Y Pwyllgor Plant, Pobl Ifanc ac Addysg - Y Bumed Senedd
Children, Young People and Education Committee - Fifth Senedd26/02/2020
Aelodau'r Pwyllgor a oedd yn bresennol
Committee Members in Attendance
|Dawn Bowden AM|
|Hefin David AM|
|Janet Finch-Saunders AM|
|Lynne Neagle AM||Cadeirydd y Pwyllgor|
|Sian Gwenllian AM|
|Suzy Davies AM|
Y rhai eraill a oedd yn bresennol
Others in Attendance
|Carl Shortland||Uwch-gynllunydd Iechyd Meddwl, Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru|
|Senior Planner in Mental Health, Welsh Health Specialised Services Committee|
|Carole Bell||Cyfarwyddwr Nyrsio, Pwyllgor Gwasanaethau Iechyd Arbenigol Cymru|
|Director of Nursing, Welsh Health Specialised Services Committee|
|Dr Alberto Salmoiraghi||Seiciatrydd Ymgynghorol a Chyfarwyddwr Meddygol Iechyd Meddwl ac Anableddau Dysgu, Bwrdd Iechyd Prifysgol Betsi Cadwaladr|
|Consultant Psychiatrist and Medical Director for Mental Health and Learning Disabilities, Betsi Cadwaladr University Health Board|
|Dr Annmarie Schmidt||Seiciatrydd Ymgynghorol, Bwrdd Iechyd Prifysgol Betsi Cadwaladr|
|Consultant Psychiatrist, Betsi Cadwaladr University Health Board|
|Hazel Powell||Cyfarwyddwr Nyrsio’r Uned, Gwasanaethau Iechyd Meddwl ac Anabledd Dysgu, Bwrdd Iechyd Prifysgol Bae Abertawe|
|Unit Nurse Director, Mental Health and Learning Disability Services, Swansea Bay University Health Board|
|Joanna Jordan||Cyfarwyddwr y Rhaglen Iechyd Meddwl Genedlaethol, Rhaglen Gydweithredol GIG Cymru|
|National Programme Director for Mental Health, NHS Wales Health Collaborative|
|Sharon Fernandez||Arweinydd Clinigol Cenedlaethol ar gyfer Iechyd Meddwl Amenedigol, Rhaglen Gydweithredol GIG Cymru|
|National Clinical Lead for Perinatal Mental Health, NHS Wales Health Collaborative|
|Sian Harrop-Griffiths||Cyfarwyddwr Cynllunio a Strategaeth, Bwrdd Iechyd Prifysgol Bae Abertawe|
|Director of Planning and Strategy, Swansea Bay University Health Board|
Swyddogion y Senedd a oedd yn bresennol
Senedd Officials in Attendance
|Sarah Bartlett||Dirprwy Glerc|
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 09:33.
The meeting began at 09:33.
Good morning. Can I welcome everyone to the Children, Young People and Education Committee this morning? We've received no apologies for absence today. Can I ask if there are any declarations of interest from Members please? No? Okay. Thank you.
We will move on then to item 2, which is our first evidence session for our follow-up on our perinatal mental health inquiry. I'm very pleased to welcome Sian Harrop-Griffiths, director of planning and strategy from Swansea Bay University Health Board; Hazel Powell, unit nurse director, mental health and learning disability services at Swansea Bay University Health Board; Dr Alberto Salmoiraghi, consultant psychiatrist and medical director for mental health and learning disabilities at Betsi Cadwaladr University Health Board; Dr Annmarie Schmidt, consultant psychiatrist at Betsi; Carole Bell, director of nursing at the Welsh Health Specialised Services Committee; and Carl Shortland, senior planner in mental health, also at WHSSC. Thank you all for your attendance this morning. We've got a lot of ground to cover, so we'll go straight into questions from Siân Gwenllian.
Byddaf yn siarad yn Gymraeg, felly rydych chi angen eich clustffonau.
