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Y Pwyllgor Cydraddoldeb, Llywodraeth Leol a Chymunedau

Equality, Local Government and Communities Committee

13/11/2019

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Caroline Jones AM
Huw Irranca-Davies AM
John Griffiths AM Cadeirydd y Pwyllgor
Committee Chair
Leanne Wood AM
Mark Isherwood AM

Y rhai eraill a oedd yn bresennol

Others in Attendance

Charlotte Waite Cyfarwyddwr Trawsnewid a Newid Systemau, Platfform
Director of Transformation and Systems Change, Platfform
Dr Karen Sankey Prif Weithredwr, Cydweithfa Gofal Cymunedol
Chief Executive, Community Care Collaborative
Dr Keith Reid Dirprwy Gyfarwyddwr Iechyd y Cyhoedd, Bwrdd Iechyd Prifysgol Bae Abertawe
Deputy Director of Public Health, Swansea Bay University Health Board
Josie Smith Pennaeth y Rhaglen Camddefnyddio Sylweddau, Ymddiriedolaeth y GIG Iechyd Cyhoeddus Cymru
Head of Substance Misuse Programme, Public Health Wales NHS Trust
Lindsay Cordery-Bruce Prif Weithredwr, y Wallich
Chief Executive, The Wallich
Martin Blakebrough Prif Weithredwr Grŵp, Kaleidoscope
Group Chief Executive, Kaleidoscope
Richard Edwards Prif Weithredwr, Huggard
Chief Executive, Huggard

Swyddogion y Senedd a oedd yn bresennol

Senedd Officials in Attendance

Gareth David Thomas Ymchwilydd
Researcher
Jonathan Baxter Ymchwilydd
Researcher
Naomi Stocks Clerc
Clerk
Yan Thomas 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

Okay, may I welcome everyone to the meeting of the Equality, Local Government and Communities Committee? Item 1 on our agenda today is introductions, apologies, substitutions and declarations of interest. We've received one apology from Dawn Bowden. Are there any declarations of interest? No. 

2. Gwaith Dilynol ar Gysgu ar y Stryd yng Nghymru: Sesiwn Dystiolaeth
2. Rough-sleeping in Wales Follow-up: Evidence Session

Okay. Item 2 then is a follow-up evidence session with regards to our work on rough-sleeping in Wales. This is a session that's directly related to some of the evidence we've already taken and some of the issues that have arisen, particularly from people with lived experience of rough-sleeping and key stakeholder organisations in providing services. And what we want to do today is to examine the extent to which integrated mental health and substance misuse services are accessible and whether such services could be delivered more effectively to address the specific needs of rough-sleepers.

We've got a somewhat unusual format today for our committee meeting. It's a little bit more informal, and we hope to get, basically, an informed discussion going at our meeting today that addresses those very practical issues, because obviously you know what the on-the-ground problems are and, hopefully, what some of the solutions might be. So, thanks to all of you for coming along.

First of all, let me introduce you all for the record. So, I'm very pleased to welcome Martin Blakebrough, group chief executive for Kaleidoscope. We have Lindsay Cordery-Bruce, chief executive of the Wallich, Richard Edwards, chief executive of Huggard, Charlotte Waite, director of transformation and systems change at Platfform, Dr Keith Reid, deputy director of public health, Swansea Bay University Health Board. I've missed out—because the order is wrong on my paper—Dr Karen Sankey, chief executive of the Community Care Collaborative, and we have Josie Smith, head of substance misuse programme, Public Health Wales NHS Trust. So, thanks very much to all of you for coming along today. We do expect to be joined by other members of the committee, hopefully very, very soon. 

If I might begin our session today, we heard that there are real issues in terms of effective joining up of mental health services and substance misuse services, and we're very keen to get to the root of the problems and to be able to point Welsh Government and others to some of the ways that we might effectively address those issues and make some progress. So, we do have themes that we want to cover in terms of our questioning and discussion, but we do want it to be more of a discursive exercise rather than a straight question-and-answer session.

But let me begin by just asking you, really, to get things under way. What are the basic practical difficulties then, in terms of homeless people, people sleeping rough, in joining up those mental health and substance services? Is there anywhere in Wales where it seems to be achieved effectively? Is there anywhere at all in Wales where they've, if not cracked this problem, shown very good practice? Who would like to begin? [Laughter.]

09:35

I'm happy to kick off.

I can speak for Cardiff—I can't speak for the whole of Wales, but we—. Despite there being some very good services around mental health and substance misuse within Cardiff, there aren't integrated services, and, therefore, for clients that are rough-sleeping, who have often experienced real trauma in their lives and their lives are quite often chaotic in nature—it is very, very difficult to get people with co-occurring substance misuse and mental health issues into mental health services, and there are too many barriers in the way at the moment. We have—. As an example, we've been supporting a client who is 60 years of age, is a woman; she's been sleeping rough. She has experienced abuse and bereavement throughout her life, she has chronic mental health issues, and she copes with those mental health issues through substance misuse. In the past, she has taken heroin. She's not taking heroin at the moment, but she is taking spice. We tried to get her to see mental health services; we referred her to a GP. She was reluctant to go to a GP because she didn't trust GP services. We finally got her to a GP, who made a referral to the community mental health team. Three weeks later, we hadn't heard back, and we've chased up the GP to be told that the community mental health team had rejected the referral until the client had addressed their spice issue, and therefore they were not able to access mental health services. And that's a story we hear time and time again. And the waiting times to access services are far too long, both for substance misuse and mental health.

That's quite interesting for us, I think, because Leanne Wood, who obviously isn't here at the moment, raised issues around professional barriers to the joining up of those services, and Leanne was under the impression that there might be some professional training and professional ethics issues for mental health professionals that prevented them providing services to people who were currently using illegal drugs. Is that part of the problem, do you think, or—?

I think, for me, there's something around eligibility criteria—that, even within the mental health directorate, secondary care will battle with primary care about which individuals they'll take. And so I think—. We've tried to actually get around that, so we run an integrated service where we have 30 agencies now that work together in an open-access service. So, we have substance misuse services there and we have mental health, but, even then, there's still an 'us and them'. So, I think—. We're currently—we've just employed or are just about to employ an advanced nurse practitioner that actually is trained in mental health, physical health and substance misuse, who'll actually be in primary care. So, I think, actually, we get around the eligibility criteria and access—they'll be offering a much more holistic approach.

I see. Okay. And there are a few people who'd like to come in there. Josie. 

Just to build on that and to reinforce that, actually, the experience that Richard mentioned in Cardiff I would suggest is right across Wales. We are very aware that, certainly, there's a different culture within substance misuse and within formal mental health services, and has been for many decades. And there is a paucity, a recognised paucity, of joined-up leadership at the very senior level, at consultant psychiatry level and consultant psychiatrists in addictions. There are too few of them and that's going to present a huge issue going forward, but I think, in terms of progress, what we really need to see in terms of workforce development is the upskilling of mental health professionals in substance misuse and likewise recognising the role of nursing and nurse prescribers, but also recognising the skills of substance misuse workers and upskilling those within mental health. These are not two separate issues. They are so interrelated that we need to recognise that in the workforce.

09:40

Are we seeing at all that the barriers that I mentioned that might exist in terms of professional ethics and training and so on might apply to some mental health professionals but not others, or—? No, it's not that. 

I think it's the culture that's actually—

I think it's very good individuals with good intention who are restricted by the framework of their department, and, let's say, their eligibility criteria, it's very tick-boxing.

I also think you're referring to a clinical setting. So, there are lots of mental health support services that aren't clinical and they're often left holding the baby. The point I wanted to make was the case study that Richard talked about is fortunate because she is already in some form of supported accommodation. There are many, many rough-sleepers who aren't, and so the barriers would increase from what Richard's describing because there is this obsession with, 'You have to be housed before you can be treated', so that leaves very few options. There is no concept of, 'We can support you both with your mental health—', less so with substance misuse, but, even substance misuse, the flexibility of creative outreach services for people on the street, for example, and harm reduction notions around mental health or particularly substance misuse, it's a very well-established culture. What about in mental health and what about sleeping rough? Sleeping rough is a public health issue. It's bad for your health. So, there isn't that urgency for treating people who are rough-sleeping. There are added barriers to what Richard's described. 

Yes, okay. Thanks, Charlotte. Could I just bring Martin in and then I'll come to you, Keith?

I think there are no really good models across Wales, and we provide services right across Wales that can help in one sense, but I would say there are areas of reasonable practice. So, if you're looking at Gwent, for example, it is probably the only integrated service in terms of the Gwent Drug and Alcohol Service, which is a Kaleidoscope-led service. It does work with the specialist substance misuse service and the consultant doctor has a role within our services and our doctors have a role within her services. So, there is some integration.

But the system falls down particularly when it comes to rough-sleepers because a lot of the contracts are about trying to get people—which I understand—through the treatment system. So, you're not—. It's a bit like the issue about work—you know, in terms of trying to get people into work, you get the low-hanging fruit and the more challenging clients who aren't going to make the outcomes, they're not going to help your data set, they're not going to help your KPIs. So, that group of people tends to get ignored, and they're very easy to ignore because virtually every treatment system has an appointment-based approach. So, you have to make appointments. So, the ridiculous situation is that you have to make appointments. You have to do things like three urine samples over different periods of time. If you admit—. Unfortunately, a lot of our rough-sleepers have a very short term in prison. If you manage to get into the specialist service where there might be some mental health service for you after being in with GDAS initially, you have this nonsense that they go in for a few days, they're knocked out of the programme, then they have to start all over again with all their appointment-based systems and try and then get a referral into the specialist service who then might be able to link with the mental health service.

So, it's a systems failure that is particularly acute with those people who are rough-sleeping who have mental health issues because we know that, actually, the services, again, going back to your point about outreach, we're not—. You need to have assertive outreach services, and that means instead of people—. If people fail their appointments, it should be down to us to get them in, but the onus is always on the individual to make sure they keep the appointments as if they're able to do that. So, for me, you have to address it in terms of, if we're going to say, 'Actually, the target of our services should be for the most vulnerable, the ones who are impacted often by death if they don't make those services'—. They also—. If you're on the street, you're likely to take drugs. So, the other big problem is this issue about taking on top. So, if my doctor is seeing someone, and he's prescribing them methadone, so they're okay—. The methadone doesn't give you the effect that you're looking for, in the sense of—it means you're not going to suffer withdrawal, but you're not getting out of it. Now, most of us—as you will know if you're running along the riverbank in Newport, you will see all these tents. I challenge anyone in the winter not to take drugs, because you want the drugs to be able to sleep and to relax and get all those horrible thoughts, the paranoia, out of your head. So, the idea that if you come into some money you won't spend that on heroin is ridiculous. But, of course, as soon as we detect you've taken heroin, we have to take you off the programme because you're effectively abusing your prescription. There is no reason, actually, that if someone is presenting okay, you could actually allow them to take on top. But it does need a radical mind shift. So, all these things we put in place for good safety, with good intentions, actually go against the very people that we need to be supporting.

