport East, and one of the things that GPs struggle with is the fact that they're generalists and they're occasionally pushing against closed doors because of the criteria and things. So, what we've agreed with children is there's a 'no bounce' policy. We will not bounce children back. We've actually developed a new single point of access for children, where all referrals go into a joint allocation meeting every week, through Families First, with all of the other agencies—so, school counselling, educational psychology, as well as our primary mental health team—and there is no bounce back to the GP. That family will be allocated to the right service to meet their needs. So, I think getting those principles agreed is really important. That's my comment.

I'd like to jump, if I could, to a set of questions on crisis care, from Julie Morgan, if you could come in, Julie.

Yes, thank you. You've already started to talk about the 24-hour access. We have had concerns expressed in evidence to this inquiry about the access in a crisis, and also about inconsistent access to health-based places of safety, and a concern about the police being used more than is appropriate. So, I don't know if you could comment on that. You have already told us that you're having this 24-hour access.

09:55

Moving towards it.

There's the mental health crisis concordat that I'm sure Members will be aware of. I think there's just generally pressure now within the system, and when one service is under pressure, that often is magnified then in another part of the system. One of the developments that has happened in recent years is that we now have an AMHP—a mental health professional—within the police control room. I know in some areas that's available 24/7. In our health board, that's 8 o'clock in the morning until 2 o'clock in the morning. So, the police will have access to that expert advice and support at the end of the phone and that mental health professional will have access to the health board's clinical system as well as the police records and so will develop a clear picture about what's going on and can give the right advice.

I think, similarly, in our health board as well, just to build on that, we've recently introduced the 24-hour unscheduled care, so, for crisis support, and that's available across all of the localities that we have—the three localities that we have—and that means that they can be offering consultation advice assessments to our colleagues in general hospitals or to the police. But, in addition to that, we've also piloted the street triage project, which was only over the weekends, but we've received resource now that we're able to extend that out to seven-day-a-week service provision. So, again, that's building on the relationships with our police colleagues. I think it comes to some of the points that you were making around access to places of safety. We do have our place-of-safety suites across the localities and it's a resource that is extremely valuable. When they work very well is when there's that prior conversation that happens, from the police, under the concordat, to the mental health providers. They have that sometimes more in-depth knowledge about that particular person, who may have been involved in services before, and we may have a better understanding of what might be better for us to support that individual at that point of crisis and it may be better to see them in A&E or at their home address rather than bringing them to a place of safety. What we have found as one of the challenges when that doesn't happen—when that communication doesn't happen with the police—is that, unfortunately, sometimes patients are bought to the place of safety without any prior communication, which then puts significant pressure on all services. So, we work very closely with the police to try to address that in a fast-time review process that we have set in place. So, we're working on that with our colleagues.

No, I'm fine thank you. Part of my challenge today—. As your questions are quite specific, and I deal with, sort of, population prevention-type activities, I think my colleagues who deal with services are better placed on these.

I just want to make sure everybody has an opportunity to have their say.

You had a very brief question.

Yes. Just on all your answers to Julie—in fact, in all your answers to us about the solutions—can you tell us every time whether it's just for adults or adults and children, because I don't recognise some of this picture in regard to children? Thank you. So, when you just answered Julie's question on crisis, was that just for adults, really?

No. For our CAMHS service, we have the same provision. So, we have a place of safety in one of our adult acute wards, but we also have a designated bed within our general hospital and the crisis team is available. But the actual CAMHS-specific crisis team is available up until, I think, 9 o'clock in the evening, seven days a week, and then that's taken on by the crisis team that support the adult services. So, it's an ageless service when we're talking about that. 

I just want to say, a constituent of mine, recently, a young boy—his place of crisis was a McDonald's in Carmarthen. There wasn't anywhere else, and that's where they kept him—24 hours. 

It is all-age, but, from a personal perspective, the incidents that we've had to review locally within Powys have been crisis in children where the concordat and our approach hasn't been what it should have been. So, I do recognise what you're saying. Our response to that is that we have multi-agency meetings weekly to discuss cases because it is about recognition of escalation, because, otherwise, in the out-of-hours period, it is more challenging, of course. 

Yes, just a quick question, really, on the notion of all-age and ageless services. I think there are a lot of people who are very concerned that this move towards an all-age service across the board in Wales is actually not going to meet the needs of children very effectively. I'd just be interested—. In the social services Act—you both referred to it now—. Children are not just little adults; they've got very specific needs.

10:00

Thank you. I feel really passionate about all-age services, but that's not about standardising and generalising; that is about specialists within an all-age service. We are certainly looking at an all-age service in Powys, and what I see is that the expertise being brought together can be beneficial for both adults and children.

It just seems to me that a lot of what you said are things that are being put in process—or are they actually there?

In terms of all-age services, that's something that we're moving towards. What we've described—those things are in place, but they do break down.

Because we have had evidence expressing a lot of concern, and committee members have raised concerns as well.

One of the things I was going to come back to in your question, Julie, was about those reviews. So, where we have had crises and incidents, there is a multi-agency review so that we can try and learn lessons, which is where the review of complex cases and putting in intervention and support to prevent the escalation—within the past six months, we've certainly seen a significant improvement with that approach, particularly for children.

It was just to ask a quick question to Will, really. I'd be the first here to say that I think that Aneurin Bevan health board are absolutely moving in the right direction and I'm very proud of the work that you are doing, but I'm sure you'd agree with me that it is a work in progress and that we have got some way to go really. I just would like your comment on that, really. I think it's important that health boards, while recognising that things are moving in the right direction, also recognise the journey that they've got to travel for children.

Yes, absolutely. I think it's probably fair to say that there are pockets of good practice and there are pilots being done, but the next stage is about how we make that a universal,population-scale service. I can talk from the perspective of Newport, which is my locality, where we have got this single point of access for children, working with Families First, but that's not universally across the whole of Gwent. Similarly, Su can touch on the CAMHS in-reach work, which is currently taking place in Torfaen and Blaenau Gwent. That's a research project. If that's successful, we then need to have the means of scaling that up and making that a universal provision.

I think it is about recognising the attention on intervention in all areas. So, for children particularly, Lynne, the pilots that are going on in schools in terms of mental health first aid, the online XenZones, the practitioners going in and supporting teachers—. There is a massive journey. I absolutely agree with that, and I'm sure we all would. There's a lot of work to do, but I think it is about recognising where we've got to as well.

Just quickly, just rounding that off a little bit really, I get a real sense that we are on a journey. Maybe we should have been further along that journey long ago, but I do get a very positive sense of momentum, but I do think there's an awful lot of joining up of that to do, and my colleagues working at a local level work hard to do that. But nationally as well the new curriculum is a massive opportunity, and we can't miss that opportunity, but we do have to make sure that everything runs along consistently and that pilot work is relevant to that big picture and is adding to it.

We have, I think rightly, spent a good chunk of this meeting talking about the context of mental health. We, I think, move now from that to where mental health issues become issues of self-harm and potentially suicide. Julie.

Thank you, Chair. I wanted to ask about how you are dealing with the 25 per cent of people who you already know about who go on to take their own lives and then, of course, the vast number of people who are not known to mental health services. So, could you give us an update on how you are treating those two groups or how you are approaching this issue?

In our health board, in our directorate specifically, we've been doing a lot of work over the last year to year and a half to really improve the quality of the review, when a serious incident or suicide has happened, in order to learn those lessons in order for us to be able to develop very specific work streams to try to improve practice and obviously then attempting to prevent that from happening again in the future.

The process that we've adopted is through the review process. So, we're trying to include everybody as part of that. So, we involve the carers, or the significant others' loved ones who have been affected by the suicide, and they will then be able to have the opportunity to ask questions, which we include in the terms of reference of our review so we can answer, or attempt to answer, some of those specific questions they might have about their loved one's journey and what led to their suicide or serious incident that's happened.

We also include the staff at all levels. We're really trying to engage and promote a learning culture. I think that what staff feel when something like that happens is that they're immediately blamed, and they have a lot of feelings of blame. They're human beings as well, and it's going to affect them no matter how much resilience they've developed through their skills and training. So, it is going to affect them. So, what we're really trying to do is to develop a culture within that investigation and review process where people are feeling more confident and able to think about how they can critically assess their own practice, and that of others, so we can have more honest and meaningful conversations. Ultimately then, at the end of it, we will, hopefully, have more honest, workable and realistic lessons to be learned that we can put into practice.

We go back to families and we offer the review and the outcomes of the review, and we do that with the staff teams as well. Like Will has mentioned, there are pockets of extremely good practice that are happening. So, what we've done recently is to develop a process, an assurance process, where we share that good practice across, but we also share those lessons learned across as well, and then go in and do the checks and support for the staff teams.

10:05

Again, I'm looking at the clock—it's terrible. I don't want to, because we genuinely appreciate all the expert evidence that we are hearing from you, but the session will finish in around 23 minutes' time. So, if I could ask for questions and responses to be brief. We'll move on to a set of questions from Dawn Bowden if that's okay.

Thank you. Thank you, Chair. I just want to briefly ask you about support for those people bereaved by suicide. We've heard reports that there doesn't seem to be—well, there isn't any co-ordinated Wales-wide support. I'd just welcome your views on where we are with that, and what further steps we need to take, particularly dealing with organisations—schools in particular, where schools are affected by a suicide. Do you have any views, comments, on that?