Bore da a chroeso yma. Mae'r pwyllgor yma wedi bod yn bryderus iawn am yr amser mae hi yn cymryd i sefydlu uned mamau a babanod yng Nghymru. Roedd y pwyllgor yma wedi argymell bod hynny yn digwydd nôl yn Hydref 2017. Rydym yn falch iawn o glywed bod yna ychydig o gynnydd wedi digwydd yn ddiweddar, ond mae dal yn mynd i gymryd o leiaf pedair blynedd o gychwyn y broses i ni weld unrhyw fath o gynnydd ar lawr gwlad efo'r mater yma. Dwi ddim eisiau treulio lot o amser ynglŷn â chi yn ceisio esbonio i fi pam ei fod wedi cymryd gymaint o amser. Beth yw'r gwersi i'w dysgu allan o'r arafwch mawr yma sydd wedi digwydd? Efallai allwn ni ddechrau efo WHSSC.
Good morning. I will speak in Welsh, so you will need your headphones.
Good morning and welcome. This committee has been very concerned about the time that it's taking to set up a mother and baby unit in Wales. This committee did recommend that that should happen back in October 2017. We are very pleased to hear that some progress has been made recently, but it's still going to take at least four years from the start of the process for us to see any kind of progress on the ground with this issue. I don't want to spend a lot of time with you trying to explain to me why it has taken so long. So, what are the lessons to be learned from the tardiness of what has happened? Maybe we could start with WHSSC?
I think the lessons to be learned are that we need to be aware of different processes that apply across Wales. Clearly, back when the report was issued, the establishment of the unit was a priority and it did make direct relation to funding being available. We subsequently had to go through various processes that are set out to establish both the revenue and capital streams. There are separate arrangements that we need to follow and there was also quite a number of challenges related to location and demand, and we had to go through all these processes and, ultimately, it has taken longer than we would have hoped.
I think it's really important, the issue, in terms of demand, because we do know that there was a mother and baby unit within Cardiff and the Vale previously and that had closed, and we needed to give the joint committee of WHSSC the assurance that there was a need for mother and baby provision within Wales, and that took some time in terms of making sure that we could look at the epidemiology, look at the numbers of placements that we had, and what that meant for us in terms of being able to make sure that they fully understood and agreed to the provision of that mother and baby unit.
But the evidence was there from the committee's work—that there was that need in Wales, and it was quite clear to everybody. Why did you have to spend so much time doing that bit of work while, surely, the need was established and the ball should have started rolling about providing the provision?
So, I guess the question is more about the number of placements that we actually have. So, when you look at the number of mothers and babies that have been placed in mother and baby units, that's significantly less than what we would have expected.
Yes, because they're not going. They don't want to go over the border to England. They don't want to leave home—they don't want to leave their babies, so they're not actually going and taking up the provision that's not there in Wales.
Just before you move on a second, Siân, can I just ask, because I think it is important for the committee to understand the process that has taken such a long time: when you appeared before the committee in the summer of 2017, we were told that a decision was imminent in July—that the decision was going to be taken on the various options then. Yet, it took until 1 June 2018, almost a year later, before expressions of interest were sought for the mother and baby unit. What happened in that year that meant that we saw that huge delay right at the start?
That was around looking at the clinical model—looking at the different ways and the number of units that would be needed in Wales, and then when we went out for expressions of interest to the health boards, they themselves had to go through internal processes to look to see if they would be interested in expressing that interest and coming forward in terms of wanting to deliver that service.
I think some of the early work—. Clearly, the committee's report was published in October 2017, and some of the early work was around looking at the options for potential delivery. So, a single service in south Wales, clearly, is going to still have some of the issues that we face at the moment with patients having to travel significant distances, and so some of the early work was looking at alternative options. It was visiting other units in NHS Scotland to try to establish the different ways of being able to provide a service across the whole of Wales.
Ultimately, it was felt, through the clinical teams, that a single service was actually probably the only viable alternative that we had, and that is what some of the early delay was around—it was to try to determine what the options were before we could go to the health boards with an outline of what we expected them to deliver.
So, it seems it took a year just to establish what the committee had established already. Anyway, we'll leave it at that.