09:45

Okay. Well, that's very interesting, Martin. Thank you. Lindsay.

Thank you. As a former rough-sleeper, I really want to cut to the chase and talk about what's really wrong. We are in a horribly fragmented sector that is faced by a serious crisis in leadership—ultimately, nobody is accountable for getting people in. And if I can refer to the justice commission report, the same thing was cited there, actually: whose neck is on the line for getting people in? There are so many people kind of in charge, but, actually, nobody is accountable. We have local authority-led models that are no longer fit for purpose. We have a lack of genuine co-production between statutory services and the third sector. If we brought that magic together, we would have the agility to respond. At the moment, there's kind of a master-and-servant dynamic, where the third sector—where the specialism often is—is restricted and bound by barriers that are placed upon us by out-of-date commissioning systems and things like that.

I do support the idea of more training. I would like to see our sector professionalised. I think there's a toxic commissioning environment that has led to the race to the bottom. We're all trying to do things as cheaply as possible just to survive, and that means now I've got £16,000-a-year support workers being chased with hammers by people who have these needs. The same with the outreach services that we run across Wales. We have teams go out in five of the cities across Wales every morning to engage with people who've slept rough that night. In Cardiff yesterday, we saw 83. That gives my support worker two and a half minutes to deal with somebody with complex needs in the darkest time of their life. We also have a problem with getting access to deliver assertive outreach, because we can't get permission to access the streets that we need to.

It's hard to get agencies to work together—we know that. And we have tried and tried to implement innovation and bring new models and bring new solutions, and we are repeatedly blocked from implementing them. Richard and I co-designed an outreach service with many other partners. We had the money for it at the time; it wasn't able to go ahead because it wasn't local authority-led, and we had all partners around the table. And that was before the tents. We had answers; we keep bringing answers and time and again, we are shut down, we are silenced and we're almost threatened. We are having to speak out against our biggest financial supporters as charities, and that also puts us in a very difficult position for challenging the things that are really wrong that people are really reluctant to talk about.

I'd like to just raise the point that sometimes division is appropriate. Not all of the services out there share the ambition for the people that we support that we have. We've had to say goodbye to a major housing provider because we would spend five years getting somebody off heroin, then they would evict them for smoking a joint. And there are people who are refusing to house the most complex because of the chaos that they bring with them. So, rather than working responsibly with those risks, there are social housing providers who are just not letting people in the door, and that is a massive problem. And that means that we're holding them in hostels for too long and then the hostels become unsafe. It's really, really difficult, but I think it's naive to think that we can get the whole sector to work together, because we can't, and we've been trying for many, many years. With the best will in the world, sometimes we've got to acknowledge which services are aligned on values and aligned on their ambition, and which services maybe need to go over there and do something awesome, away from us. Sadly, there's enough business for us all.

I agree with what Martin's saying about the radical mind shift. The real thing that's stopping people coming in is that the offer that we have in services is less than what the streets offer. So, if you're in the throes of addiction, you've got all these complex mental health issues, let's throw in a learning disability to make things interesting, you can turn that pain off with spice or heroin quite easily. We can't offer people that. You can be nobody in a flat, or you can be somebody on the streets. There are cultural implications for people who've been out there for a long time.

I would like to see things like heroin-assisted treatment; I would like to see us offer medical-grade solutions to people that are going to meet their needs, but that is going to take radical change. But I think we're in a situation where we've got to look in the mirror and say, 'Do we want this to change or not?' We've got to get these things off the 'too hard' list. The evidence is there. At what point are we going to get out of our own way? Sorry, I'm ranting. [Laughter.] I'm really mad about this.

09:50

Lindsay, the point you made about outreach and assertive outreach, and some streets being off-limits to you, then, could you tell us a little more about that? That's Cardiff city council, is it?

One of them, yes. Some places are trying to get our outreach vehicles out there and things, but it's just that streets are too narrow and things like that. But in other areas, there's so much pressure from businesses. We've had a very public discussion with FOR Cardiff, for example, the business improvement district for Cardiff, about whether our services should cease on St Mary's Street and Queen Street. Our outreach services go where the people are. The people aren't there just on the off chance that we might come round with a boiled egg in the morning.

We've also had things that we've tried to pilot with our welfare vehicle, in partnership with Richard and some other organisations, and we need to put them in prime locations. So, we did a pilot last February when we saw 40 people in one day; it was the day we had the snow. Massive engagement—we got more people in in one day than has ever happened before in Cardiff. Richard's team were running over with sleeping bags, we got people warm, we got phones charged, we did engagement. The guy running around with moss on his leg, who has always told me to 'eff off', I offered him a coffee and he said, 'Yes, please.' For us, that's an outcome. That was working, and we've lost the pitch because it was sold to a McVities biscuit van. Do we want to sell biscuits or do we want to solve homelessness? I know that it's disruptive for businesses for us to be out there, but, again, do we want to solve this or do we not?

At the moment, we've got a welfare vehicle out one day a week in Cardiff, but it's shoved around the back of the museum. We're getting some engagement, but just not at the level that we were before, because people don't want to leave their pitch. It's lucrative to beg on those streets.

Okay, Lindsay. Is there anybody amongst you that wouldn't agree with the use of heroin, as has been suggested, in dealing with these issues? Would anybody oppose that?

I think it's definitely a tool that could be used. I think you have to—annoyingly, in all these things, you have to look at the relative cost and the cost benefit, and all I mean by that is that, for me, there are other priorities. So, for example, as people know, I've often banged on about drug consumption rooms, because I can't understand why I'm giving someone who is a street homeless person a needle to inject, and I know they will be injecting illegal drugs, and the only place they've got is the street. And even if they're in a hostel, they dare not inject in a hostel, because they'll be chucked out of the hostel—you know, that's the legislation.

I also think that we must get people into treatment. It's not good enough at the moment—there are too many people who can't access treatment across Wales. And one thing we've committed to do—well, sorry, not 'we've committed'; the Welsh Government have committed to do—is to make sure that there isn't a postcode lottery. But when it comes to substance misuse and access into just basic treatment—. Sian Chicken, who you know runs Gwent Drug and Alcohol Service, she goes, 'I'm totally in favour of doing heroin trials, but I'd like to make sure, first, that everyone gets access to treatment.' And at the moment, that is not happening. You cannot get—. It's the reason why you're getting—. Arfon in north Wales is now looking at us providing a prescribing service, because it can't get people through treatment in north Wales. It's why we're being asked in Cardiff to provide a rapid prescribing service, which is fine in one sense, but actually then creates another organisation doing another little bit of things, which creates not the seamless pathways that we really need to have. So, I think heroin prescribing, in an ideal service, absolutely, but I would say that we need to get the basics right. So, we're going for the Rolls-Royce and we haven't even got a Mini.

09:55

Okay, Martin. Sorry, Keith—I know you wanted to come in some time ago.

That's all right, thanks very much, Chair. I think we've heard many of the points that I wanted to cover eloquently covered already. I guess, taking a slight step back, the issue about mental health and substance misuse services is not just an issue for rough-sleepers and homeless people, it's an issue for anyone who's got a substance misuse problem. So, the capacity issues are across the board, and I think that has come through, but they're amplified and magnified when you're dealing with people who are in unstable or insecure accommodation, or in no accommodation at all. So, I think that that goes to what Martin's just been talking about—lack of capacity and postcode lottery. That is amplified, and the impact of that is much greater for rough-sleepers, but it's there for anyone with dual diagnosis.

Going back some way in the discussion, I think the issue about mental health and substance misuse, and the difficulty of access to either/or services, I think that is an issue and we need to be building more dual-diagnosis services. It's about a combination of factors, as these things always are. It's difficult to deal with or to diagnose mental illness in someone who's substance misusing because of the psychiatric medical process of diagnosing mental illness. So, that's led to a traditional separation of mental illness services and substance misuse services. The point that has come up more recently in some discussions around rough-sleepers is: well, is mental illness actually the underlying problem? And often it's not. The underlying problem is maybe more of a mental distress or psychological problem, a behavioural problem, rather than what we'd traditionally call mental illness. So, people who have got into a situation because of their behaviour or their lack of skills or inability to function within a set of norms or traditions or culture, and so it's not that they're ill, it's that they're different. So, how do we cope with that difference?

Can I just explore this point that you're making here about behaviour? Because I met with a specialist recently who suggested to me that around 20, maybe 30 per cent of the population in prison, on-street homelessness, a higher percentage of school exclusions, 20 per cent of people presenting to drug and alcohol services—have attention deficit hyperactivity disorder or autistic spectrum disorder-kinds of neurodiverse conditions. And it was suggested to me that there could be a process for screening people for that and a treatment available, so that, potentially, those people that you could be describing in your contribution there could be diverted away from prisons, the streets, and treated appropriately, rather than just made into a problem and put into an institution somewhere.

I think in theory, yes. The issues that have already been traversed are: where is the workforce to engage with that group going to come from? Where's the capacity for that? Already in our mental health, mental well-being services, we don't have the workforce to deal with those already in place.

I accept that point. I used to work as a probation officer, and I can think back now to my previous case load, and if some of those people potentially could have been screened and taken out of the probation service, then that leaves more resource, then, for dealing with everybody else who doesn't maybe fit into that category. It is a question of investing in professionals, from the Government's perspective, but that could be one of our recommendations.

And prioritisation—I guess that's the other thing. And the sense that people who have substance misuse issues or are homeless—there's an element of moral hazard there, that, somehow, it's going back to the Victorian concept of the deserving and the undeserving poor. So, we have to set that aside. They are people—they are amongst the most vulnerable people in our society. If we as a nation are concerned about tackling inequalities, then let's start with the biggest inequalities and direct resources in that direction. That would be one thing.

And the other thing was around having a person-centred approach. The issue about the traditional types of treatment and intervention for these types of issues, and Martin talked about this sustained engagement with professionals, or with others providing treatments and interventions and support. And it's how we get away from a service-centred approach, which is, 'Well, this is the offer and you must come along every Tuesday at three o'clock', to, 'This is the offer, we're offering an approach, how are we going to provide that to you, given that you can't come along every Tuesday at three o'clock? How can we engage with you as an individual?' and moving towards a more person-centred approach. A number of speakers have talked about the need to be more nimble in their approach, both in dealing with individuals, but also in terms of commissioning services and responding to actual need rather than perceived or institutional situations. So I think those are the issues that I would traverse.