I've got a very strong view. I think the postvention area is a key area for us to focus on. So, the evidence suggests that, for every one person that commits suicide, 10 people are significantly affected. So, I think I did the maths correctly in that that's around 3,500 people every year in Wales. I think we need to co-ordinate that response much more effectively. I think part of it is around—and I think this has come up when other witnesses have given evidence—real-time surveillance. I think it would be quite helpful. That would tell us where there are potential suicide clusters or contagion effects, it would give us ideas about patterns of means of suicide, it would tell us about whether that postvention work is happening systematically. That's the key, isn't it—whether all those services come together in a co-ordinated way every time. I think that's really important. So, I think that real-time surveillance would allow us to actually audit whether that is happening or not.

I think it would be about gathering together the data that the police hold and the data from the coroner's office, and then feeding that back—

—into the local teams. That's the way it would work. I think there are a number of charities out there that can help. They're not always made available. Most safeguarding children's boards—so, this is specifically for children—will have a PRUDiC policy protocal, a procedural response to unexpected deaths in childhood. That needs to make sure that the right support's pulled in. The Samaritans offer the Step by Step programme for schools and colleges. That's not universally accessed, I don't think. So, it's an area we could probably strengthen, yes.

I was going to come in. I think the Talk to me 2—the separation between suicide prevention and, actually, support in the aftermath of something is really important. I think there is an immediate response, so, through the reporting of an incident, whether that involves the health visitors, the school nurses, particularly for children, but also recognising—you said about the charities and the support there—also pastoral support, religion and that element as well in terms of support.

10:10

And the Help Is At Hand resource is very, very good. But, again, whether that systematically—

It's the co-ordination of it, it seems to be, it seems to me.

It's the co-ordination of it. We're actually keeping a local directory of where those resources have gone. They're currently held by coroner's office, the ambulance service, funeral directors—Cruse have had hard copies, all the GP practices. But, for GPs, if they're not—and health visitors—dealing with this every day, they sometimes forget. So, someone needs to hold the ring and take that responsibility for co-ordinating the response.

We probably need to follow that up with some of the—. Sorry, I'm, again, conscious of time, so I will move on to—. What actions do you think are being taken to ensure that the NICE guidelines are being followed? The NICE guidelines are very clear, but we've been getting some evidence that they're perhaps not being followed through to the extent that we would expect them to, and just your views and comments on that, really.

The are two sets of NICE guidance—

Yes.

So, we've heard that about 60 per cent of patients are receiving psychological assessments in line with the guidance. So, clearly, we're not getting to everybody, so just some views on why that might be.

I'll attempt to answer on that. Certainly, there is annual reporting around our compliance to NICE guidance, and that reports through to our mental health and learning disabilities committee, a sub-committee of the board. There is analysis of that. Sometimes it isn't about money and how that's been allocated; it's about the other resources so we can put money in, but, particularly from a Powys perspective, we have real challenges in terms of recruitment of specialists. And that'll be the same for Hywel Dda, I know.

It is about creative approaches and the stepped approach that Will and colleagues have described earlier in terms of that intervention and support. So, I think the annual review and auditing of compliance is important to help us then target. So, it's an intelligence-based approach to targeting interventions based on areas of non-compliance.

Yes. Sorry. Were you going to say something? No. So, this is about what starts—the GP, then, isn't it? Usually, somebody's presenting with incidents of self-harm to the GP, and it's what follows on from that. So, you say it's really at that point that things are falling down?

I think it's—. Again, I said earlier, it's not easy to answer because there are many people who will self-harm who don't present to the GP, and I think this is where we need to take a much more wholesale approach—and where the research and assistance from Public Health Wales—. Because it is about teachers, but it is about caring communities and friends who know. I think this is where the education and training, raising awareness, reducing stigma is so important.

Absolutely.

And, speaking of training, we'll go on to a couple of questions from Angela.

Yes. I've just got the flip slide of the same coin on training. How do we train our staff to really be able to spot signs of mental ill health and then follow that up, obviously, by the signs of those who are potentially at great risk? Do we need to alter GP training, because we keep talking about the GPs are going to be the front line, and I talk to GPs, and they say, 'Oh, yes, I think we did about three minutes on mental health at some point during our entire training thing'. So, how on earth are we supposed to be relying so much on people who don't have the armoury and the instruments to help them? 

Finally, and I think, Nadine, you touched on it, actually: how do we build emotional resilience into the staff who then have to deal with the fallout of a suicide or a serious mental health situation? Because it must be very painful for the staff who are caught up in it.

Can I start off? I may not be able to take you on the whole journey, but if I just start at the very beginning of that, I talked earlier about a great deal of work going on in our schools, but also a lot of work under the ACEs banner—the adverse childhood experiences banner—that is relevant to this is also going on not just in schools, but across the police service and other public bodies. So, there's something about teaching people what is normal child development, for example. If we focus on children, what is normal behaviour and what are normal wobbles through life? And I think that sounds very simple, but, actually, I think a lot of professionals don't necessarily have that. And then really beginning to understand, trying to get people to understand, the impact of things like adverse childhood experiences and why that makes some children act a little bit differently from what they might expect, and it's really just taking people on that journey, but then—you're quite right—beginning to know that this is the point where I need some additional advice. So, if they're general staff like teachers or even school nurses, it's a very difficult thing to actually define at what point do they need to recognise that.

Very quickly, and others will take on from me there from the more specialist end, but in terms, then, of the impact of dealing with children or adults, indeed, with mental distress, again, through the ACEs work that's going on at the moment in Wales and the trauma-informed practice, there is a strong recognition of that. The ACEs work with the police service—and you may hear more about that later, perhaps—really identified that it was all very well talking about the client, but, actually, the professionals were really experiencing the impact of dealing with that, and I'm sure that dealing with suicide must have a tremendous impact upon professionals. So, I think there are initiatives that are happening and working on that, but it doesn't completely answer your question, so I don't know whether colleagues have got some views about the training of professionals in dealing with mental health problems and, indeed, mental health crises.

10:15

I think the issue for me is the reach. We've got the national training framework, which I'm sure you've heard about a couple of times already, and there are three levels within that. The universal level is how you'd really get the reach, because the workforce is under a huge amount of pressure at the moment, training budgets are under pressure, so how, in that competing environment, you would raise the profile of this particular issue and the training required in this particular area—. And then there's the selective training, the gatekeeper training, that I think is absolutely critical, because people are worried about getting it wrong, aren't they, so they need to have—

Yes, absolutely. I would say that level and then the indicator training, which is people who are providing more direct therapy and treatment. So, that middle level is absolutely critical—that gatekeeper training—I think. There is an online—. The Royal College of General Practitioners have got an online training module; I'm not sure what the take-up of that is like. I would imagine it's not great. But I think that gatekeeper training, and then the other thing is we've got the national training framework, but there's a myriad of courses out there. I have the list. There are 38 different courses across those three levels that are available. So, how we protect the training budgets, how we protect the time, what, of that training, is accredited, what's the quality standard—it's a big issue.

So, just following up on that very quickly on GP training, because they are the gatekeepers and they are the ones who can put people down the right path, we keep talking about how GP practice is changing and how we need to have mental health professionals in there—well, we haven't got them, so we need to rely on our GPs. Do you think there is a case for examining the actual training of GPs, that there should be a rotation that includes a longer or more in-depth element of mental health work?

I'm not a GP, but it would sound like a good—you know, it sounds sensible. The thing is that primary care is changing. I was at a meeting with one of the GP practices this week and they are looking at appointing a community psychiatric nurse within the practice, because they recognise that they need that skill mix now within primary care. Not everyone needs to see the GP, so a lot of practices now employ a clinical pharmacist, they'll employ a physio, and some are increasingly employing mental health professionals. So, I think that's a move in the right direction.

The mental health transformation fund will be really important in terms of looking at mental health practitioners supporting in primary care, but particularly GP practices. I think there's something really important in terms of the focus of support for staff outside of the mental health specialty. We've indicated, I think, that some 28 per cent of patients who've committed suicide are not known to mental health services. So, actually, the training—I'd move away from training to awareness raising in the general setting. I know you particularly focused on GPs there, but, wider, the staff who come into contact with individuals who're self-harming or are clearly demonstrating signs of being at risk, there's wider—. I cannot say enough that the mental health first aid training has been excellent, and I think there is something about—

We're doing a research project with Swansea University looking at structured professional judgment, rather than mental health assessment being a tick-box exercise, and I think, for the generalists—. So, we're starting that within the emergency department and we're going to look at primary care next, as part of this research project.

We need to wrap up on training, unless you've got something very brief.

I was only going to ask Nadine—. I wondered if—. Because the example that you gave earlier about the programme that Hywel Dda have put in place to support staff—. One of the things we'll be considering, I guess, afterwards, is how we push best practice around Wales. As we are out of time, would it be possible to have a little paper on that? Would you mind, because I think that that has always been the challenge in the NHS—we get these great examples of fantastic things and we can't seem to get them out there?

10:20

We'd be happy to do that.

I think Lynne might have a question on supporting staff, or maybe you want to go on to talk about records and so on.

I think there are two issues, aren't there, really? I recognise that staff who have lost someone to suicide—that is enormously traumatic. So, I would like to ask about the support that's available for NHS staff in that situation, but also what steps are in place to reduce suicide risk amongst NHS staff who have a range of access to means, in particular.

Shall I start? I think that's a really good point, and one of those things, in terms of stigma, that I think the work—I know you've got the ambulance service coming in next, but some of the work of the Welsh Ambulance Services NHS Trust in terms of recognising—. I think this is about staff stories; it is about raising the profile. There's support that we put in for teams, where there's been a suicide—it is the same that we can put in for individual staff, but I don't think it is about a scattergun or general approach; it's about looking at what individual needs. It's about individual assessment, and support being put in, depending on those needs, but it is there.