Looking at the timeline, there seems to have been a lot of to-ing and fro-ing between the temporary model and the long-term model, and then changing minds—not going that way, going that way. Did that lengthen the whole process, because there were two models going on at the same time? Maybe Abertawe.
Yes. So, first of all, can I just say thank you for giving us the opportunity to come and talk to you today? We're really pleased that we're going to be developing the mother and baby unit in Tonna.
I suppose, just to say, we deliver primary, community and secondary mental health services for our local population, but, as you know, we deliver some specialist mental health and learning disability services as well, so forensic psychiatry, for example, and also learning disability services for ourselves, Cwm Taf and Cardiff and Vale health boards. We think that this opportunity will really help us build on those strengths, so we're really pleased to be able to do that.
Clearly, we are part of WHSSC, in that we are one of the health boards that is a commissioner, but we're also the provider as well. So, what we've been doing is working really closely with WHSSC and the other health boards, in terms of working through the service model, and then looking at what is the best option, and so responding to the requests from WHSSC to look at an interim model, or also the permanent model. So, we've been working through and developing the business cases around both of those, and that does take some considerable time. So, as you say, there has been some to-ing and fro-ing about whether there should be interim or permanent solutions. So, what we've been doing is working up the options and the business cases that would support either the interim or the long term.
Yes, exactly—it seems to have created that confusion, and maybe it would have been better to get on with the interim and then be planning longer term for the longer term solution, rather than looking at both models at the same time. Would you accept that that would be a lesson to be learnt?
Absolutely. The issue is that, I think, initially, we thought that the longer term model was not going to come in that much different to what an interim model was going to be. So, there was probably less than a year, in terms of that timescale, at one stage, and therefore a decision was made that the preferred option would be to go with the longer term model for the sake of a 12-month period. However, when that planning was done, it came out that that timescale slipped considerably, and therefore we needed to rethink about the interim model alongside that.
I think, certainly, in the early part of the process, we did go through stakeholder engagement and a consultation process. And, clearly, a new-build service was the preferred solution from the stakeholders at that point. So, we did proceed on that basis, and it was only when the indicative costings started to come back, and the timescales, that we had to look at an interim option, because both the cost and the timescales for a permanent solution were in excess of what originally was envisaged when we set out in June 2018.
I think what we should say is the reason for the timescale for doing a new build, as opposed to the interim solution, is because of the time it takes to go through the business case process, because it is a really robust business case process, where we obviously have to do a lot of work internally, in terms of the service model, going out to tender, going to out to write the business case, getting it through internal approvals within the health board, getting it through the WHSSC approval process, and getting it through the Welsh Government capital process. So, it's the time. So, it's the scale of the cost, which means that the business case process is that much longer.
And do you think that that is why you're the only health board who's willing to take on this challenge?
I know that there were two health boards that expressed an interest initially. I don't know why Aneurin Bevan withdrew their expression of interest.
Can you throw any light on that?
I think that was around the timescales that they felt they weren't going to be able to deliver the service at that time. They felt that it was outside the timescales that we had expected to be able to deliver a service, and that they were unable to. However, when you ask about some of the challenges, I would say that it is a challenge in terms of working through individual organisations' processes, from putting business cases together, having to approve them internally, and, then, of course, WHSCC don't have—. So, we don't secure any capital revenue, so that has to be done to the health board. So, which comes first? Do you secure the funding? Do you secure the capital? So, there's a little bit of balance that goes there as well, and that is a challenge.
A allaf ofyn i fwrdd iechyd Betsi pa mor—? Faint o ymgysylltu sydd wedi bod efo chi yn ystod yr holl broses hir yma o gyrraedd lle'r ydyn ni heddiw?
Can I ask Betsi Cadwaladr health board how much engagement has there been with you during this long process of reaching where we are today?
WHSCC has engaged with the health board. Both Dr Schmidt and I were not directly involved at that time. But there has been engagement with the director of mental health, who, unfortunately, is currently off sick; he was supposed to come here to give you further details with regard to the engagement in the process.