10:00

Thanks, Keith. There are a few other panel members who would like to come in, and I'll bring in now, and then we'll go over to some of our committee members, who would like to raise some matters. Charlotte.

I just wanted to give an example, Leanne, you might be interested in. So, not only are our prisons and homeless people full of—they're known to have a much higher percentage of adverse childhood experiences. And so, Sian Moynihan—she's the clinical lead for the children's hospital in Cardiff, the children's health centre—recognised that the number of referrals that she was getting for social services from parents and families believing that their child had ADHD, behavioural issues, looking for that diagnosis, and she recognised that, actually, it's not behavioural, it's trauma. This is a trauma response playing out. And so she has created a screening process for her psychologists and people who work in that service, and a lovely, lovely education intervention then with families, about, 'This actually isn't behavioural, this is trauma', and does the ACEs work in a very asset-based way with those families. She describes exactly what you describe: by giving that information to social workers, she's getting better referrals. By giving that information to families, they're having a better understanding of how to deal with what's happening. What she's left with is actually dealing with the cases she should be dealing with, and therefore she's got more resources.

I think it's a point worth making that children's mental health services across Wales—Gwent being a great example—have used their transformational money really well, and have understood this need to be trauma informed. So they absolutely understand the need to be much more flexible in their approaches; much less 'three appointments and you're out'; much more dissemination of their expertise throughout the whole sector—so not waiting until somebody's really sick to see the most expert person, but moving that knowledge all the way through, right through to the third sector. And then, of course, what happens is that you reach the age of 17 and a half and you get referred to adult mental health services and you get stuck back on the waiting list. That is really what is happening, which is frightening.

I just thought you might find that interesting on your point, Leanne.

Just actually building on that—I keep swapping what I'm going to say. One of the things that Public Health Wales has been charged with is developing the substance misuse treatment framework for children and young people. And there's very much a recognition that, actually, if we are going to move to a much more preventative approach, a much more public health approach, then we really need to recognise that preventing the pool of entrenched and really seriously problematic individuals needs to start much earlier on. So there is the suggestion that children and young people, rather than finishing at—. So, the services finishing at 18 would finish at 25, which would tackle some of the issues around engagement in prison, for example.

Touching on the ADHD note, I think, certainly, having spoken with a number of mental health professionals, it isn't just particular cohorts or diagnoses that are problematic. They've highlighted to me people who have been diagnosed with personality disorders very, very often are falling through the gap. So I think it's important to be mindful that there are various vulnerable populations, and vulnerable diagnoses, that are more likely to be falling through the gaps.

Then this one, just finally if I may, just touching on Martin's note around what we could do perhaps to be pragmatic in our response to people who have substance misuse and are rough-sleeping, I think one of the things that we have very much tried to push towards is a recognition—and it's very well evidenced, right across, certainly Europe—of the need for rapid engagement, rapid treatment. At the moment, we have substance misuse services, we have methadone, we have various interventions that we can provide, but certainly, having looked at the data, you're talking somewhere between 20 days and three to six months to access that. Elsewhere in the UK, we have same-day prescribing. We really, really need to introduce and recognise and remodel our services, because an individual's motivation is at its height when they walk through that door. If we push people back and push people back, we are going to always be on the back foot rather than in the lead and at the forefront of prevention.

The other model that's adopted is 'Don't kick people out of services.' You do everything you can to retain people in treatment. Whether they are actively engaged, remotely engaged, outreach engaged, they are not removed from the system. So, I think those two elements in a treatment service would go a long way.

I recognise and I'm very familiar with the evidence on heroin-assisted treatment, and that's very much guided towards people for whom treatment has failed repeatedly. We're talking about, broadly speaking, 5 per cent of the most entrenched and problematic users. So, it is in the armament, but we're not doing even, as I said, the main proactive early engagement to prevent that entrenched use, and we need to do that first.

10:05

There seems to be a lot agreement from everything you're saying on core issues that need to be addressed, including the whole revisioning of what we're trying to do, but also some of the mechanics that we need to do. And it strikes me, reading through some excellent briefing material that's been provided for us, and having spoken as a committee to people who are experiencing exactly the problems you've talked about, that the solutions have been known about for some time, that Welsh Government have brought forward their plans on how to address this, they've identified exactly the same problems, most recently back in 2015 in the plan, yet here we are in 2019 where we get to a point where Welsh Government officials in May 2019 state that progress has not been as strong as hoped in this area, there is a need to align substance misuse and mental health services more closely going forward, and to consider structures.

As a backbencher and as a former Minister who liked delivery, liked to spot the thing, deal with the evidence, and so on, why is it taking us so long if there's agreement here on what needs to be done to change things? Is this just a matter of, 'It's too difficult?' Is it a matter of resources? Is it a matter that—let me put a challenge to you—there are too many organisations on the ground trying to overlap and do slightly different things? What's the problem here that we can't fix this if we all agree on what the issues are? Am I being naive? Sorry, Ministers are allowed to be naive, because this is exactly what I would be saying if I was pulling you in in front of me as a Minister in the past: 'Why? Why can't we do this?'

In our experience, we had a huge problem—I'm in Wrexham—with local politics. I think there's been real tension between different public sector organisations, and I think a lack of ability to actually accept innovation and support innovation. Our project—I'm very biased—is hugely successful and, actually, it's not in the local strategy. It's not recognised by the local authority. We haven't been able to access funding. So, I think there's an element of that. I think, also, the culture within big organisations. Our health board is in special measures yet again, and I think it's currently inert. I think it's become very risk averse. There's no, almost, head space. We talk about innovation and change, but actually there's no ability to support that.

There was something about going back to the ownership. I think that it's everybody's problem but nobody's responsibility. When we try to get funding, because ours is very multi-agency—we have 30 agencies working together, which is fantastic, so we're delivering on the ground—we can't get funding because mental health will say, 'It's not really our responsibility, public primary care, so it's not really our bag', and nobody will take ownership of it. For me, there's something about a successful project, so rather than everybody battling for funding, it's actually, 'That project is recognised as multi-agency, let's attach the money to the project and share that out with the agencies that are involved.'

Going back to Lindsay's point, I think it's very much about not forcing everybody to work together, but the like-minded organisations with the same values coming together and having an opportunity to develop their projects together. At the moment, funding is coming through public sector organisations and our funding has been blocked by the local authority. 

I guess, for our project, it's very much been about like-minded people. So, it started off with myself as a GP and one of the mental health managers that I met at an engagement event with the homeless in Wrexham. It's basically evolved that more and more agencies and individuals have come forward because—it's almost been self-selected—actually they're really interested in the work we're doing and they've wanted to be part of it. So, it's very much been, I suppose, a grass-roots approach that we've developed the service with people using the service. So, as they identify gaps, we then try and address the gaps. And actually, organisations are coming forward. So, we get e-mails once or twice—

10:10

I'm just trying to get an understanding of the clash of values. What's that all about?

I think, for us, it's very person-centred. Mark's been to visit our project, it's very friendly, there's no judgment, there's a lot of compassion and kindness shown.

Yes, and I'm in the health board. A regular experience for us—. We're from local authorities and from the health boards, and a regular experience we witness—. So, for example, substance misuse services, some of our guys will turn up for an appointment 10 minutes late, will be very polite, will apologise, and they're told, 'Come back in three weeks, you can't have your prescription.'

I'm really taken by that grass-roots approach there. The difficulty from a Welsh Government perspective would be if that is, for example, a very good example of how you can do this, or if there are other examples, it's how you make that the norm, albeit provided by different non-statutory providers alongside the statutory. We have now a national director of health and social services—

In some ways, I think area planning boards have been generally a bit of a failure in my view, and they're the ones who commission out services. I don't think they've been a total failure, because I think you do need your local provision and it actually has to reflect your local community. So, I think there is definitely room in the model to have grass-root responses, and that's how you get innovation. So, I've no issue with that.

But, if I'm looking at our drug-related deaths—so, I'm looking purely at the substance misuse service; we need to integrate with other services, but I'm just going to give you the substance misuse thing—there are record drug-related deaths and it keeps going up. Wales actually is doing a relatively good job in terms of funding, unlike England, but still we're not tackling that structural issue. This is against my vested interested to say this, but we know that the most effective way of reducing drug-related deaths is to make sure people are in treatment.

If we agree that this is a national state of emergency, we need to have a national response, and I would like to see the creation of a national prescribing service that is a mix of third sector and statutory sector, so instead of the area planning board, you as Welsh Government can say, 'That person has to be in treatment and that has to respond in this way.'

What happens in Welsh Government, in many ways, is it devolves that responsibility down to an area planning board. The area planning board lies. How can Rhondda Cynon Taf—? I went there when they were recommissioning services. They called it an integrated treatment service. I was there, incandescent with rage, and told the director of public health he was a liar and that this was not an integrated service. You had NHS, you had third sector, you had criminal justice, and they were not in any way working together.

This is happening across Wales in a lot of area planning boards, and to be frank, it is really upsetting me, because I'm thinking people die because we're not having the right attitudes and the right response and the coming together of people. I totally agree with Josie—we had a pre-conversation about it—you wouldn't necessarily run it by the NHS. I don't know what model you need, but we must understand this is not acceptable.

So would you then all accept, albeit it might upset some people, the need for greater national direction over what is provided, how it's provided, the change in mindset, the professionalisation, and all those things? Because if you have more national direction, it inevitably will impact upon some providers on the ground who will say, 'That's not quite our thing.'

I think there's a tension—. I sit on our area planning board in Swansea bay. I think there's a tension between the consistency that comes from national direction and a national service and the ability to create a critical mass of expert resource and to focus attention on an issue, and what we were hearing about earlier, which was about the need to have responsive services, to have services tailored to local situations, and to have the ability to have that nimbleness to respond rapidly.

I think some of the tension that I've observed as a relative newcomer to Wales in this sphere is about a health system, which is under significant financial pressure, feeling reluctant, and there have been some conversations, which I have not been party to but have overheard or have been informed of, around whether we should be releasing resource from the health service to third sector providers to provide services because our bottom line in the health service is under pressure. And the answer is, if it's the right thing to do, yes, of course, we should be doing that, because, going back to the other point, it's about what's best for the individuals, the patients, the people at the centre of this. So, I think whilst a national approach is attractive it carries some inherent risks, and actually making local approaches work better would be my preferred option. 

10:15

Okay. Could I just bring Richard in at this stage? Richard, you've been quite patient. 