Peer support is quite important, so in secondary care, as part of the grand rounds, the psychologists are running Schwartz rounds, which allow professionals from across different disciplines and different pay grades to talk about the emotional aspects of delivering care. I don't know what others think, but I think that's a really—and we're looking to extend those Schwartz rounds now into primary care as well. All health boards will have an employee well-being service, they'll offer counselling, there'll be debriefing following a significant event, but I think the tailoring of that support for that individual, and that happening in a timely way—we need to tell our staff that we care that they care. That's a really important message we need to get across and that the help is available when they need it. 

That needs to be consistent, not only when something has happened, an untoward event has happened, so we have the supervision, the peer supervision, the opportunity, or to try to carve out some time for staff to actually take a step back and reflect on practice and how it's impacting upon them, because without them, we don't have anything. So, it's really important that we have that consistently happening.

The same, I think, applies to the police service, the fire and rescue service and WAST, who are dealing, day to day, with very traumatic events, and it's just equally as important for them, obviously.

Is there anything in terms of suicide prevention, then, that you think we should be picking up on? Obviously, people who are affected by suicide are more at risk of suicide, so is there anything we should be aware of in relation to that?

My own sense is much more focus on public awareness raising, through the media and other sources. I'm going to mention Coronation Street, but some of those—I've only watched it for research, obviously, but some of that storyline around suicide has been really important. We mentioned earlier the royal family and how they've really raised the profile. I think that's what's important. But targeting—so, we know that middle-age males are at high risk. It's how we target in different ways.

Yes. One of the issues that have been raised with us is that there are issues, challenges because of confidentiality. Are there any particular recommendations you think that we should be looking at in relation to that? Do you think that the guidance needs to be reviewed for NHS staff on this kind of thing, or is it working very well at the moment?

From my own sense, I haven't been aware of any local issues in terms of information sharing. There are clear protocols in place and a clear suicide review, which are multi-agency. So, I haven't personally picked that up, sorry, Lynne. I don't know if others have.

In our area, we have, and we've recently reinforced the message. I'm trying to get a better understanding of what it is that's preventing staff, in some cases, sharing some information with people, whether that's about confidence, again. It's at the initial point, but right through the care process as well. It's about reinforcing the—.

And one of the issues is, obviously, access to patients' records for everybody that need them. Do you think there's enough work being done on that? How achievable is the system that the Royal College of General Practitioners has called for where patients' records move with the patient, which is particularly important for students who we know have got a particular suicide risk as well?

10:25

From my perspective—really important. We've got the Welsh clinical information system, which is being rolled out across Wales. There are challenges—I'm thinking particularly in terms of mental health now—and the amount of support that we've got to implement that locally is challenging. But it is absolutely the right way to go. 

[Inaudible.]—as it develops is a huge logistical challenge, but I think it'll certainly help.

Yes, one of the things that's come out of the evidence that we saw is that very often people who present with substance misuse are bounced into that service because people see the substance misuse rather than the risk of harm. So, do you have any thought on how we might be able to get a more holistic, wraparound service for particularly those who are struggling with drugs or alcohol?

It's a very good question. I think there is a national joint treatment framework for people with recurring mental health and substance misuse problems, and we have a complex care group within the health board that looks at that and is headed up by one of our addiction psychiatrists. But I think we need to understand the needs better. Again, I think we need to understand where people are bouncing between services and aren't getting that co-ordinated and holistic care. 

We've recently been rolling out a training programme for all adult—it's actually 75 per cent achieved at the moment—mental health services to provide them with the skills, understanding and knowledge of people who are maybe presenting with substance misuse problems. As we will know, substance misuse may be impacting on mental health, and mental health upon substance misuse, or there may be no connection at all. So, actually, we need to be able to upskill our staff to be able to better assess that. 

But also, one of the things that we've done recently, which has really benefited us, is to co-locate those teams. So, in particular areas we have substance misuse teams and mental health teams in the same building, so at least then they can put a face to a name, they can start those conversations, and that leads them to better joint working—joint assessments happening, consultation advice happening formally, but I think it's about that relationship building as well. 

And those treatment services work in a pyramid, so there's the universal bit and then there's the specialist bit for mental health and substance misuse services. I think the issue is where there's a mismatch between the two. Someone might have a very significant mental health issue but a relatively minor substance misuse problem, or vice versa, and it's how the services are flexible enough to accommodate those co-occurring issues.

And how they're monitored, and their oversight, is through the mental health development planning partnerships, and all of those sub-areas within mental health are reported up through there. So, you can start seeing alignment, which is positive. 

Thank you. Now, I was cutting some corners earlier on to make up time. I've squirreled away a minute and a half, just to go back to one question that I know Caroline wanted to ask earlier on in the session. 

Diolch, Cadeirydd. When mental health patients are discharged from in-patient care, obviously the follow-up treatment and care is extremely important. I wonder if you could tell me the proportion of patients that are seen within five days in accordance with the 'Together for Mental Health' delivery plan for 2016-19. Thank you. 

I can't give you the specific information for that today, but I can certainly share that with the committee following—. But one of the things in terms of any discharge is that assessment upon discharge, and a risk-based approach to follow up, notwithstanding the target. 

I've got the data. 

You probably don't need to go through all the data now. You can send it to us, but maybe make some comments about what the data tells us. 

Telephone contact is pretty good within 48 hours. The national confidential inquiry suggested that 72 hours is the key. Our crisis services are moving towards that. The other issue is the records. When the Welsh community care information system is in place, it'll be much easier to audit that as well. 

We can do the same thing. I think, just to touch on the national confidential inquiry, what we've done in Hywel Dda is we've benchmarked our services against the quality and safety standards that were identified in the 2016 review, and that's where our work streams have developed from—one of them being a 72-hour follow-up. One of the challenges that we're facing is our information technology infrastructure in order to be able to capture that information very quickly without a manual search.

10:30

Diolch yn fawr iawn i chi i gyd fel tystion. Mi wnaf i eich gwahodd chi, os ydych chi’n gallu meddwl am bethau yr ydych chi wedi methu eu dweud ac rydych chi ar dân eisiau eu rhannu â ni, i fanteisio ar y cyfle i gysylltu â ni yn ysgrifenedig eto ar ôl y sesiwn yma, â chroeso. Diolch yn fawr iawn i chi am eich tystiolaeth lafar chi heddiw.

Mi fyddwn ni’n gyrru trawsgrifiad atoch chi o’r hyn sydd wedi cael ei ddweud yma yn y pwyllgor y bore yma er mwyn ichi gael gwirio hwnnw am gywirdeb, i wneud yn siŵr ein bod ni wedi cofnodi yn gywir yr hyn sydd wedi cael ei ddweud gennych chi. Ond a gaf i, ar ran y pwyllgor, ddiolch yn fawr iawn i chi am eich tystiolaeth? Diolch yn fawr iawn.

Mi gymerwn ni doriad o bum munud rŵan cyn y sesiwn nesaf. Diolch yn fawr.

Thank you very much to you all as witnesses. I would invite you, if you can think of anything you might have missed out and are desperate to share with us, to take advantage of the opportunity to contact us in writing again after this session; you'd be welcome to do so. Thank you very much for your oral evidence today.

We'll send a transcript to you of what has been said here in the committee this morning so that you have you can check the accuracy, to make sure that we have reported accurately what you have said. But on behalf of the committee, may I thank you for your evidence? Thank you very much.

We'll take a break of five minutes now before the next session. Thank you.

Gohiriwyd y cyfarfod rhwng 10:31 a 10:38.

The meeting adjourned between 10:31 and 10:38.

10:35
3. Atal hunanladdiad: Sesiwn dystiolaeth gyda chynrychiolwyr y gwasanaethau brys
3. Suicide Prevention: Evidence session with representatives of the emergency services

Bore da a chroeso nôl i'r ail sesiwn heddiw yn yr ymchwiliad yma i atal hunanladdiad. Mae'r sesiwn dystiolaeth yma efo cynrychiolwyr y gwasanaethau brys. Mi hoffwn i groesawu: y prif gwnstabl cynorthwyol Jonathan Drake o Heddlu De Cymru—prif swyddog arweiniol Cymru ym maes iechyd meddwl, grŵp prif swyddogion Cymru; Alison Kibblewhite, pennaeth lleihau risg, Gwasanaeth Tân ac Achub De Cymru; a Bleddyn Jones, pennaeth gorsaf, Gwasanaeth Tân ac Achub De Cymru. Diolch i'r tri ohonoch chi am ddod atom ni y bore yma. Nid oes angen i chi gyffwrdd â'r meicroffon o gwbl; mi fydd o'n dod ymlaen yn awtomatig. Mi awn ni'n syth i mewn, os cawn ni, i'r cwestiwn cyntaf. Mi ddechreuaf i yn eithaf cyffredinol, os caf i. Ym mha ffordd ydych chi'n meddwl bod angen gwella hyfforddiant mewn ymwybyddiaeth neu hyfforddiant mewn atal hunanladdiad ar gyfer staff gwasanaethau brys, a pha mor hawdd ydy cyflawni hynny i wella'r safon? Pwy bynnag sydd am fynd gyntaf—.