At that time—you are right; we are going back to 2017—the position that we were in with regard to the perinatal services was that we were starting to develop it from a clinical point of view, and we had some problems in finding the expertise in employing people. That is something that probably my colleagues found the same, because it's a very specialist field. And we have been lucky enough to have Dr Schmidt, who is one of the few consultant psychiatrist experts in perinatal in the UK, I would like to say, and Dr Myers, who is possibly one, or arguably one of the few expert clinical psychologists in perinatal, with a long experience in perinatal services.
So, at that time, it was a very embryonic service that was developing, and we were hungry for data to understand the demand. And that is something that I'm afraid is a Welsh problem. We are very much based on paper rather than an electronic system, and there has been significant delay for the electronic system that I think is important, because planning services with no data is incredibly difficult. And I'm talking in this case as we are responsible for the strategy and service redesign. So, it's not only applicable to perinatal services, but in general.
So, I'm not saying that is a guessing—[Inaudible.]. So, you need—. What we initially listed was to understand our reality and our demand, and to create our own database of clinical cases that will inform the future of the services in north Wales. And so, we did. And like my colleague, I want to thank you for the possibility of being here, because now we can have a much better scenario and data to substantiate any kind of decision, at least for north Wales, and for north Wales matters. So, the engagement happened—a different level than us, I have to say. Perhaps Carole can comment further.
I can pick that up. We did have a number from north Wales on our stakeholder group when we initially started to look at the options. And we had Betsi Cadwaladr health board representation at all of our clinical workshops, and we have both management group and joint committee, which is an internal process within WHSCC. The chief executive of Betsi sits on the joint committee, and we have two senior planners and finance, who sit on the management group from Betsi as well, from the management group. So, Betsi have been very much involved in both the development, the planning, and, then, the decision making throughout.
Okay. But a lot of those have been different people. That's not your problem, but that's the truth of the matter. You're new to the situation; there have been other people all along, but that is a problem for the health board rather than WHSCC.
I think I'd just like to add as well that, as part of the process, I talked about developing different options. WHSCC have engaged extensively with NHS England regarding access to services for patients from north Wales. This has been ongoing since 2018, and, unfortunately, there have been quite dramatic changes in the organisational structures and commissioning arrangements in England. And we did have, on the table very early on, the possibility of looking at developing services with the Cheshire and Mersey area, but due to the changes in NHS England, all those developments are on hold whilst they go through their structural changes. They're creating something called 'provider collaboratives', where a single organisation is going to lead across the whole mental health pathway, and until that's put in place, they said they weren't able to progress those discussions any further with us.
And if I may comment further. That was my understanding—that there was a plan to develop some provision of a mother and baby unit for north Wales, jointly with the north-west region. And we embraced it. We thought that was a solution, because there is a clear need in north Wales for an MBU. But, of course, with the change in the position of NHS England, I think we need to review the position for north Wales.
Can I just ask, on that point, is this an interim solution, or a permanent solution—[Inaudible.]—north-west England?
A permanent solution.
It will become permanent, potentially, yes.
Can I just ask, Dr Schmidt, how frustrating is that for you? That there are still—
It's extremely frustrating for the team on the ground, not having a mother and baby unit that our mothers can access easily. And we do have a lot of mothers who refuse to go. So, our nearest mother and baby unit is Wythenshawe Hospital in Manchester. So, that's the one we like to use, but if it's full, we have to go further afield to Birmingham, Brockington, both of which we do use. And, sometimes, our mothers just refuse to go altogether, because, depending on where you live in north Wales, Manchester would be one to three hours' drive, and, obviously, if Manchester is full, it's a much longer drive.
So, a couple of weeks ago, we were looking for two beds, and the only bed in the whole of the UK was in Morpeth, which is more than four hours' drive from north Wales.
Where is that?
It's in the north—. I had to look it up myself on Google. It's in the north-east of England.
Yes. So, both patients refused to go, and the one still isn't in an MBU, and the other one has now gone to Brockington. So, if we have a mother who needs to go, it's always a difficulty. There's the odd occasion where we decide that somebody needs to go, and we can get the bed in Manchester, and they go the same day, but that's quite rare.
Okay. We'll come on to the connection with the new provision, and hopefully, that can help.