Yes. I think whatever the structure is on a national or local authority level, the important thing is that it works on the ground. We have a system, at the moment, where we're treating conditions and not individuals. We're getting individuals discharged from services because their lead need is something else. We've got to change that. We've got to take a no-wrong-door approach to substance misuse and mental health, so that if somebody presents to a mental health professional in psychosis with a substance misuse issue, that is actually dealt with, and if that person is seeing the wrong person that they are not discharged before an immediate appointment is made with somebody who can help them further, rather than just saying, 'We cannot help you, you've come to the wrong place.' We've got to take that no-wrong-door approach.

We need to improve training and awareness among mental health specialists around substance misuse and conversely substance misuse specialists around mental health, and we need immediate referrals to the two. We don't need gatekeepers, we don't need GPs to gate-keep, because that can be a barrier that—. For a lot of the clients that we're working with who are rough-sleepers, the point at which they want to seek help is fleeting, and as soon as you have to wait for an appointment, as soon as that treatment is delayed, you've lost that individual.

And that links in to assisted heroin prescribing services, because a lot of the clients that we've worked with, some of them have been on the streets for 10 years. They've failed time and time again in treatment services and we need a change of approach to help people like that who are pulled in to the gravitational pull of street culture activities. Their life becomes more chaotic, because they need to spend every waking minute out on the streets in order to raise the money to fuel a heroin addiction that they're stuck in a cycle of trying to beat.

And if we can step in for those smaller—. It is a small group of people, but it is a significant group of people. If we can step in and set up heroin prescribing services we can immediately switch off that gravitational pull. And as soon as you switch off that gravitational pull, you open up the doors to lots of other support and treatment, including mental health, because those services are unreachable for somebody who has to spend 23, 24 hours on the street, engaging with the public to raise money to fuel an addiction. And for people who failed in services we need to take a step change with that. Yes, we do need consumption rooms, and I've always been very vocal about that. That does require a change in the law, but heroin prescribing services don't.  

Well, where to start? I've got so much to say off the back of all that. To speak to Charlotte's point, I think we need to be more aware of how the system has traumatised people as well, and work within a power threat meaning framework. What I mean by that is that if we're doing assertive outreach to engage the most entrenched rough-sleepers, if we look too official, that in itself could be traumatising. So, there's a real role for peer support here and I think we can't underestimate the power of lived experience. Do you talk to the council official or the well-meaning copper, or do you talk to somebody who's walked this path and been there and got the scars to prove it? We're seeing pleasing results with these models.

I would also really welcome the opportunity to work in a formulation-driven approach, rather than a diagnosis-driven approach. It's really, really difficult for us to get people into services because we can't meet certain thresholds and certain criteria. If we can deal with working with somebody, based on the symptoms as they present, no matter what caused them or what the label is, that's how we're going to actually change things in the short term and the long term, while you guys battle against legislation and all those other things that need to happen.

An example of that is, if you look at the most recent NICE guidelines for co-occurring substance misuse and mental health, the criteria for what constitutes a serious mental illness don't include post-traumatic stress disorder, eating disorders or personality disorders. That's absolutely no good to me because they're the very clients that are the most difficult to manage in community-based emergency housing. We're not a medium-secure unit; we're doing the best that we can with really good intentions and very, very limited budgets. But, actually, they are the conditions that we're trying to work with. And if you look at how that person got to where they are and just work with the formulation that's in front of you, rather than saying, 'Well, you fit this box, so you have to go there and navigate this ridiculously complex pathway', that's how we're actually going to be able to change it. So, I'd like to see a case conference based approach where we wrap the services around the person, rather than bouncing them all over the city, between different places, and attached to that personal budgets as well, which have worked very, very well in our Anglesey housing first project.

10:20

Can I just ask where, if anywhere, that case conference approach currently exists?

We're doing it in Anglesey at the moment with our housing first project. Karen is doing it in her community care cafe, without the support of the infrastructure around it. There are pockets of real good practice, but we can't get the system out of its own way.

In Gwent we have the joint assessment management system, which I explained, with the specialist service. It has key problems, because, as I've said, people can be locked out of that system, but there is a joint assessment between the specialist service for mental health and the drug service. I just don't think it's that effective. But it does happen, which is better than nothing.

I think the case conference approach, where you focus on the individual presenting and what's required, at least flushes out where the obstacles are if somebody says, 'Sorry, you can't have that.' At least it's flushed out: 'We've got an issue here because we've got a lack of resource over here, et cetera.'

But we need to change where that happens. So, at the moment, a lot of that happens in the local authority-led gateway systems. If that breaks down at that point, I end up with vacancies in my night shelter. That should never happen when we're seeing 83 people in the morning. So, it's how we provide provision through the night, because Richard's right, when the eureka moment happens, it's fleeting, and sometimes it's at four o'clock in the morning. We need to be there with the service, or at least with somewhere to go when there's nowhere else to go, to have that conversation and try and get the motivational work in at that point.

I've lost my train of thought. What was I talking about? What was your question again? 

The case-conference stuff. I would like to see a night team and a day team, and proper handovers in the morning, which is part of the model that Richard and I designed. It also draws on some of the good practice and the learning from Wrexham on how we could maybe replicate some of that in Huggard as a day centre, and then use the Wallich outreach services all through the night to take the service to people when they need it, where they need it.

Okay, if we could hear from Charlotte, Karen and Josie, and then I'm going to bring in Mark and Caroline. Okay. So, Charlotte.

Thank you. Just, Huw, when you were talking about what's the heart of the matter, it resonated so strongly with me. Even when I got this invite, I was like, 'Are we really going to go and talk about this again? It's not like we don't know.' So, there are two things for me that are about mindset and culture.

It's about scarcity. There's an absolute scarcity mindset, particularly in health. And when you're in a scarcity mindset, you batten down the hatches and you retreat, and that behaviour is—you've heard it all here today. How do you get people out of that? I'll come onto that in a second.

And the other is about empathic strain. I think it's really important. So, we can educate as much as you like. There's a really good example of the housing workforce becoming more trauma informed. So, we've had loads of really good training about that way of working from front-line local authority providers through to hostels. But yet the Shelter report, 'Trapped on the Streets', demonstrated that whilst awareness and knowledge of more empathic, compassionate and flexible ways of working, person-centred ways of working, is really high, there's an inability to behave like that because they feel constrained by, 'Computer says no. I can't do that; my manager doesn't agree. I can't do that; I've got too many on my caseload. I can't do that; I've got to follow the process.' So, the process, the way that we do business, hasn't caught up with the values that absolutely are there. But people are then just worn down, fed up and tired. If you are seeing homeless presentation after homeless presentation, and that's your job, you start to believe that the whole world's broken and you can't help anyone. And that becomes normal for you. We just don't invest in—and it's not expensive to invest in good clinical practice, which also comes to the point about competition.

So, if you've got a sector driven by competition, it means nobody can be vulnerable, so nobody can say, 'These are the lessons we've learned. Look at what a cock-up we made over here, we need to change it.' Nobody can be vulnerable, everybody has to be brilliant all of the time to keep their contracts and keep doing their work. Well, if you can't have a system that's vulnerable, you don't have learning cultures that shift and are agile and that can flex, unless you completely step outside of the system and are prepared to do something else.

That comes back to leadership. So, leadership. We absolutely, as a nation, should be setting out our stall and saying, 'These are the minimum standards we expect,' and then this comes down to commissioning. I'm sorry, but we have no idea how to commission for complexity. We just don't. We do not commission for complexity and, therefore, show me how you measure me, I'll show you how I'll behave. You can know that you are in a really not very good service—I saved myself then. You can know that, but actually your KPIs can be fantastic. So, you will just be seen to be doing really well and nobody will question you, because we don't have the rigour of a national standard as to what it is to behave like this.

Back to the point about complexity, which leads on from Lindsay's point, the silo mentality is alive and well, in case you hadn't noticed. So, I think in the health sector—I'm sorry, this isn't personal—it's about professional snobbery: 'You can't come here telling me about your people with mental health issues. Only we can tell you who's got the mental health issues.' Again, I come back to the children and adolescent mental health services—flying the flag—particularly in Gwent, they are doing amazing jobs of busting that mentality and actually spreading that knowledge, so that everybody can have some of that, because we know what we're dealing with, we just need the expertise to help it.

But just for that to be a warning sign as well, this silo mentality, that actually we mustn't believe in the homeless sector or substance misuse sector that only we have the solutions. So, if you are going to—. I agree with the case conference approach, but you need to take the learning from, for example, team around the family—

10:25

Where those things worked well, it was where the lead relationship was allowed to flourish. So, if that lead relationship is with the hairdresser or with the pastor, use them. It hasn't got to be the expert service who comes in and does the expert thing, and that's how we disseminate. We're in a batten-down-the-hatches mode.

Another point I just wanted to make, and it's my final point, was actually, though, despite the scarcity, health can do it. The blue-light system exists for pregnant women who have substance misuse issues. They can be blue-lighted through all the right services, because we want to protect that baby—

Doesn't it come down to deserving poor, though, again? This is a client group that nobody cares about, isn't it?

Yes, why can't we do the same? Yes, exactly. So, they can do it; they just don't.

A couple of points. I guess, for me, as somebody who has stepped outside the system, it's actually really quite fraught, and I've been ostracised by the health board, by a local authority and by other organisations. I had a smear campaign against me; the local authority were partly involved in that. I was really shocked, actually. You step out into something thinking, 'I'm doing good here,' and, actually, it's been difficult.

I think there's something about how you get funding to successful projects on the ground, because we had a ministerial visit, were offered rough-sleeper grant funding, and that was blocked by a local authority. They then gave that funding to another organisation to set up a health and well-being drop-in service for homeless people, which is what we were doing really successfully. That other organisation had the money and didn't actually set anything up. So, there's something about how we get in. At the moment we've had a year's funding and that will run out in March. So, for the first 18 months, we all did it as volunteers, because we were all really passionate about it. We then managed to scrape out a year's funding from the health board. That now finishes in March, so, potentially, the project folds.

Again, when you talk to people about funding, it's nobody's problem. It's, 'Well, this is not us, go to somebody else', and actually nobody takes ownership. So, for me, there is something about pooled budgets and a budget going from all organisations into a project, but who would make that happen? Because, actually, the organisations won't do that themselves. So, I think there's something about that, how you actually make good things sustainable and learn from that.

I think the big thing for me is if you have a national directive, it's how you change those attitudes and the culture, because that's really difficult to do, and I think that's a long-term process and you won't get quick wins from that. I'm really shocked, day to day, watching the way my peers in health treat these people. It's really quite shocking. So, SMS service, if you're 10 minutes late, you can apologise; you're 10 minutes late and you don't get your script for three weeks. If you get frustrated with that, you get banned from the service. It's shocking.