Good morning and welcome back to the second session today in our inquiry into suicide prevention. This evidence session is with representatives of the emergency services. I'd like to welcome: assistant chief constable Jonathan Drake from South Wales Police—Welsh chief officer lead on mental health, Welsh chief officer group; Alison Kibblewhite, head of risk reduction, South Wales Fire and Rescue Service; and Bleddyn Jones, station commander, South Wales Fire and Rescue Service. Thank you to the three of you for coming to this meeting this morning. You don't need to touch the microphones at all; they will come on automatically. We'll go straight into questions, if we may. I'll begin, quite generally, if I may. In what way do you think that training needs to be improved in awareness and suicide prevention for emergency services staff, and how easily could that be achieved to improve the service? Whoever would like to begin—.

I'm very happy to take that question. 

Bore da. Jon Drake ydw i. 

Good morning. I'm Jon Drake.

Basically, we've invested significantly across Wales in all aspects of mental health training. The most recent iteration of our training for all front-line staff is a two-day course, which is authorised by the College of Policing, and it includes a specific module on suicide and suicide prevention, dealing with people in crisis. Across Wales as well, we're rolling that out to all our front-line staff. So, 1,000 officers, for instance, in the South Wales Police have received that training. Each force as well tailors that training with local partners, so it looks a little bit different in each force area. We are also doing inputs as well to our call-handling staff, who are often dealing on the phone with people who are at points of crisis. If I'm honest, I'm struggling to think of ways that training could be improved. I think it's continuing to deliver that training and to roll it out across the organisations is the approach that we're taking. 

10:40

Mae'n dda clywed yr hyder yna sydd gennych yn yr hyn sy'n digwydd ar hyn o bryd. Ai rhywbeth diweddar ydy cyrraedd at y math yma o safon o hyfforddi yr ydych chi'n gallu bod yn gyfforddus efo fo? 

It's great to hear that confidence in what's happening currently. Is this something recent—reaching this kind of standard of training that you're comfortable with?

Absolutely. So, it's been continuous, really, for several years, but a particular intensification over these past 12 months. Certainly, changes in the law around mental health as well has prompted the need to refresh our training provision as well. But it's absolutely key.

From a fire service point of view, we have specific areas of our services that have been trained, particularly where we know that there are higher instances of suicide—so the Newport area. So, we have trained 109 staff there in safeTALK and ASIST as well, so that if they do come into contact with people who are in distress, they can negotiate with them and try and interact until perhaps the police turn up as well. So, there are specific areas.

I think that perhaps we would like to roll it out on the basis of the violence against women group 1 training, where there is some sort of package that could go to all staff—both corporate staff and operational staff. That would be quite useful.

I think that we do—. Senior managers are having some training through mental health charities, and we have got Talk to me 2, which we've taken part in and that we roll out a bit further across the service. But, yes, definitely: there is some scope there. We have across Wales, I guess, 2,500 to 3,000 firefighters operationally who could benefit from further instances. We also do safe and well visits, where we go into people's homes. So, there are mechanisms there where, if we identify people's vulnerabilities through, perhaps, mental health, we have got mechanisms to refer them back to local authorities and health boards as well. So, there is that basic awareness, I guess, amongst operational staff, but I think we could improve it, definitely. 

Ocê, diolch. Wel, mae yna nifer o gwestiynau mewn meysydd penodol i'w holi gan yr Aelodau. Mi awn ni at Caroline Jones yn gyntaf, a chwestiynau ynglŷn ag iechyd a lles staff.

Okay, thank you. Well, there are specific questions on different themes from Members, and we'll go to Caroline Jones first of all, and questions about the health and well-being of staff.

Diolch, Cadeirydd. Although there a number of initiatives highlighted in the written evidence aimed at supporting the mental health and well-being of staff, are all emergency staff able to access the support that they need at work, and are there any examples of good practice that could be rolled out more widely? Anyone—.

Okay, I'm happy to take that. So, certainly, across Wales, if I talk about policing—significant investment in terms of counselling. Obviously, some of our staff have mandatory counselling in high-risk areas—those who would view indecent images of children, for instance, have mandatory counselling and welfare support. One of the recent additions across Wales as well is Mind's Blue Light programme—so, the training of many Blue Light champions who can offer help and support to staff as well as peers, which is really important as well. I'd highlight that as probably an area of good practice at present. 

In terms of fire and rescue, any traumatic incident—we'd follow that up from our occupational health department. So, a trained counsellor will contact all individuals involved to offer them assistance immediately and invite them to seek further support if needed. Along with the Blue Light access they have, we've got access to a service chaplain and trained counsellors. If they want to do that on an anonymous basis, they can do that by themselves through their own means as well, if they don't want to seek advice through occupational health. From that point on, they can get signposted then to—. If they have deeper trauma, they can see a more specialised response if needed.    

All three services as well have an emergency services employee assistance scheme. So, we pay that across the three services, and it works out at about £2 a head. That is confidential access to any support, so they get somebody on the end of the phone who actually works with them as well and can signpost them to further counselling if required. So, every person in the fire service has access to that as well.

10:45

It's been running for about a year now, and I can only say from south Wales, but there were about 100 people who accessed it over the first six months, and I think we've been pushing it and trying to make sure that people are aware of it, so they don't have to talk, necessarily, to line managers or colleagues. So, it's good.

I think you've partly answered some of my second question, and that's about the specific support relating to specific incidents. Although you said, Bleddyn, about them being contacted, and them not doing the contacting, then, if you like, I didn't hear that from the other two—Alison and Jonathan. I just wondered if you could elaborate on that for me.

Exactly the same as Bleddyn says, yes. We'd identify—

Absolutely, and offer welfare.

—if they need support, and, then, what kind of support they need. How soon did you say that they are contacted?

The following day after an incident, basically. So, if there's been a fatality or a serious injury, they're contacted the following day.

Our approach is very similar as well, across emergency services.

I wanted to ask what greater scope there was for the fire and rescue service to play a greater role in suicide prevention, and you've already mentioned the home visits—the safe and well home visits. I don't know if you could expand on how those visits are used or could be used more to identify the risks.

Yes. At the moment, we carry out, approximately, across Wales, 70,000 home fire safety visits, as they used to be called before. We've obviously realised now that, with the Making Every Contact Count, there's further work we can do. So, we've always traditionally—. When we're in people's homes, we've tried to target the highest risk people in terms of fire, but there are generally other vulnerabilities as well, and a lot of them are around mental health.

So, each of the services has a safeguarding officer, which has got contact to all the charities, if you like, local health boards and social services. So, we're hoping to train all our operational personnel so when they're out there, if they identify a person who is vulnerable who could also, obviously, link with mental health—issues like hoarding and that sort of thing—that they're identified to a safeguarding officer, to make sure that the people they're coming across have access to the right services to help them and support them. So, it's quite a vast area we can cover, with 75,000 visits per year.

We are developing, definitely, yes.

I wanted to talk about the crisis care in more detail. I've heard senior police officers describe to me that they are the first line of response or first defence in a crisis situation, and I've also heard constituents tell me about the difficulties they have with accessing mental health practitioners when there is a crisis, usually with a loved one, and it's almost always, isn't it, 2 o'clock in the morning on a Saturday, when everybody is under immense pressure? So, I just wanted, first of all, your views on how well you think the crisis care, or the crisis concordat, is being implemented. How much joined-up working do you really think there is between the services and mental health professionals who are supposed to be part of those teams?

I'd describe the relationships as very strong in terms of governance and the commitment around early intervention. At a strategic level, that's really good. I think the challenge is often for us with our 24/7 crisis at 2 or 3 o'clock in the morning—there's a more limited range of partners around. In truth, we've done quite a deep dive into mental health demand across Wales, and we estimate that around 12 per cent of all policing demand incidents—12 per cent of all our incidents—are directly related to people in mental health crisis. There are examples that I've looked at where we've spent 35 or 36 hours of police time dealing with individual cases. So, I think there are opportunities to certainly reduce the length of time that officers are spending with people in mental health crisis, but also to involve mental health professionals at an earlier stage of that as well. There are initiatives across Wales that are taking place, such as CPNs within police control rooms or triage arrangements. I think those are really positive. It's an opportunity to information share. Often, we're dealing with people as if it's our first time, and yet half of people we deal with are already known to mental health teams or hospital wards. So, I think there's a better opportunity to join up. We'll always be there at a point of crisis. The core role of police is to protect lives, so we'll always be there for people, but I think there are more opportunities around early intervention, more opportunities to join up better, and specifically I'd like CPN access within every control room across Wales.

10:50

I wanted to discuss that. So, you say that it's mostly happening, or only in some areas? I think that's such a logical way forward. What do we need to do to ensure that it does happen in every control room in every part of Wales?

Well, in south Wales, we're commissioning that service presently. We'll identify 12 months of funding; the challenge is sustaining that provision longer term. That's where we struggle at the moment. Across Wales, most of that is funded by policing, and there's some contribution from health boards. There's a real question about whether we can sustain that provision. But when I look around the UK, looking at good practice, it seems that triage, sharing information at point of crisis is absolutely key in terms of protecting people. So, that's why, certainly in the short term, even if we need to pay for it, we'll make that happen.

A slightly different question, but do feel free to answer the other one as well, but, again, to all of you: as a rule of thumb, how many times when you're called out to somebody in mental distress do you know with absolute certainty that you have a place of safety that you can take them to? And how many times are you left going, 'Oh my goodness, I'm going to have to take them back to the station. I'm going to have to do this, I'm going to have to do that. I'm going to have to scrabble around or stand in McDonald's'?