Just to clarify, obviously, that was one of the committee's recommendations, was that a unit be established, even in north Wales, or over the border, in collaboration with NHS England. Suzy, you had a supplementary.
Well, precisely; it's from, let's say, Caernarfon. That's a four-hour drive to Tonna as well. So, the same risk is still present, despite the fact that it would be an all-Wales service. Obviously, I'm delighted to have it in my patch.
We're very aware that the MBU in Swansea is not going to improve our situation, because I've also looked at the distances, and, from wherever you are in north Wales, it's going to take three to five hours to get to Swansea. So, I think, if our mothers are refusing to go at the moment, I think it's very doubtful that Swansea will be—
And how much data have you got about mothers refusing to go?
We know exactly the number, actually—
I think, we're probably—
We are going to come on to that.
But if you could answer that question, it leads on beautifully.
It's just on my mind.
Okay. Can I complete that with regard to the Swansea option, of course? When the engagement happened with WHSCC, and working with Betsi, the direction of travel was about the geographically natural north-west. So, north Wales is geographically naturally connected to the north-west region. And, now, the shift in NHS England position has to put under question what we do next, because we clearly have a need in north Wales for a mother and baby unit. We will talk about the strategy, I hope, with regard to the direction of travel of services in north Wales, and where perinatal fits into it. However, generally speaking, our data—[Inaudible.]—at the minute, probably indicates, if we include north Powys, which is geographically closer to north Wales, that we probably need about four beds of a mother and baby unit.
And, just to give some numbers, some concrete—
Okay. We're going to come on to talk about demand in a second. Just before we move off this first section, you must be as frustrated as we are really about the pace of progress on this. Can I ask all—WHSCC, Betsi and Swansea Bay—what could you have done differently? What could have been done differently, or initiated by Government differently that would have got us to this at a quicker point?
One possibility would have been, when the decision was made, that we somehow explored options to take this outside of normal health board process. So, clearly, having to go through all the governance structures, and the different health board internal structures, WHSCC structures, the Welsh Government's capital investment structures; if a decision had been made right at the start to say that this was a priority development that the capital and revenue would be ring-fenced, and we would have been able to explore options about going outside the process, it may have been possible to have done this quicker.
Any other comments from the health boards? Would you have supported that, because it seems to me that the dual process of WHSCC and the health boards has been a real break on this, really?
So, I suppose my reflection would be that clearly, what everybody wants is what's best for the mothers and their babies, and we need to go through proper robust governance processes to make sure that—. It's public money, isn't it, so we do need to make sure that we are going through that. I think, if we'd been able to be clear about whether it was going to be a permanent or an interim solution, and we could have been working those up at the same time, then that would have made it quicker.
From my point of view, I can only answer from a clinical point of view, because I'm the chairman of—[Inaudible.]—service redesign. And I would like to say that, over the period that you have mentioned—2017-18, we have delivered, following a long engagement with our population, patients and carers, quite a convincing strategy that has been presented, not to this particular committee, but to the Welsh Government, and accepted, and we have a very robust internal governance, clinical governance, with regard to the development of services. So, we are in a different position than we were when probably this process started.
Of course, I cannot comment with regard to people changing at health board level, because that is something that you are more insightful on than I am, but, from our point of view, we are probably in a different place with regard to clinical leadership, and clinical involvement, and patients and carers' involvement, than we were four years ago.
Thank you. Suzy, on demand.
Yes. I'll just start with the data side of this, as it's already started to be explored. Obviously, we've got the figures for the referrals and placements to MBU beds, but why doesn't the data that we have include those who should be getting those placements but don't? Because that's what we need to assess demand for, not the people who are already getting into the small number of spaces that are available.
So, that is health board data. So, health boards, we don't even know, sometimes where—. If you look at the data that we provided, we have the number of referrals, and then we have the actual number of placements. So, we don't actually know why those women didn't go into—the reasons why they didn't go in—
Well, I'm sorry, but, as part of these lengthy processes, wasn't that an obvious question to ask?