Housing. We've been working with the housing options team in our project, and regularly we're getting young men being told, 'You're young, male and healthy, you're suitable for the streets'. How can that even happen? So, there's that real lack of compassion and empathy. And I don't think that's a quick win—that's a long-term plan, really.

10:30

Thanks very much, Karen. Josie, and then I'll bring in Mark and Caroline.

Really, to build on that and to refer back to your point around what is the role for the national as opposed to the local, I think we recognise that local delivery and knowledge of local systems and the population locally is vital. But I think, from a national perspective, one thing to say is that I personally am supportive and think it's of benefit that the substance misuse is now within the mental health division within Welsh Government because at least that lends itself to greater tie-up. But none of these issues that we have talked about today happen in isolation. There are really embedded determinates of health and well-being, poverty, communities, I think. And, touching on the values point that you made, what I would like to see, and I think would be of benefit long term, is a recognition of the national role to set the priority agenda to say, 'No-one gets left behind'—

Absolutely. And I think that—. We know that rough-sleepers experience huge amounts of abuse and violence and everything else, separate from all of the other issues they're going through. There is a national role to set the culture and the values of Wales to say, 'We all matter'. Every person we leave behind has implications, both cost, if you want to put it in that respect—. Violence in communities and criminal justice, business—it all impacts. So, we don't leave anyone behind, and I think that is very much the role of that national agenda.

Do you think it was a mistake to ditch the priority need for prisoners, then, given what you've just said?

I think that we need to recognise that there are individuals who are already at a risk from birth—they're vulnerable from birth in the context of their setting, and I think that we need to recognise it. There are inherent inequities and we need to address those inequities in whichever way we can.

Yes, just picking up on several of the points that you've raised, and, for me, the proof of the pudding in Wrexham at the hub, which meets actually in premises donated by the Salvation Army, which is how it can go ahead—. Karen recently won an award from the police and crime commissioner. The Met police have been to see it, because they've heard such good things about it. The Department for Work and Pensions are in there alongside many others, and yet social services have excluded themselves on a technicality after a single incident. The question is what can we do in our recommendations to Welsh Government to encourage or even require statutory bodies—housing, health, social care—to be in the room, and, if there are issues, co-producingly finding solutions rather than excluding yourself in those circumstances.

With reference to neurodiversity, when we took evidence some weeks ago from a panel or group of rough-sleepers and former rough-sleepers, the group I was listening to repeatedly brought up the word 'Asperger's'. They self-identified. Many of them said they'd been diagnosed or they had relatives who had been on the streets who had been diagnosed with Asperger's.

Then you get into the issue about trauma—you know, chicken and egg. I work with large numbers of families with deeply traumatised children who've been denied assessment and diagnosis on the grounds that the parents need parenting classes. After they eventually, sometimes, win their fight for assessment and diagnosis and find that the children are on the spectrum, yes, they've got trauma—they've got trauma because nobody's taken the time to understand who they are, to identify their communication, sensory or social processing needs and have therefore dealt with them in precisely the wrong way, and they've ended up in the worst possible circumstances because of it.

And I think Dr Reid said, 'Where's the workforce and expertise?' Well, come to some cross-party autism group meetings or some cross-party group on disability meetings, you'll see where the expertise and the workforce is. I work with countless organisations and individuals in the third sector, some of whom are highly qualified professionals, who receive no statutory funding for the work they're doing, and desperately want to be able to do more to share that lived experience, training and understanding with statutory service providers. So, how can we actually do that? How can we ensure that we go forward on that agenda and overcome the assumptions and 'we know best because I've got a title' mindset?

And, finally, in terms of substance misuse interventions, as you know, we take a tiered approach, up to tier 4. A decade ago, there was a series of reports to the Welsh Government, commissioned by the Welsh Government, independently provided, stating that we needed a mixed menu of provision, including tier 4, for people with complex comorbid conditions. And yet, instead of the three model centre agreed with Drug and Alcohol Charities Wales, we ended up with only one, and that predominantly providing acquired alcohol brain injury services, but wanting to do more.

The Welsh Government set up a framework for referrals, most of which were to bodies in England, and yet most of the referrals ended up going to bodies in England, which were not on the framework, and now the framework has expired. So, how important is it, or not, for us to once again recommend effective tier 4 provision being provided through statutory-funded third sector or other providers?

10:35

Okay. Well, there's quite a lot there for potential response. I think I've got Lindsay first. Lindsay.

One of the Wallich values is to speak truth to power, and just to speak to Karen's point that there will be reprisals for me and the Wallich for being as frank with you today as I have been—just so that you're aware of that.

Tier 4, yes, we definitely need to improve access to tier 4, but, at the moment, my services can't get people through the assessment; we just can't get people through it. So, in some situations we're using legacy donations and things like that to pay privately because we just can't access the other pathways to get people into residential-based treatment.

We need engagement before assessment, and that can take such a long time. We need to do that, on their terms, from doorways. So, back to the point about mobile provision—going to see people where they are and orchestrating a community response around that so that businesses know what their role is in this, the police, education, everybody knows exactly what their role is in getting this alignment.

There was a point about priority need and prisoners—yes, that was a mistake. If we just got the prison pathway right, rough-sleeping would reduce by 40 per cent.

Complexity isn't understood. There are some local authorities and some practitioners who are driving forward strategies that they don't understand, and I mean that with the greatest deal of respect. In some places, for example, you've got an excellent housing benefit expert trying to strategise the complexity that all of us bring as people who've been around this block many, many times. That isn't acceptable, and it's not going to cut it. I would like to call for ministerial alignment across health, housing, social care and criminal justice, which I know causes some problems because of the devolution thing, but we are all being called on to collaborate and to work together. I call for that from Ministers, because, until that crisis of leadership is addressed, this isn't going to change.

Just on the justice issue, I know there's been the report about bringing justice into Welsh Government; it's desperately needed because, again, an agency like us, we have loads of different masters, but one of those is the Home Office, which is—. So, we have to do some things that the English Parliament, or the UK Parliament, is asking us to do and then other things that the Welsh Government is asking us to do. So, I think bringing justice into the Welsh Government would be much appreciated, because we can make sure we streamline what we're doing and make sure that there aren't the disjuncts that happen.

But, on the issue about tier 4—because as a member of DACW, a previous chair, I felt I ought to address that issue—it is definitely the case that tier 4 is chronically underfunded. I know that we've looked previously at—with CAIS, for example—the sad demise of Rhoserchan, which was near Aberystwyth, to try and resurrect that. And to try and talk to Welsh Government, actually, there is also—it's a terrible thing to say, but there is actually opportunity. If you provide really good residential services, you can actually get people from England to come across—I know it's a weird idea, but actually have people from England come across who actually pay for some of that accommodation. So, that is, in many ways, a work-creation scheme.

But it is really, really difficult in terms of getting—. For example, Brynawel is a good centre, but it was run by someone who, in my view, wasn't really fit for the job he was needing to do. They've got a new chief executive officer there who's a lot better. But, again, it's having the regulation about what the centre was for. And, because they were chasing funding, the problem was that they were trying to meet a whole range of needs. Well, actually, you can't do that within a relatively small setting. So, you need to have plans about what it is we want to provide with tier 4 services.

I think, for example, in the Wirral, there's a really good scheme, particularly with alcohol detox, where the accident and emergency department is plugged into the detox in the Wirral. So, the hospital—they go into the hospital, they're seen to be in a very bad way, but they can immediately be transferred to Birchwood, to the residential service there, where there are doctors and nurses who can assist them. But they're in the right setting rather than the wrong setting. So, I think there are radical things we can do there.

But, primarily, as you quite rightly say, Lindsay, there is very little funding for anyone with a drugs issue to get into a tier 4 service. It just doesn't really happen in any significant way. And if you're going to, you're going to end up in the psychiatric unit. A lot of people that we help do not want to end up in the psychiatric units, so they won't go to the so-called detox provision that is there. I know that it is an issue that is really a major one for DACW, which has now also linked with the mental health service Hafal to try and make sure we're addressing both the drugs and mental health issue.

I think, when you're looking at residential, we should have residential services that look at both the co-occurring issues, because it's very rare, actually, that someone who is needing residential does not have co-occurring, because otherwise there's no problem—we're normally detoxing them in the community anyway; that's an established pathway. And, actually, for the majority of the people, treating people and detoxing people in the community, providing day rehab, is effective. But there is a significant group who also need residential, and that needs investing, and it needs setting out what it is exactly that we are requiring. And I think that is—as you quite rightly say, it has to be mental health and substance misuse combined services, and not too big. My other big concern is that we create these very large organisations—not organisations, large bases; I don't care how big the organisation is. But, actually, smaller units, I think, are much better, both for the community and, actually, for the person receiving the help. If you're trying to put 50 people with dual diagnosis issues into a hostel or into a sort of rehab, that is not good in my view.

10:40

Can I ask a question about talking therapies? My understanding is that 60 per cent of all women who present to drug and alcohol services have a history of sexual abuse, which often they're self-medicating for. We talked about ACEs earlier on—a lot of this stuff is unresolved from childhood. It seems to me that there's very little connection between the services you're all providing and then talking therapies as a way of trying to either prevent substance misuse or mental health problems as a result of ACEs, or to try and deal with the traumas after people are presenting. Have any of you got anything to say on that? 

Just on—. As a substance misuse service, in the sense—we've got a range of services here. But we do try and invest in the training of our staff to be able to provide some of those talking therapies—cognitive behavioural therapy, motivational, et cetera. There comes a point where they can do some of that work, and then there comes a point where they need to refer to a specialism, and that then creates a problem. And it does go back to—

But they're disconnected. Shouldn't they all be connected up together—

Well, I agree—

—so that if you need a bit of that you can get it there, and if you need a bit of something else you can get it, and it's all—

Yes, absolutely. I'm totally in favour of integrated services. Obviously, it's going back to the point of if your first contact—. Your first contact is a really important person, who, in a way, can act as—call them 'navigators' or whatever else you want—who can navigate and work with you alongside to make sure you're getting to different services. But that person actually has to have quite a high skill level and needs to have at least some of the basic skills of talking therapy in order to actually talk enough to find out what the problem is, because, otherwise, if they can't talk to them, all they deal with is—in that silo mentality, I'll be going, 'Okay, they need to be on 60ml of methodone.'