In terms of taking people back to a police station, that risk is diminishing, in truth. I think it's more that you take them to an alternative place of safety but then be with them for a long, long time waiting for a handover or identifying the best place that that person could go to to be looked after. So, I think, in terms of taking people to police stations, that risk reduces, in truth.

But if you're taking them to a place of safety, surely there's somebody already there in that place of safety, or are they literally unmanned?

Well, no. Often, we'll sit with the person until they're assessed, particularly if they present a risk to themselves or others, or often a risk of absconding as well, and we'd rather remain with them than have them leave and be at risk.

Could you define 'common places of safety' just so we know what we're talking about? 

Well, under the new mental health arrangements, a place of safety could be, for instance, a relative's home. So, you could actually take them to somewhere else where they could be looked after, but ordinarily, in this context, when we're talking about crisis and extreme crisis, it would normally be to a hospital.

But then you still have to wait for the professionals to turn up and—

We still need to wait, yes, for that assessment. 

Only that we would be probably responding to the immediate, emergency event and then handing over that person to the police because we have no facilities, and we're not part of the crisis concordat either. If it was purely a fire incident, we do have a fire emergency support service that's run by the Red Cross. So, if it was at 2 or 3 o'clock in the morning, they would come along with a vehicle and provide some support to that person as well in the interim. But we have no facilities; we would be handing over, in those case, to the police. 

I'd just like to touch on two other points quite quickly. The first is that, for example, in Hywel Dda there's been some fantastic work on street triage, crisis cafes—I don't know why they're called crisis cafes, but people have got worries and they talk to a mental health professional, and they are also manned, I think, actually, in the main by the police. But do you have a view on triage and a view on what else we might be able to do to—? Because, I think, sometimes, some of that very obvious work out on the streets helps to defrighten people, destigmatise quite a tricky area. I just wanted to have your view on that.

Absolutely. I think it's a case of keeping an eye on all of these initiatives. So, there are various models around triage from street triage to drop-in centres through to basing staff within our control room to give advice in real time and, if necessary, speak to people who are in crisis. So, very much support—. I don't think there's one golden nugget that can solve everything, in truth, so I think it's around having as broad a range of options as you can possibly have. 

10:55

Something that we've led on as fire and rescue within south Wales is—we've used the Samaritans' signage, the Talk to Us scheme. So, we've identified some of the hotspot areas along the River Usk within Newport where people who are in crisis may look to harm themselves or put themselves in harm's way and put the signs along the bridges just in the hope that it can start that early conversation and people can seek help from the trained professionals.

Finally, 'Talk to Me 2' suggests that police custody suites are somewhere where suicide prevention measures are very, very critical. I noted in your evidence that you say that you offer everyone a call to the Samaritans. Is that everyone or is that just people who you believe are at risk? I wonder how you evaluate that, because I wonder if just the shock—. I guess some people are used to going in and out of police custody suites but, for other people, might just the sheer shock of doing whatever it is they may have done be enough to make them feel unhappy for a while?

Absolutely. What happens when someone is booked into custody is that there's a risk assessment that takes place that looks at how they're feeling and any indicators around the risk of suicide or self-harm. So, we complete a risk assessment for every person who is detained. We know, for instance, that people who are detained for certain types of offending will be at higher risk—people who are detained for the first time, or they may express feelings of concern around self-harm. So, that's really important in the custody suite. There's some other—we term it 'safer detention'. So, we've looked at every aspect of custody provision, and that includes the designs of cells to remove ligature points—all of that as well. We can put people under constant supervision. We have video monitoring as well. So, basically, whilst people are there, everything that we possibly can do to keep them safe—. When people leave custody, we also ask how they're feeling—so, when they're leaving as well. Particularly, for certain types of offences—for instance, those that involve offences against children or sharing of indecent images—we also work with the Lucy Faithfull Foundation to provide specific intervention and help for those people who are leaving, because that's regarded as a high risk.

Have you found that a call to the Samaritans has helped people or is it that they actually want a tangible person to talk to?

I think it's useful to offer. I can't say, in terms of evaluation of success, whether that's been evaluated, but I think it's part of the range of options that we offer whilst people are in those high-risk situations.

Sorry, last bit. Is this now being offered across the whole of Wales, would you know? And also do you know whether every custody suite does have a safe cell that is ligature point-proof?

So, physically, there's a provision within Merthyr at the moment where there's help from the Samaritans, but what we want to do is for that to be available consistently across Wales in terms of telephone access to the Samaritans. So, they certainly offer that in terms of access, but in terms of something specifically around police custody, that's what we want to be able to expand it to.

Lynne—regarding work with young people and children particularly.

Yes, I wanted to ask the police about something in your written evidence, where you've said

'It is important to note that advice from educational research is that discussing the issue of suicide—even in a controlled and sensitive fashion—can have a detrimental effect and in fact can encourage young people to attempt suicide. Therefore, we have established that officers do not speak about it. '

Now, that directly contradicts what this committee has been told about the need to have sensitive discussions with young people. It also contradicts the evidence that the Children, Young People and Education Committee took on this. While I'm not suggesting that the police are the right people to go in and have those conversations, I would be interested to know the basis of that research that you've referred to, because there are a lot of experts out there who think that we need to be having those conversations with young people to prevent suicide.

Yes, sorry, obviously that's our submission, so that's the view that uniformed police officers within schools should have training on recognising signs and symptoms and understanding suicide better. What they shouldn't be doing is leading lessons, if you like, around suicide prevention. But if we just wind it back a little bit in terms of activity that could prompt a child to feel really depressed, really worried or, worst case, suicidal, police officers have a direct role in schools in delivering messages around things like sextortion, sharing of self-generated indecent images, use of the internet and social media, online grooming. So, there are masses of involvement in terms of suicide prevention from those officers in schools and, rather than talking about suicide, being able to prevent that for far more at an earlier opportunity—that kind of risk-taking behaviour is where we see we have a key role.

11:00

Okay. So, rolling it back a bit again, during the children and young people's inquiry, the police called for mental health education to be embedded in the curriculum in Wales. Is that still your position, and do you think that has a vital role to play in suicide prevention?

Yes, absolutely, I do. If I can put my cards on the table, I think the schools programme we have, where officers go in—I've only been in Wales two years myself and I view that as a real jewel in the crown. We have emerging threats around online child sexual exploitation, around grooming. Being able to have that direct access from the organisation that holds the intelligence around the latest threat, and to be able to give prevention messages directly to children I think is a real jewel in the crown for policing in Wales, and for Wales as a whole.

Thank you, Chair. On the terminology that you use, particularly in your evidence—the fire service evidence—you refer to the process of changing the ways in which incidents of self-harm are reported. You suggest using the term 'person in distress' rather than 'rescue from height' and so on. Do you think that that inconsistent terminology across the services is a potential problem?

I do. I think it causes difficulty in creating usable data. For example, when a call handler with any agency takes that call from a member of the public, they might describe it as 'a person on the wrong side of the bridge' or 'a person on a scaffold'. So, how we then categorise that internally could be interpreted differently. So, we could describe that as something we call a 'person in precarious position', which just could lead to a standard kind of rope rescue incident when, in reality, it's a person in crisis, in distress, that requires the support from the person embedded in the police control and the concordat that's there to support them.

So, in a sense, you don't need the report to say, 'They're on the wrong side of the bridge' or whatever. You just need to know that there's a person in distress.

No. If we agree nationally that we're going to describe these incidents as 'a person in distress', I think it just funnels the outcome and gives it far more clarity. In terms of sharing data, then, across the health boards, and identifying high-risk areas, if there is an emerging trend in a particular area, like we had in Bridgend a few years ago, I think we'd identify that a lot more quickly across the agencies because we'd be able to collect that data and say, 'Right, we've had a number of these incidents now, what was the outcome? Where were the locations? Can we do mitigation measures quickly? What are the outcomes of those individuals? Is it the same person?', and I think we can push the services at those areas more quickly.

Absolutely. Do the police use particular terminology, then, in those circumstances? Would you support having a common terminology across all the emergency services?

Yes, I'd support a common terminology, but, in terms of working together, I think the ethos of all the emergency services is to work really closely together, and I think the co-location we have within control rooms really assist with that as well.

That all helps, yes. I think you've actually answered the question I was going to ask you about the real-time surveillance systems. I think you were kind of alluding to that already, weren't you, in terms of how that can work across services so that you can develop early interventions in those areas. So, I think that's probably already been covered, Chair.

Yes, we've already touched on this, but how will you all reduce access to the means of people taking their lives? What plans do you have to stop that?

I know we've targeted, and we've spoken about, the areas in Newport along the Usk river. We're rolling that out further because we've identified car parks and tall buildings as well. So, we're going to actually widen that in terms of where we put the signage. Another member of the public may be travelling in a lift with somebody who is agitated, so at least they could signpost them to the helpline for the Samaritans and things like that. So, there's definitely work to be done on a broader area once we can get the data right, to actually identify where those areas are, but there is work going ahead to make that happen.

11:05

If I may, I think there's a responsibility for policy and planning in terms of—. When we're making new structures, new car parks, yes, we can look at the aesthetics, but let's also look at mitigating and reducing the access. I'm not saying make everything a caged cell, but I just implore you to have a look next time you're on the sixth floor of a car park—have a think how easy it is to climb out if you wanted to. And I think that's in the gift of the planners in the future, to put that on the designers to make that design solution.

Bridges and things like that, definitely. We've had an incident this week at the Chartist bridge in Blackwood, where somebody has jumped off it—a fairly new bridge—so, they need to start thinking at planning stage, 'What can we actually do to deter people from using those sorts of structures?'