But that's not quite the same as professional trauma counselling, is it? It's—

Yes, that's what I'm saying. I think it's having that initial conversation, working out where the complexity of that issue is, and then having an integrated service so that I can go to you and go, 'Actually, this person would really benefit from that talking therapy.' So, it is making sure everything's integrated, but it's also making sure that the staff on the ground who are receiving people are well qualified and well trained in order to make up a really good relationship that then can move them smoothly on, because the problem is people falling out of the system. So, I might have someone and I can go, 'Yes, it'll be great, I will ring up X at the women's council and they will set you an appointment at 3 p.m.' Issue closed. That never happens. So, that's the reason I'm saying about making sure that we're holding that person—very much like you were saying, Lindsay—and then making sure that we are physically, if necessary, taking that person to that next stage. So, I agree with you, we need to make sure we have got a proper, integrated system.

But it also means we need to have properly trained staff, and one of the big problems with this race to the bottom is that the people who are working with the most chaotic people, and that would be—. For example, hostel workers in the Huggard are often paid much less than my substance misuse workers. I don't know why that is, because, actually, they're dealing with people, for example, 24 hours, and my person's dealing with them for maybe 20 minutes. So, we need to make sure that, actually, we are not professionalising in the wrong sense but giving people access to skills.

A big loss we had—I think Welsh Government need to revisit this—is the drug and alcohol national occupational standards. We had this idea of national occupational standards, where, actually, when you're commissioning services, you don't just commission the service, you look at, 'What is the training that that agency will provide for their workforce to make sure they're going to be capable of meeting the needs of those individuals?' That isn't difficult to reinstate. The DANOS programme would be a national training programme to make sure that everyone working in the respective fields is getting the right and appropriate training, in order that we can make sure that we're dealing with people and making sure we're moving people. Because that's a skill in itself—moving people to the right services. Does that make sense?

10:45

It was a bit of a rant.

At the Wallich, we've been focusing on making all our services psychologically informed environments, or you might have heard the expression 'PIE', and that's very much about getting the relationships right, but also managing the external environment, so that it feels like home and it feels like a place for healing, not like a service and not like a temporary thing. Under the old Supporting People structures, the PIE work wasn't eligible, depending on which local authority wanted to be the most purist. So, I'm really hoping that when the housing support grant guidance comes through, the interventions with the most evidence behind them are going to be eligible under the funding streams that we need to access.

Also—I've lost my train of thought again. Sorry.

Don't worry, while you're thinking of that, Lindsay, Josie wanted to come in anyway.

Just to really touch on both the rehabilitation and the psychosocial support, going back many years, 25 or so years ago, I worked in Cardiff in what was referred to as a residential therapeutic community. So, within that, it was a 17-bed place for people who were identified as homeless, but also had complex needs, substance misuse and mental health co-occurring. All of the staff within that were trained to provide psychosocial interventions. We were all trained up, we were all experienced in substance misuse and/or mental health, and that model seems to have vanished in that period. So, I'm wondering whether that's something worth exploring, and I know the international evidence review highlighted therapeutic communities as a potential option.

But alongside that, I would absolutely stress that there needs to be a pathway from that. So, complex needs within a therapeutic community is one, but then, as you try to move people on, you then need to have the capacity for supported accommodation, semi-supported accommodation, independent living with daily support, and then independent living. There needs to be a progress, so people can have the time and the space and the interventions to move to independence, and to move on, quite literally, from services. There needs to be a pathway out, as well as a pathway in. But I would certainly suggest that exploration of the residential therapeutic communities is a possible option.

I've remembered. [Laughter.] We need to be sure that we're not asking staff members to operate outside their area of competence, so all Wallich staff are trained to work with anxiety, depression, the low-level stuff, and that's appropriate. But, actually, what we're seeing on the streets is a much higher level of complexity and illness, with people floridly psychotic, and in such levels of distress that we're getting phone calls back to central office saying, 'What do I do with this? I can't get anybody to help.'

10:50

Some of it's spice-related and some of it is just because they're really, really ill, and they've dropped out of the system as a result of 10 years of austerity.

I ask that because some of the service users we spoke to talked about the growing prevalence of spice, and the inability of services to be able to deal with that. In the same way as we've got used to working with people with alcohol problems or heroin problems, spice is a new one, and it just reminded me of what you said there, then.

It's really difficult, and a lot of the skills that my guys are using on the streets are reasoning-based. If somebody's frontal lobe isn't working—you can't reason with somebody who's totally unreasonable. So, that's really difficult.

We try to go a little bit rogue on some of the talking therapies stuff, because we were so frustrated that we couldn't get the right level of support for our guys. So, we launched something called the Reflections network, where we've commissioned a network of counsellors and therapists across Wales. So, basically, if someone goes in the night shelter on a night, we can have a therapist waiting for them by morning. That was oversubscribed within 48 hours. So, it's working really, really well, and we're really, really proud that we're able to offer that, but I guess my key message from that is that services like ours are constantly trying to find work-arounds for a broken system.

What we would like to see, speaking to Josie's point, is a micro-village model. We've got to stop putting people with complex trauma and this level of mental distress—lumping people together in institutions, which then retraumatises them, and retraumatises the people who are trying to help them, who have also often come through the system and have their own trauma. So, the levels of vicarious trauma that we're seeing at the moment really need to be addressed, and we really need proper clinical supervision, like Charlotte's suggesting.

If we worked with a micro-village model, almost like a therapeutic community, but on a housing first model, as well so that that becomes their home, and if they use on their premises, that's their home, so there's no reason to throw anybody out, and actually that becomes a hub then of support where the services come in. For the most entrenched people, I think that would work.

Just a couple of things. I wanted to mention the Bridge project, which an excellent example of taking people from the streets straight into an environment where they can detox. It's a partnership with Cardiff and the Vale health board. From what I understand, it's massively underfunded by the health board compared to what they need. However, it is successful—something like an 85 per cent success rate at getting people through the detox element into the therapeutic element. So, that is a homeless hostel in the city of Cardiff with a therapeutic element, so it's not like it's not possible—group therapy daily, talking therapies available; again, a service going over and above what it's commissioned for and drawing on its own resources, as the Salvation Army, but it does exist. And then they move people on with support into—. So, it's not like it can't exist, and whilst I agree with the lack of funding for tier 4 provision, we also need to recognise that people need to live in the environments in which they are then going to live, and so there is something about creating more—and that goes for rural areas as well as city areas—something much more contextual to your life.

Then, back on the point about psychologically informed environments, I was part of delivering that training to all housing and homelessness staff across Wales, and what the research on that is telling us is exactly the point that Huw made earlier about the reasons why this won't embed. It's not that the staff don't want it, believe it and need it; it's that, actually, it won't embed because the system cannot find a way to resource the proper expertise for those. And we are talking the difference between high eviction rates and no eviction rates, so you're talking about perpetuating the problems that you're trying to solve, or stopping the stem. So, I can't believe that the investment isn't less in needing clinical supervision, the right training for staff.

So, for example, I was once part of managing a series of hostels, and having been a social worker, I walked into this hostel where children were being brought back from out-of-county placements, because they were reaching their eighteenth birthday—so these were people who were in secure units, £4,000 a week, coming back to homeless hostels in their local area. So, what we didn't have in that hostel—but, of course, what we also had was a staff team feeling under siege, high turnover, low morale, very frightened staff, and we know nobody can change any type of behaviour if they don't have a safe base. So, if the staff don't feel safe and the people living there don't feel safe, it is just a cooking pot for more and more arrests, disruption and a spiralling upwards of problems.

So, when you know those things are happening now, today, and you know what the solution is, you really have to work hard on the cultural issues and the reasons why they won't happen—so, the race to the bottom, the need to be best, the lack of vulnerability, the lack of agility. Our need to maintain our own expert position is just so strong, people are very invested in those positions.

10:55

Keith, is there anything you might say at this stage in terms of the health board and the health sector, and the extent to which you recognise some of the shortcomings identified in the health service, or are some points that are relevant to the health sector being missed?

A lot of this argues, to me, for the necessity for pooled budgets in order to deliver. If we can agree on what the outcomes we're trying to achieve are, in the same way that we've been trying to do with adult social care, to actually get health authorities, local authorities and others, perhaps on a regional footprint, to actually agree pooled budgets to deliver those outcomes, and if that means certain types of support facilities—. So, beyond the integration of services to, actually, this idea of a model where you have therapeutic communities and so on. Am I wrong?

Well, I was going to come at it from even a half-step further back than that, which was about the commissioning process, which the health boards are an integral part of. So, what money—? I've heard a number of criticisms or observations that the health board is not putting in adequate funding for the services provided. There are a number of pressures on health board funding. Health board funding for homelessness or substance misuse services is competing with health board funding for joint replacements, for cancer services, and the like. And I'm not saying that's a justification for the behaviour or the relative prioritisation, I'm just using that as an observation that it's a difficult line to tread from the health board perspective. But that's all the more reason to tread it as best we can.

So, I think it comes back to the commissioning perspective, so understanding need, understanding models that are appropriate to address that need, thinking about commissioning for outcomes, maybe, rather than having very prescriptive service specifications to allow the flexibility to allow some of that innovation and vulnerability to flourish. And then, perhaps, trying to look at longer term commissioning programmes to provide stability in the sector to allow service developments. I think that's where I would see that, and the pooling of budgets and creating that financial stability would be an element of that. So, I think there's a focus on that as being a system response. That would be what I would say on that. And people can say, 'Well, yes, that's fine, Keith, but that's a very health-focused approach', in which case, I'm very welcome to say, 'Well, how do I need to develop my understanding?'

Can I ask a question in terms of priorities, just generally? I would have thought that preserving life would be the top priority. So, in this field that we're talking about here now, street homelessness, we're seeing suicide rates, we're seeing low life-expectancy of street-sleepers, we're seeing people die of alcohol and drug problems; one in five hospital admissions in Wales relate to alcohol; one in 10 deaths are alcohol-related. Surely, the money should follow that priority, in terms of preserving youth, young life. People are going to die eventually, but in this field, we are seeing so many people die so young. Shouldn't that be a driver in terms of where the budgets go?

Before you answer that, can I ask a related question, which follows on very much from that? You've talked about commissioning and competition for resource and, of course, there is competition for resource, but smart commissioning, in some of the ways we've heard proposed, fits the early intervention/prevention model and keeps people out of general practitioner surgeries, accident and emergency departments and hospital beds. And often a tiny sum, in relative terms, into these intervention projects, will generate multiple savings in terms of the NHS local health board budgets. Is that not the case?

It is the case. So, it's about creating a model of investment that recognises the return and accrues as a public good or to other parts of the public sector, not necessarily the ones making the investment. And that's sometimes the challenge. So, as a health sector or as a local authority, you're putting money into a system, but you're not necessarily receiving the financial or the public good benefit back to the bottom line of the council or the health board. We need to get beyond that, and I think the policy environment in Wales is probably ideal to get beyond that, but the culture in the various sectors hasn't yet got beyond that.