So, you could do something on a bridge that would make it more difficult?

Yes. A higher barrier, or—. If you look at—[Interruption.] Yes. Rail bridges are very good at this; they're quite nondescript, but a higher barrier that is really difficult to climb up on. But that's got to go in at the design stage rather than try to retrofit that across Wales.

Do you think that the Welsh Government is taking that message forward about the need to embed that?

I hope so; I think that's where it needs to come from. Because I think that can—. If that's their planning policy, then it just takes the choice away, doesn't it?

Who identifies, specifically, where the potential suicide hotspots might be and then puts more signage up, or Samaritans signs or—? Is that you who does that?

Yes. So, anecdotally, this would come from the evidence we gather from some of our statistics, but moreover, anecdotally, of having attended the incidents. So, that's how I've picked the hotspot locations for south Wales. And I think, if we change the categorisation, that will improve that even further. But, yes, it's about just trying to react to the activity in those areas and put the appropriate measures that you can in. For example, some of those bridges are listed bridges, so you can't put any kind of safety net or barrier on. So, I think the bit of signage is just a little bit of a triage option that is a step in the right direction, I think.

We've got a couple of minutes left. Can I ask you for some—? Do you want to go first, Angela?

Yes, I wanted to rain on your parade slightly. I hope you don't mind, but do you really think there's an enormous amount of benefit—? Can you quantify the benefit that might be had by putting a sign up in a danger spot that says, you know, 'Think again: call the Samaritans,' or would we be better off spending that money preventing people from getting to that point? And do you think it's—and I don't know if there is such a difference—. Is there such a thing as the impulse, the momentary thought, versus the person who thinks about it very carefully and plans for quite some time? And, therefore, who are you trying to stop by this sign?

Yes. There's evidence that says that when an individual is in crisis and is taking that step to take their own life, they say that there's a moment where they're open to suggestion, and that's what safeTALK and Assist is based on, that suicide first aid, that you can suggest an alternative to somebody and they are open to suggestion. So, the hope is that, if they're on their own and there isn't any emergency service presence, that they may see that sign. These signs are around £30. So, they may see that sign and it might just be the prompt that says, 'Okay, yes, I will give them a call.' And I think, for £30, it's definitely worth it; if it saves one life, I think that's worth its weight in gold. 

No, no, I don't dispute it, I just wondered if there's—

I totally agree with you, that if we had the—. It would be brilliant now to retrofit every high location, every high risk, yes, it would be brilliant. That would be—

To include barriers and stuff, that's going to be—.

But what you'll find is that bridges are listed and we can't do that, so let's do something.

I was just going to say that I think you're right, early investment further down the line is really good, and that's about, as well, raising public awareness in general—that they see a person who might be in distress, make the call to the emergency services. Once we are there, very few people take that final step because we interact. So, if we can get there quickly, it's a more successful outcome, definitely.

I will finish then, if I may, by asking you for some just personal reflections. In your long-ish careers in emergency services, you will have been touched by suicide. How does that affect the people on the front line from your experience, and are we dealing with it better now? I think it's very important that we're holding this inquiry, actually, that we're talking about it. If there's one thing that you think we could suggest as a recommendation, what would that be, perhaps?

11:10

Okay, if I may, I've got three things. So, two I've mentioned, which are the schools programme and the community psychiatric nurses in police control rooms—those would be two things. The third, I think, which, again, is fairly new, is multi-agency safeguarding hubs, so, basically, where partners in real time share information about threat, harm and risk of people in the community. I think the more you can reduce the risk of people falling between cracks, where information is known by one agency and not shared with another, the safer that people will be, so, if I had one wish, it would be that, across Wales, MASHs—multi-agency safeguarding hubs—were mandatory, membership was mandatory, and we had 100 per cent coverage. There are many different areas of threat, harm and risk for vulnerable people. This is one of them. Taking that approach would help everyone.

Can I just pick up on that, going back to—? Is that similar to the hub that they have in Gwent, the Gwent Police, the multi-agency—? It's primarily around missing children, I think.

In my own force, for instance, we have hubs in Cardiff and in our northern basic command unit for Cwm Taf, and, basically, it's partners from health, the local authority, education, policing, third sector organisations that particularly look at adult and children safeguarding—anyone who's at risk, sharing information in real time and agreeing joint courses of action, going forward. I think that's absolutely key if we're to protect vulnerable people in all forms.

And you in the fire service—the impact, the depth of impact, and that wish.

I think that operational crews, when they're going to what, sadly, turns out to be a body retrieval—it's always felt as a failure on their part and, you know, that this person has been failed. If it's in certain areas, you might find that there's a trend that certain crews go to the same incidents, that they do need that support. But we've definitely moved a step forward and people are talking about the effects of going to fatalities on mental health, and I think that broader conversation is happening. You saw it at Grenfell, that even the chief officer there has said she's had to access mental health, so it's something that we're talking about. Every fatality affects our crews.

Ocê. A gaf i ddiolch yn fawr iawn i'r tri ohonoch chi am ddod i mewn atom ni'r bore yma ac am siarad mor agored efo ni? Mi fyddwn ni'n anfon trawsgrifiad atoch chi o'r dystiolaeth sydd wedi cael ei rhoi inni'r bore yma er mwyn ichi gael ei wirio fo am ei gywirdeb o. Ond diolch yn fawr iawn ichi unwaith eto am ddod i siarad efo ni.

Mi awn ni'n syth ymlaen i'r sesiwn dystiolaeth nesaf—rhyw ddau funud wrth inni gael tystion eraill i mewn, ond mi ddown ni â'r sesiwn yna i ben. Diolch yn fawr iawn.

May I thank all three of you very much for joining us this morning and for speaking so openly with us? We will be sending you a transcript of the evidence that has been given to us this morning for you to check it for factual accuracy. But thank you very much once again for coming to speak to us.

We will move immediately to the next evidence session, and just take a couple of minutes as we bring in the new witnesses, but we'll bring this particular session to a close. Thank you.

4. Atal hunanladdiad: Sesiwn dystiolaeth ag Ymddiriedolaeth GIG Gwasanaethau Ambiwlans Cymru
4. Suicide Prevention: Evidence session with Welsh Ambulance Service NHS Trust

Bore da ichi, dystion—gwesteion, roeddwn i'n mynd i ddweud. Croeso ichi fel tystion yma i drydydd sesiwn dystiolaeth y dydd, eitem 4 ar yr agenda heddiw yma, sef y sesiwn dystiolaeth ddiweddaraf yn ein hymchwiliad i atal hunanladdiad—sesiwn dystiolaeth gydag ymddiriedolaeth gwasanaethau ambiwlans Cymru. Tri o dystion o'n blaenau ni: Claire Bevan, cyfarwyddwr ansawdd, diogelwch, profiad cleifion a nyrsio'r ymddiriedolaeth, Stephen Clarke, pennaeth iechyd meddwl yr ymddiriedolaeth, a Nigel Rees, pennaeth ymchwil ac arloesedd yr ymddiriedolaeth. Croeso i'r tri ohonoch chi. Nid oes yna ddim angen i chi gyffwrdd â'r offer o'ch blaenau chi. Mi fydd y meicroffon yn dod ymlaen yn awtomatig. Felly, mi allwch chi ganolbwyntio yn llwyr ar ateb y cwestiynau, fel rydw i'n gwybod y gwnewch chi. 

Mi ddechreuwn ni gyda cwestiwn gen i: pa mor gyffredin ydy hi i staff gwasanaethau ambiwlans ddod i gysylltiad â chleifion sydd wedi ceisio, neu o bosibl wedi bygwth, cyflawni hunanladdiad?

Good morning, and good morning to you, witnesses—I was going to say our guests, but, of course, you are our witnesses, here for our third evidence session today, and this is item 4 on today's agenda, which is our latest evidence session in our inquiry into suicide prevention with the Welsh Ambulance Services NHS Trust. We have three witnesses: Claire Bevan, director of quality, safety, patient experience and nursing from WAST, Stephen Clarke, head of mental health from WAST, and Nigel Rees, the head of research and innovation from WAST. So, I'd like to welcome the three of you. You won't need to touch the equipment before you. The microphone will come on automatically, so you can concentrate entirely on answering the questions, as I know you will do. 

We will start with a question from me, and that is: how common is for ambulance services staff to come into contact with patients who have attempted or possibly threatened suicide?

11:15

Shall I start off? Thank you for the opportunity to come today. Maybe just to put into context, I'm not sure how much detail you know about the ambulances services, but, for example, last year our total number of 999 calls to the service was around half a million, and out of the half a million about 30,000 were coded as mental health/self-harm categories. What I would like to say is an element of caution around any figures, because often people will ring up with something else, and, if you want, their anxiety or distress will be masked by abdominal pain, chest pain, respiratory problems. So, those are probably underestimated figures. 

Our services are split into hear and treat services, whether that's through our NHS Direct Wales 111 line or through the 999 control centres. In relation to the 999 control centres, of that 30,000, about 17,000 of those end up with us actually going to attend that person's home or residence—wherever they are—and, basically, we are transporting about 11,000 individuals to hospital as a consequence of an outcome of their assessment.

In relation to NHS Direct Wales, we basically have around about 278,000 calls a year, and around about 4,500 of those are linked to self-harm, suicidal ideation. So, our staff who are on the telephone triage, as well as our front-line staff, obviously have significant interaction with people who are in the self-harm category, or indeed suicide ideation, or actually attending a suicide end-of-life experience. 

Just for a bit of context, I'm the head of research and innovation, but also a paramedic, and have worked on emergency duty since 1989. So, I've got an academic interest and a research interest, but obviously a professional background in this area. Claire mentioned the way that we code our emergency calls. Sometimes that can under-represent the true figure of self-harm and suicide-related behaviour. We did a study with Swansea University and one of our English partner ambulance services where we took routine data and then we compared it to what was actually on the narrative of our patient care records—so, when the crews turned up, what they actually wrote down. It was a very small study, so I emphasise that the research in this area is very limited. It was a small study, and we found that, in around 10 per cent of our cases of patient contacts, they involved mental health problems, and half of those were related to self-harm and suicide. So, it's very much an under-reported presentation to ambulance staff, but, again, in the interviews that I've conducted as part of my PhD in which I've interviewed paramedics, all paramedics recognise that this is a significant presentation to them in their working life. 

Thank you. I think Angela wants to explore this a bit more. 

Yes, I do, and I don't know where to start, because I've got a load of questions, actually, to ask you. Because I happen to be on this page, and I think this must be directed to you, Nigel—I think this is your work here—. You're talking about joint mental health and police response units have been implemented in some countries rather than the ambulance service. So, my questions are: first of all, in a call centre, are you able to definitively define on every occasion whether you need a mental-health-experienced paramedic or ambulance crew to go out, or when you get there that's when you find the extent of the issue? That's question one. Question two would be if you were able within a call centre, because you have the support within the call centre to be able to handle a call in on 999 where it is a mental health issue, would you then be advocating the use of a combined, perhaps, police and mental health response, rather than an ambulance response, or do you see that as coming under you and maybe it's combined with the ambulance service?

11:20

Shall I just take the initial overview? I have to say, I've only been in the ambulance service for two and a half years; I come from quite an acute and primary care background. What I'd like to say is that, certainly in the last 18 months, two years, we've made significant progress with working collaboratively with the police, and we have actually developed within the Welsh ambulance service clinicians in our control room, and what we have is support from the commissioners, and we have expanded the numbers of paramedics and registered nurses working in our control rooms to take these examples of such calls. 

Where we have made progress over this last year, 18 months, is our clinicians actually spending time in each of the police control rooms. So, just as an example, every year the police received about 20,000 emergency calls per annum from us asking for help, and also within a year the Welsh ambulance services received about 27,500 calls from the police asking for our help. So, we can make such a difference by that collaboration and working together, which we have done. So, this is for all calls, not just for mental health, but a lot of the calls that we are working together on have a mental health context. 

In South Wales Police, for example, during 2017-18 we've provided 1,229 hours of clinical presence in their control room with a paramedic and a nurse, and we avoided the despatch of 900 ambulances that could be used for other calls, and we released 528 officers from the scene. We've got similar figures for Dyfed-Powys Police and North Wales Police as well. So, I think your question around how we can then signpost on to a specific registered mental health professional, this is where we are working together with the police and with the health boards to remodel the clinicians on our clinical desk, and working with police control, so that we have more clinicians with mental health qualifications. 

I'm very proud that Steve is here with us today. We've been working on developing our mental health improvement plan in WAST, which was approved last July by our board, and with the Welsh Government's support and the commissioner's support, we have been able to appoint Steve as our first ever head of mental health in WAST. So, we want to grow our capability and professional presence within our organisation to be able to work in more collaboration with the police, to take this joint working further to be able to better respond again to people in crisis.   

Yes. Be gentle because this is week five for me, so I'll speak generally, if I may. I agree with everything that Claire said. I think at the hear and treat end of things, WAST seems to be on a fantastic journey of collaboration with the police. To get to the heart of your question, I think it's about beyond that when we see somebody in their own home, and whether we need a consistent response from WAST, the police and mental health services. There's a range of approaches to that being tried within Wales, across the border and internationally as well. I think the evaluation of some of those is limited, but there are some really promising things like street triage. I don't know if you've been watching the Ambulance programme on BBC One where—

Yes, it is very addictive, but it is actually a very real representation of the life of an ambulance service. It was really interesting to see street triage feature in that in the very first episode, where you saw a mental health nurse, a police officer and a paramedic working together to help somebody to resolve a crisis for them. That's a great model, and something that is being explored across Wales, as well as many other approaches. I think the test of all that will be that we come up with approach 'once for Wales', because I think there's an opportunity to do that for Wales, to do things once and to do them well, so, to come up with a common model and to make sure that it's implemented well and that we—

11:25

So, it would be a pacer, but with the ambulance service in as well.

Absolutely. You know, we need to settle on a model and then we need to implement it.

So, given what you've just said, do you actually feel then that the ambulance services do have enough support, both as front-line staff and as call-centre staff, to be able to handle and identify those who are in mental distress? Do we need to put in more training, or is there a recognition that the training modules—?

I think, as I explained earlier, we've literally—. We're a year into our first approved mental health improvement plan, and Welsh Government and the commissioners have been supportive with that first phase. As I said, we are thrilled to get the clinical leadership in place. However, on the resources for ongoing training, obviously we are working further with our commissioners and Welsh Government in relation to being able to provide the evaluation of what we've already achieved, but we know we've still got a long way to go.

It's really great, this winter, we put on an awful lot of support and I'm sure we'll come on to talk about staff well-being, but in relation to skills and clinical practice, and developing and working with health boards around pathways, we know that we've got an awful lot more to do. But the feedback from staff who have attended the training has been overwhelming, and being able to see individuals' confidence rise when they've been through, for example, the ASIST training, whether they're on the telephone triage or whether they are face-to-face, you know, responding to somebody in the community. We've got around about 3,000 staff. We've got another 2,000 community first responders. We have a lot of staff to support through this training, and it's going to take some time.

I know that a colleague of mine is going to talk about staff training—and I can feel the Chair's eyes boring into me—so, can I just ask you a last little bit about places of safety? So, is this collaborative working with the police and mental health professionals enabling you now, when you find somebody in distress, to find alternative places of safety, rather than automatically having to take them into a hospital or trying to triage them in their home? And also, is it helping you when you come to the tricky patient who obviously needs your help but is then refusing it? Of course, that's something we see quite a lot on that 999 ambulance programme. That must be such a difficult situation to manage as a paramedic.

If I just take the first part of the question, I think, in relation to where we've actually seen the expansion of the clinicians on our clinical desk, that has made a real impact, most definitely. And what we're seeing, and I'm just looking at some of the figures over this last year, where we see in a month at the beginning, or April 2017, we might be seeing 2,223 patients in a month with overdose poisoning or psychiatric suicidal behaviour, and we were actually taking half of those to hospital premises. Now, that might have been a psychiatric unit or an ED. By March 2018, similar numbers, 2,166, we were only taking 500 to a hospital. So, where we doubled our clinicians on the clinical desk in November-December 2017, we've seen a real impact on that clinical, professional support by our paramedics and nurses in our control rooms. I think that's the way to go: that we have a directory of services, we have a different pathway and options for those clinicians to direct those individuals for help. On the tricky patients, I'm going to ask maybe Nigel to come in here.

I think the inquiry's recognising the complexity that we're dealing with. We're not dealing with one condition, as in a heart attack, where you can fast-track them into services where they get a stent put in. You're dealing with a continuum, from somebody with thoughts of self-harm to maybe minor cutting, right through to people with serious mental health problems who maybe are about to kill themselves. So, that's the challenge, and in that case mix as well are patients who will have physical injuries that need to be seen and assessed in hospital, will have medical problems and may have overdosed, which again will need that assessment in an emergency department. So, it's recognising the complexity that, yes, we want to treat people in the community and in crisis teams, but for many, many of the conditions they maybe will be intoxicated with alcohol, which again is a big challenge. Our crews report the challenges like getting access to crisis services for patients who are intoxicated and, in self-harm, just under half of people who self-harm have consumed alcohol. So, I think we need to recognise the complexity, but we are on that journey, as Claire mentioned, and recognise that it's that bespoke support from mental health services and a range of services that will be part of the solution.

11:30

To fellow committee members, we'll come back to issues on multi-agency working and stigma, if we can, Julie, because you've raised two issues there—one on care and referral pathways and one on staff support and welfare—and I know Dawn's got questions on both of those.

Thank you, Chair, because it does absolutely follow on from what you've just been saying. I know, from the time when I was working with the ambulance service, you didn't have alternative care pathways. Basically, if somebody rang 999, you had to take them to A&E. So, that development towards alternative care pathways is a significant move in the right direction, but your paper clearly does talk about the challenges that you have with those alternative pathways. Do you want to expand a little bit more on that because it seems to be about the alternatives that you agreed not being available, really?

Going back to our NHS Direct 111 service provision, we have quite a robust directory of services evolving with each of the seven health boards. So, that is basically the tools that our staff will use to redirect people to appropriate care and appropriate pathways, and similarly in relation to our clinicians in our control room. I think in relation to our staff who actually are going out to see and treat, and if they are making an assessment that they need to take the individual to a direct pathway, where we're working with seven health boards—and we know that everybody's on a different maturity journey. We've got some health boards who have got very robust pathways and 24/7 access and we've got others who are not quite there, and that may be due to some challenges around workforce and recruitment or it may be that the development of the pathways is still in progress. So, we're working in real collaboration with the health boards.