So, in terms of prioritisation, prioritisation is set, to a large extent, politically in the health sector; it's a very politicised sphere. So, you're all politicians—if you're wanting a higher profile for the sector, then there is an element that's within your hands to make the case for that—

11:00

Well, I always assumed that the NHS was about saving lives. Have I got it wrong, or is it only some lives?

The NHS is about saving lives. It's also about living longer and healthier lives. So, how does this issue impact on that, and what are the political or performance priorities that are handed to the health service by politicians and how do they align?

To go back to that ownership, and, again, who's responsible—that's a health problem, actually, because health are saying, 'Well, actually, the local authority should fund this', and the local authority is saying, 'Well, health should fund this', and everybody's passing the buck to somebody else to fund it, so nobody funds it.

There's a big problem with health accountability. We've got an elected health Minister, and then he always says that the boards are responsible for taking decisions, and there's a big disconnect in terms of accountability on that level alone, and I think that then filters down as well. But that's another discussion for another day, perhaps. Sorry, Lindsay, I know you wanted to raise—.

In terms of pooled budgets, I think, interestingly, Welsh Government have got a good model, because if you're looking, for example, at the out-of-work service, which is a Developing a Caring Wales thing, which we used to call Cyfle Cymru and then there's another one which is Gofal, and, anyway—. The positive there is, actually, because Welsh Government said, 'We want to see mental health and drug services work together', they've commissioned it in that way, and lo and behold, you've got, suddenly, Hafal joining DACW, you've got drug services thinking, 'We need to align with Gofal and other groups', and that actually drives that change. And I think that's what we need to be doing. You're absolutely right when you look at pooled budgets.

And going on to the housing first issue—a positive thing—I mean, we were aware of Wallich, but we hadn't particularly worked with Wallich until this commissioning of housing first. And because that's an integration of housing, mental health and substance misuse, suddenly—we've known each other for a long time—but, suddenly, I'm talking to Lindsay about particular opportunities and work, which we can then co-deliver with other partners. So, I do think the way—and this, in many ways, is what I was saying a bit earlier about trying to have a really focused approach on substance misuse treatment: people will follow the funding, and if they can see that that's where the money is going, then they will work together and the silos thing begins to break down.

Okay. I'm going to bring Josie in and, after Josie, perhaps we could talk a little bit more about housing first, because we've touched on it, but perhaps there are a few matters we might explore a little further. Josie.

It was really just, actually, more of a question. If we want organisations and systems to work together and use the funding to the best of their abilities, regardless of whether they directly see the benefits, and I'm very familiar with that—. At the moment my understanding is that different organisations have different outcomes and performance indicators to meet. If we had shared ones, then we would be forced to work together to achieve that outcome, and then failure from one system—one organisation or another—would be far more transparent.

I agree with you, and my only observation on that is: in order to get to that point, where we have shared priorities and a shared focus on what the essential outcomes that we need to do within this sphere are for the next five, 10 years, or whatever, those need to be actually done in concert together, and then signed off, and then align the funding—this is how it works—then you align the funding, and then say, 'These are the outcomes.' And then it means that you're not outside the box, because if you can deliver those outcomes, you're automatically somebody that gets got to, to say, 'Can you help deliver this part of it?' and so on. These are fundamentals of how your realign systems. So, it's not anorak-style, it's fundamental internal Government—how do you agree—?

When I was talking about national direction earlier on—not a national direction that is simply top-down, but a national direction that is agreed, that is long term and we get on with it, and we line the funding up so that everybody who wants a bit of that funding to deliver the agreed outcomes, they can then say, 'Well, we've got expertise, we can do this locally—we can do this.'

11:05

Oh—. I agree with you. [Laughter.]

Sorry, I need my reading glasses on. I meant Lindsay, sorry.

It's all right, my moustache confuses people [Laughter.] Just to speak to that point, what I would like to see is an increase in financial governance around how that funding is then distributed. And whether pooled budgets are the answer or not, that's not my expertise, but what I would like to see is a separation of duties between commissioning and delivering services. You can't be the poacher and the gamekeeper. We went for a lovely contract up in Anglesey and we didn't get it because the local authority awarded it to themselves. What are charities supposed to do with that?

Okay, thanks very much for that. Housing first—we have pilots in place. There seems to be a view that at least some of them are quite effective in terms of dealing with rough-sleeping and homelessness and the co-occurrence of the substance misuse and mental health issues. Could I take that that's a general view, that it's promising at this stage?

It's a bit too early to say, but what I would say, going back to the funding issue, is that I used to be on the Pobl Group's board, which was Seren and—. But in terms of work-wise, we did very little with them, because they're housing, we're substance misuse. Yes, there are people in their hostel that have substance misuse, but that's our job, so they have to come to our centre. So, really, very, very minimal stuff. What I found, for example, in Gwent, is that suddenly, the phone is being picked up by Pobl and being picked up by me going, 'Okay, how are we going to deal with this grant? How are we going to actually work together to make this happen?' And it's exactly the same as I was saying with the Wallich, when we were looking at a scheme in Swansea.

So, I think it's very difficult, except for Anglesey, which might have been going longer, but I think it's genuinely difficult to see how it works. But I think the fact that those conversations are happening at senior levels and then it's translating in terms of, 'We're looking at joint appointments for staff', that has to be a positive way forward. But I think you probably need to—housing first probably needs to come back in a year's time to go, 'Actually, this is what happened on the ground', because, at the moment, except for your scheme, it's very, very much in its infancy, isn't it?

I think the pilots that happened around housing first have been really, really positive, but it isn't a silver bullet. The concept of housing first still has to get past all the structural issues we've been talking about today. Housing first isn't about bricks and mortar, although that is central to give somebody accommodation; it's about the support that somebody receives within services. So, if there aren't integrated services on offer, you can't help people overcome the traumas that they've lived, you can't help people to put their lives back together again. So, housing first isn't a silver bullet.

Even in Finland, which has been hugely successful, they have different models of housing first out there. They still have emergency accommodation. When you speak to people in Finland about people with very, very complex needs, they say, 'Why would you put people like that out into the community?', because their housing first model has different accommodation units for people with complex needs. They are self-contained units in a block, very similar to some of the supported-people accommodation we already have in Wales. So, it's looking at the principles behind that, but it's also looking at the support that goes into that; it's not just about bricks and mortar. We do need more social housing, we do need better support for people who are living in the community, but this is about aligning services and making sure that we've got the right support for people, no matter what accommodation they're in.

And just by putting the words 'housing first' above the door doesn't make that project work. It's about the actual support that people get, whether they're in a unit with 10 other people, whether they're in a shared house, whether they're in a self-contained flat out in the community—different accommodation models are going to suit different people differently. But it is the support they get that's really important.

We ran the first housing first pilot in Wales. It's in its eighth year now, up on Anglesey. Just to give you an idea of the outcomes from that: so far, we've supported 151 people, 74 per cent of them were successfully housed, and 51 per cent of them are still there. So, we're really pleased with those outcomes. Like Richard said, it's not a silver bullet. The problem that we find on a small island like Anglesey is that we're running out of the really cool landlords that will give people a chance. We put people in their homes, we stabilise them, we withdraw support—that remains their home. We're running out of landlords that will give people a chance, which brings me on to the substance misuse policies of housing providers, particularly those who are offering social housing.

We need to make it safe for them. We need to fully accept that if we are going to use housing first with people who are still in the throes of addiction, they will use substances in their home. That is going to happen, which puts a landlord at risk under section 8 of the Misuse of Drugs Act 1971. We need to remove those risks for landlords, because people are still talking about this. I share your eye-roll, Josie, because we should be well past this by now.

11:10

That's a Westminster legislation issue, though, isn't it?

It is, aye, but we have a joint working protocol with the police that makes it very clear under what circumstances they will pursue a prosecution and under what circumstances they just want us to get on with it. And even now, there are housing associations that won't accept that.

On that very point, at the end of the third Assembly, in a similar inquiry, we took evidence regarding what were then embryonic social letting agencies. There was one in Dolgellau that was housing the people whom landlords didn't normally want to house because of the risks, and taking that risk away. It was set up as a social enterprise, as an initiative of the then National Landlords Association. It became a non-profit social enterprise, and in the early days, when we took evidence, it was hugely successful.

But, on the back of that, instead, we got the roll-out across Wales of private rented sector access agencies—some local authority, some housing association—that were a good thing in the sense that they extended potential social and affordable supply, but they didn't remove the risk, and, therefore, the same problems were being encountered that you highlight. So, could we be looking at something like the social letting agency model, whichever sector ends up running it?

We could, but I think we're back to our old crisis of leadership again. The Welsh Government has a degree of jurisdiction over housing associations, to a point, in terms of the standards that they're regulated against. That's great. But when it comes to issues like this, they are literally tigers with no teeth. Welsh Government are as frustrated with these developments as I am.

Yes. Yes, so it would work in PRS, but we've still got housing organisations that hold too much power, which are taking public money and then picking and choosing who they house. I don't think that's part of the deal.

Can I follow up with a question on that? We've had information that there are 200 people released from Cardiff prison every month, and 47 per cent of those people come out without a home. I wouldn't know how many of those would be sex offenders, but I would guess a significant percentage of them would be. Are there any specific housing first accommodation blocks for sex offenders, where they could perhaps receive ongoing treatment—from probation officers, perhaps, or other third-party agencies? Or are these people just coming out of prison and potentially being on the streets, and nobody knows what risk they pose to anyone?

My frustration—[Interruption.] Sorry. Go ahead.

There is certainly supported housing at the moment that's funded through the Supporting People programme that will meet those needs out in the community.

They do exist, and, yes, they hold some of the principles of housing first. They don't necessarily run via the banner of housing first, but they certainly follow the principles of housing first. The idea is that people are in that accommodation until they can be stabilised, until they're ready to move on to independent living, which is the only break with housing first. The idea of housing first is that people can stay there as long as they like. So, we need a balance there, because we need a housing model that is sustainable.

Unless you've got an ever-expanding social housing provision that can just take people, let them live there for as long as they want to live there, and the next time somebody comes out of prison, you're finding another social housing—. There is that move-on need at the moment within the current provision. Because, in order to have housing first, you have got to have housing first, and that's what we don't have in Wales.

Just sticking with prisoners for a moment, a pathway is in place, and I think Welsh Government has told us as a committee that efforts have been made, and are being made, to make sure that that pathway works more effectively, given that that is the new preferred method of ensuring that people who come out of prison have somewhere to live—Welsh Government's preferred method having ended automatic priority need for prisoners. Do you have any sense that that pathway is starting to succeed and does it address these co-occurrence issues? Lindsay. 