In fact, this morning, we were supposed to be at Hywel Dda. I've got another colleague who's actually gone to present our mental health improvement plan with the Hywel Dda team. But, it's how we actually join up the needs and how we better share the information. When I came into the Welsh ambulance service, I realised we hold so much information of value to the health boards, and we've actually set up a much more robust way of actually sharing information together now, so that we can prioritise our improvements together and look at our population demand and need and actually bring those solutions together. So, we are on this journey, it's going to take time, but where we are, we do see variation, and that does bring challenges for our staff, particularly if they're working across health board areas. So, where we want to get to is a collective system within that collective vision for the people of Wales, but we're fairly early on. 

I'd agree with what Claire has said—obviously, she's my boss. [Laughter.]

Yes, absolutely.

Yes, exactly, and my objectives are coming up, so I need to be on side. 

I was really struck by Hywel Dda's evidence earlier and their plan feels excellent and the transformation journey that they're on is absolutely world class. So, I think that's wonderful. And that made me think, 'Well, Wales actually has the best mental health services in the world, they're just not all in one place, and they're just not the same everywhere.' So, I think that's the challenge that Claire has identified. I think when we operate as a national system across Wales and we've got seven health boards to interact with, what would be really helpful would be to have a dashboard of crisis services, so we know where services are 24/7, where people can self-refer, where we can refer, where people have a single point of access, where there are alternatives to hospital admission—that would be—[Inaudible.]—crisis houses, which is a movement that's under way in Wales as well. So, in my opinion it feels like we have this for emergency departments, and we have this for emergency beds in acute hospitals across Wales. We know where out ambulances are 24/7, we know where our people are, we know where our resources are—if we could have something similar to that from a mental health crisis perspective, that would be so helpful, because we would be able to think of the crisis system as equal across Wales, and we would know and shine a light on where there is inequality.

11:35

Basically, it's the not-one-size-fits-all, isn't it? It's identifying what the appropriate pathway is for a particular patient in any case. 

Exactly, yes. What 'good' looks like.

Which brings me on to the point that Nigel was making earlier on, following on from Angela's question about people with complex and multiple issues when your crews arrive. Is the alternative care pathway part of that process? The type of patient, in particular, who I'm thinking of is somebody who presents as being drunk and disorderly—I think that's what the police call them, isn't it? They've had too much alcohol, they've passed out, whatever it is—so, your crew's response to that is that they've got to be dealt with in terms of what's presenting to you, but the reason why they might be intoxicated is because they have serious mental health problems. So, at what point are you making that judgment? Is your first response, 'We have to deal with the immediate situation in front of us, and that is that someone is in danger because they are intoxicated', and that it follows on from that? What happens there?

Okay. So, the reality is that the emergency service, the ambulance service, was developed to treat life-threatening acute emergencies—

—and all of our training, how we code patients and categorise patients, historically was designed for that. So, when we encounter somebody who is intoxicated and who may have longer term substance misuse or alcohol problems, then our first, immediate consideration is their well-being at that time. In most cases, that will end up in an emergency department attendance, because it's very difficult to assess people who are intoxicated. They are a vulnerable group, and making that assessment—whether they're intoxicated because of alcohol, drugs, overdoses—is very difficult in the absence of time and diagnostics. But you do hit on a point, really—with the numbers of patients we see with substance misuse and alcohol problems, we're an opportunity for health promotion. I provided some evidence to the position statement for the College of Paramedics some years ago on the substance misuse strategy for the Welsh Government, and again highlighted the role of ambulance services and our crews in signposting people for services. But the reality is that you are dealing with somebody intoxicated—  

So, you have to deal with that immediate issue and then it develops from there.

I just wanted to ask a little bit about support for ambulance staff. We've heard from the fire and police services, and they seem to have quite well-developed support mechanisms for their staff, particularly those who have had to deal with suicide incidents and so on. I know that, talking to paramedic in the past, the support available in the ambulance service has not always been the best. I'm assuming—and perhaps you can tell me—that that has changed. So, I'd just like to know a bit more about the types of support services that are now available to staff who have to deal with pretty traumatic incidents, which range from—well, which range from everything you know. In particular, what types of services are in place for people having to deal with suicide? 

I think it might be helpful to talk about the organisational context to start off with. I know that when Tracy Myhill, our former chief executive, came into post about three and a half to four years ago, there was a massive exercise undertaken with staff across the organisation, with engagement and listening, to develop our organisational vision and, basically, to agree what our organisational behaviours were and how we all signed up to that. These behaviours were actually created by the staff and in partnership, focusing on: 'I will be kind, caring and compassionate', 'I will ask and listen', 'I will be honest and open with myself and others'—the critical one—'I'll be my best', 'We can do better together' and 'I'll own my decisions'. But I think the one 'I'll be honest and open with myself and others' is about how we're creating, if you want, a culture of where we're open and honest and asking each other, 'How are you?' When we have had incidents we have had an immediate debrief process. So, when somebody's been to a child death or a hanging we will have an immediate debrief process. What we're actually encouraging is—. We've got 244 team leaders going through a leadership development programme at the moment, to build on that culture of openness and honesty, giving feedback. We're looking through our development now. We've got a whole new clinical structure that's come into the organisation where we're encouraging supervision and feedback to individuals—a different layer of support.

So, that's about, if you want, organisational structure and culture. However, this winter, we have actually really embraced taking forward a whole new set of support for staff, and I'll ask Steve—do you want to pick it up? 

11:40

Great, yes. So, I think, just a tiny bit of context: Mind's Blue Light have recently undertaken a survey of all blue light services across England and in Wales, to a degree, as well, and it was really quite interesting to see from that that about 53 per cent of ambulance staff across the UK are reporting having a mental health problem, where it's much, much lower than that in the general population—something between a quarter and a fifth—and about 15 per cent saying their mental health is poor or very poor, and it's about 4 per cent in the UK population. So, there is something about these roles in blue light services that are uniquely stressful and challenging, and perhaps Nigel can say a little bit about that. But these are tough jobs and you're seeing some quite extraordinary, some quite out of the ordinary things in your day-to-day work. 

So, I can't claim the glory for the mental health improvement plan, because the implementation of that started before I started. There's a huge amount of work going on on things like when you experience a traumatic incident. So, Claire's already mentioned you have an immediate debrief. We now have a system in place called TRiM. You've probably heard that from some of the other services as well, which is trauma risk assessment and management. So, a TRiM practitioner will contact the person within 72 hours of their exposure to a traumatic incident and offer a TRiM session with them, where we'll look at the risks and the strengths and anything that's happened for them, and that will be followed up, then, for a second session later on, usually around four weeks after that. The evidence suggests that that's the maximum optimal window. So, 72 hours and then four weeks post, continuing to think about risk but also about the strengths and plans. And then on top of that we have a range of other services that are with the TRiM process. So, we have an online cognitive behavioral therapy offer, we have our occupational health service and we have our well-being support service that contacts people when they've been off sick. The next challenge for us is to look at all of that in the round.

We want to think about prevention, early intervention and resilience. So, what can you do when you start a shift to start that shift well? You may have had a row with somebody at home or you may have had a bad start to the day—you're carrying something round with you—how can you start the day well? How can you flag when things are getting on top of you during the day and what can we do about that internally in the organisation? So, all the gamut of—. Starting with prevention, early intervention and getting all the way through to people who have severe mental health problems—. And we do have, as this establishment will have, people who've had severe mental health problems—all organisations do and we do too—and we need to put robust pathways in place for those people.

So, there's a process of review of our entire health and well-being pathway to start with prevention, early intervention, and then we think about high-end need as well, and reviewing all of the elements of that, and making sure that everybody knows that. So, for instance, you can't get access to your pay slip or something until you've actually clicked and x-ed out the well-being pathway, so you know that people are actually aware of that and they know where to go and that it's really open access for them. 

So, part of the aim of that, I would assume, would be helping to reduce your sickness levels, particularly for stress-related illness as well.

11:45

Absolutely, yes.

It's about how we measure staff well-being. We hold a quarterly pulse survey within the organisation. There's obviously the NHS Wales staff survey, but we have our own organisational pulse survey, so we actually monitor it very regularly around how well staff are feeling and our engagement index. So, that's really important to us, and then you can do a deep dive into an area if you feel there's additional support needed in a particular area of the service or in a particular team, and that's work, as Steve said, that we're reviewing—you know, the well-being pathways. But there's not just one tool that fits all—we need, if you want, a repertoire of tools that we can, actually, provide as support to staff. And certainly, over the winter, we access Mind and we access TASC, which is the ambulance charity that supports staff. They actually came in and spent time with our staff in the control room over the winter so that we could actually build some additional support during times when the system was under significant pressure. We have purchased over 200 licences for something that's called Headsted, which is about building resilience. We've been particularly targeting our 'hear and treat' staff, and that's an online, e-learning programme over a period of weeks, and that's about how individuals and teams can build up resilience proactively rather than waiting for people to go into crisis and then go in to support them from that perspective.

So, we're building up the well-being side for staff but also balancing it with their training and their confidence to be able to respond to people in crisis—hear and treat or see and treat—and it's part of maintaining our staff well-being as well. We want them to be confident with being able to deal with—as Nigel said, there are so many different scenarios that they encounter in their daily work lives. But we need to make sure we've got all of these different mechanisms wrapped around our staff to support and allow them to talk and give us feedback about what it's really like. I think the other measure is that our board, our executive team, are out and about. We're an all-Wales service and we're really committed to being out there with our staff to actually understand what it's like for them and it's given them that opportunity, not just through the pulse survey, to actually sit down and talk with our staff, to understand what they're experiences and needs are, and what we can do differently to support them better.

Diolch yn fawr. Julie, shall we come back to the stigma issue?