11:15

It all exists on nice flow charts and drawings, but the reality of the practice is very, very different. We are seeing unacceptable levels of people being released into homelessness, and one of the things that could alleviate some of those pressure points is looking at the universal credit regulations around how long somebody's property can be held for, because we're seeing people on very short sentences going past that 13-week threshold, losing their accommodation, coming out street homeless, and, actually, we're all paying for that crime because it costs an absolute fortune. So, that's one very simple change that could be made for how we hold the accommodation of people on short sentences that would have quite an early impact.

I mean, certainly, one of the biggest problems is release on a Friday because although services should be seven days a week, they're not in reality. So, trying to deal with the issue when someone comes out at five o'clock and by the time they get to you your service is closed is a really, really problematic thing. So, there needs to be something along the lines of—. I've raised it with the Home Office. I'm part of this thing called RR3, and they keep saying, 'We know it's a problem but we can't do anything about it.' And it's one of those things where you go, 'We need to have—.' If they're going to continue to release on Fridays, it does mean that we need to have services on Saturdays. It's not so bad in Cardiff because it's a bigger city, so, actually, it's sort of—

It depends who you are.

No, sorry—. It's not great in Cardiff or in Newport or in the cities, which is where we're focusing on rough-sleeping, but it's ten times worse if you're providing services in Powys because obviously services are much tighter in the amount of staff they have. So, actually, to get them to see anybody is virtually impossible. So, all I'm saying is that the release is a real problem. It's a problem in every city area. It's very, very difficult to get them housing, very difficult to get them a script, but it is one of those things: where you're in a more rural community, it is times 10.

It is difficult to understand why they couldn't be released on a Thursday. 

I just can't get my head around why—

They don't release on a Saturday and Sunday, do they?

No, that's right, just Friday.

So, they could just stop on a Friday as well, surely.

Yes. It's to do with sentencing. They did explain to me why—. In terms of the weekend, it creates a bigger problem for them in terms of their sentencing. 

Just very briefly, Public Health Wales have been commissioned to develop the substance misuse treatment framework for prisons in Wales. So, we are in the process of writing the gold standard, which includes full, appropriate development of information systems such that their discharge notifications are part of and everybody is informed. It's a huge piece of work, as you can imagine, certainly that part of it. But just to note that in the first two quarters of 2020, we will be doing stakeholder—and listening to all of that. So, very mindful that discharge and homelessness post prison release and referral back to prison fairly rapidly is very much on that agenda.

It's just a quick point, really, to elaborate on the through-the-gate services, that the way they were commissioned meant that it's a numbers game so that they're often having to deal with too many cases than they can get to within the time frame within which it would make a different. So, that's why—. And often the sentence bit exacerbates that. If you're on a short sentence, by the time you've got a through-the-gate worker in, you're out. 

But nobody's seeing any improvement at the moment, really, are they? Is there?

There is improvement. I think the police and crime commissioners have been very good in terms of—. I only can talk about the treatment side of things, but they have linked much better with the treatment providers, and, actually, by taking more responsibility, it does mean, like Dyfodol, it would mean that people would get access, on the whole, to treatment. They've still got to get to us, but it's by far—. It's not where it should be, but if you're looking where it was three or four years ago, it has improved. So, people like Alun Michael and Arfon Jones have actually made a difference in the way that they've commissioned services.

That's your substance misuse services, but in terms of rough-sleeping, is there any improvement in terms of prisoners coming out and having somewhere to live? Through the pathway, is anybody seeing that? No.

11:20

At the Wallich we used to freak out if we were over 20 rough-sleepers in the morning on breakfast run. Now we're seeing more than we can count. That's not an improvement, that's a disaster and a human crisis that we need to deal with now.

I want to just pick you up on that point, really. Our hub runs on a Friday, so we get lots of people. We get about 60 people, on average, using the hub every Friday, and we get lots of people coming out of custody on a Friday. Our biggest problem is we have no paperwork. So, they turn up, they've had a medication change while they've been in, all sorts of things happening, and we have no information. So, even as their registered GP, I can't access information. So, then we're under pressure to prescribe because then they'll come out with no medication as well. So, we have to prescribe and we actually don't know what they're on and can't find out what they're on. So, we're having to sort of guess—

But that's only relevant to prisoners who've served under 12 months, though. So, surely, anybody over 12 months, or anybody who's a young offender, would come out with a probation officer who should be able to help with all of that.

I mean, a lot of these chaps just turn up, not necessarily with somebody. And they're saying, 'This has changed, I need my medication', and we have no information.

Just another point, I guess, on that, with integrated working, one of the biggest problems we're having now is people being really overcautious about the general data protection regulations, but also not having a data-sharing platform. So, we've been trying really hard, because I'm a cluster lead as well, to try and develop something. Obviously Welsh Government have invested in the Welsh community care information system, but GPs aren't, primary care aren't involved in that. So, we've actually got mental health, community nurses and social services all linked up, potentially, when it does come in, but primary care aren't linked in and we hold more data, probably, on individuals than anybody. So, there's something around how we bring in some sort of data-sharing platform.

I know that WEDFAN have piloted something down here, which has been really successful, and I don't know whether that's going to be rolled out. I'm not sure. But they've actually developed some tech that does apparently meet all the—. They tick all the right boxes and actually allow you to share data with different agencies, including third sector. So, for us, that's a huge gap at the moment.

Okay. Well, we could make some inquiries on that front. Huw.

Can I ask what seems like a very niche question? Because we should be looking at the ex-custodial population as a whole and making sure that they are offered the right wraparound solutions, both in terms of accommodation and support. But the estimate suggests that roughly one in 25 of those people leaving in prison are armed forces, ex-service people. We were just discussing this before you came in. I was checking, 'Are they still a priority need?' And we looked, and we think they are. It's written in legislation that ex-forces people are a priority need for housing.

Do you see any difference, from your experience, in the way that ex-forces people being released from custody, released from prison sentences, are being treated within the accommodation provision by local authorities and other housing providers locally?

I don't have the figures off the top of my head, but we are seeing a lot fewer veterans rough-sleeping than you would expect. I don't know what your observations are.

I think it's because they're being prioritised.

We did some research about seven years ago looking at the instance of people accessing low-threshold services in Cardiff who had been in the armed forces, and at that point, we were looking at 13 per cent, I think, of people. That figure has significantly dropped. So, we are seeing fewer people in the armed forces coming through our doors.

Could I ask one final question, please, and that's the extent to which proposals set out in the Welsh Government's substance misuse delivery plan—and, indeed, the forthcoming 'Together for Mental Health' delivery plan—the extent to which you think they'll be effective in addressing the issues that we're discussing? I know the latter is, I think, still out for consultation, isn't it? But in terms of the contents, the direction of travel of both, are they on the money, as it were, in terms of achieving the sort of progress that needs to be made?

I think the to-do list is on point; I think the environment in which we expect those things to be achieved isn't. They're the real things that we need to address, and we've kind of done them to death, I guess, this morning.

Okay. So, in terms of their content, it's probably along the right lines, but in terms of making sure that underneath that, those who would be tasked with delivering the services, the commissioning systems, and the resources are in the right places and designed in the right way to enable it to happen.

11:25

I really hope we're not sat here again in three years having the same conversation, because I suspect we will be.

It's the structural issue. I think the positive is it's more of a harm-reduction approach, so it should mean that we are able to prioritise those who most need our services, going back to the point about, actually, when you do put in a policy initiative, like the veterans one—that was a real surprise to me as well as to you—that there seems to be a really positive impact. I think, if there's more priority on low threshold, that will help the rough-sleeping community in particular, because they're the ones who are furthest away at the moment from treatment.

But, I do think that if you're not going to address the commissioning issue, you're not really going to get much change, because what I see on the ground is that certainly longer term commissioning is better, because it takes away the competition. Competition is not normally a positive, because that means if I'm competing with the Wallich over a service, I'm going to be, over that period of time, not talking so much, because I'm trying to protect my little bit of space.

And possibly crying at the end.

Exactly. So, think longer term commissioning, longer term planning. But I do think you have to address the structural issue, and I think that isn't really addressed, because it's still giving it back to area planning boards.

Just on the mental health strategy, I think we feel hopeful, given the progress in child and adolescent mental health. I know I've said that a number of times, but I just think it's so important, because what they've done is invest. With the transformation fund, that's enabled the current system to exist whilst you create another one. So, you haven't got the challenges that you talked about in, 'How do I prioritise in the context of scarcity?' But I think we're looking forward to once this delivery plan is over and we can influence the next one, so that we see the trauma-informed paradigm shift in adult mental health services that just isn't there, and we're not necessarily confident it will happen in the next three years.

Okay. Well, thanks very much, and thanks to all of you for coming in to give evidence to the committee today. You will be sent a transcript to check for factual accuracy. Diolch yn fawr.

3. Papurau i'w Nodi
3. Papers to Note

Okay. The next item on our agenda today is papers to note. We have three papers—papers 4, 5 and 6. The first is correspondence we sent to the Minister for Housing and Local Government, and that's on rough-sleeping in Wales.

Paper 5 is correspondence from the Deputy Minister and Chief Whip updating us on work done to improve transparency on equality data published by Welsh public bodies, and that relates to our work on parenting and employment. That's a positive development. 

And paper 6 is correspondence from the ombudsman, providing additional information following our recent annual scrutiny session. Is committee content to note those papers?

4. Cynnig o dan Reol Sefydlog 17.42(vi) i Benderfynu Gwahardd y Cyhoedd o Weddill y Cyfarfod ac ar gyfer Eitemau 1 a 2 o’r Cyfarfod ar 21 Tachwedd 2019
4. Motion under Standing Order 17.42(vi) to Resolve to Exclude the Public from the Remainder of the Meeting and Items 1 and 2 of the Meeting on 21 November 2019

Cynnig:

bod y pwyllgor yn penderfynu gwahardd y cyhoedd o weddill y cyfarfod ac ar gyfer eitemau 1 a 2 o’r cyfarfod ar 21 Tachwedd 2019 yn unol â Rheol Sefydlog 17.42(vi).

Motion:

that the committee resolves to exclude the public from the remainder of the meeting and items 1 and 2 of the meeting on 21 November 2019 in accordance with Standing Order 17.42(vi).

Cynigiwyd y cynnig.

Motion moved.

Item 4 then is a motion under Standing Order 17.42 to resolve to exclude the public from the remainder of this meeting and items 1 and 2 of the meeting on 21 November. Is committee content to do so?

Thank you very much. We will move into private session.

Derbyniwyd y cynnig.

Daeth rhan gyhoeddus y cyfarfod i ben am 11:28.

Motion agreed.

The public part of the meeting ended at 11:28.

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