So, from the health board's perspective, we are starting to collect that data. It's not easy to collect, but we are starting to collect it locally through our clinicians, and we've got some data for the ladies in Swansea Bay. And, often, it is that the MB units in England are too far away, so exactly what you mentioned, and they don't want to be away from their other children, or their family. So—
I'm tempted to say 'duh'.
Absolutely. So, we're in the process of trying to gather that data nationally, and the core data set for mental health that's going on nationally will help that. But, at the moment, we're relying on local data collection. So, we're working with our informatics department so that information comes in automatically, rather than people having to ask everybody all the time and record it on paper—
Which I understand is difficult. Is that a similar position in Betsi?
No, we have data with regard to the people—
Yes, you hinted that you might—yes.
—and I can give you some numbers if it's helpful for you.
I've got data from one year—2018, May 2018 and 2019. We had seven admissions to an MBU during that period, but three who required an MBU actually were admitted to a general acute psychiatric unit, and 15 mothers had refused, fundamentally due to distance, as you mentioned before. And out of these 16 mothers, the outcome was that six were admitted, again, to an acute psychiatric unit because they could not be treated, and eight received home treatment from the acute services' home treatment team. So, that is the outcome.
So, the need was identified, but it wasn't able to be fulfilled in the way that you would have preferred. I appreciate that you did take steps to do it.
Yes. There is an argument, if I may interrupt, that the 15 mothers that didn't access the facility, we don't know, but, arguably, they may have had poorer outcomes. And the reason is, we know from research that when you've got an acute mental disorder, or a psychiatric disorder, and you are a new mum, being admitted to an MBU, when needed, of course—it is still a [Inaudible.] environment—facilitates attachment to the baby, facilitates the attachment of the baby to the mother, but, also, if it's local, to the extended family, because we don't have to forget about fathers or partners, and the extended family.
So, we don't know what the outcome has been, but if you read this data from a scientific point of view, based on the current evidence on the outcomes for mothers in an acute psychiatric state, you can argue that maybe the outcomes were poorer.
As I say, it wouldn't have been your preferred way of helping these mothers.
If we could, we would have admitted these people to a mother and baby unit. And we don't know, because, clearly, if the mothers didn't have capacity and were at very high risk, we would have used the mental health Act. But their choice, in this case, the need for an MBU was assessed and identified and they refused. And, as I said, when the team and Dr Schmidt looked into the data collected over the last few years of experience, I agree with your comments that, mainly, it was because of the distance of the MBU that was available.
Thank you. Sorry, Carl Shortland, you wanted to say something here.
Yes. Going back to the data point, I think WHSCC were frustrated as well. And I think if we go back to the original evidence, we did ask for some of the data to be collected at that point. But what we did do is—. We clearly know about any requests for mother and baby beds that have come into WHSCC. We know how many patients are placed. We have—
Sorry, come into WHSCC—why would they come into WHSCC, particularly?
It's a request for funding.
All of the mother and baby placements are funded through WHSCC. So, we get a request through from every health board in Wales. Those numbers we knew. We knew how many patients subsequently ended up in mother and baby placements. We have always funded a request for a placement. We've never refused to fund a request. There has been, on occasion, sometimes difficulties in trying to find the beds, but more of the data around the alternative treatments, such as Alberto has just talked about, have been very challenging to get.
But what I would say is, from that point, we did acknowledge that we needed to proceed with the development of the mother and baby unit. So, it didn't actually delay the process, but there is still a gap on understanding the total demand. And, if anything, the demand for mother and baby has gone down in 2019-20. And there was a feeling that, with all the increased investment in community services, until that had reached the point where there were full services available in each health board, the actual true demand was quite difficult to judge. But as I say, that hasn't stopped us. We have proceeded on that basis, but it is an issue.
Okay. Did anyone else want to come in there, because I just want to challenge that on two fronts in a second?
I just want to say, one of the problems with the data is, when the community services came into existence, we had no data, other than WHSCC would have known how many mothers had been admitted. But, how many mothers were admitted without their babies, or into home treatment, or who've got no service—we had nothing. So, we started in Betsi from May 2017, and we know that, since May 2017, we've had 15 admissions to mother and baby units and we've had 15 women that we know who've refused, but that data is only as good as the practitioners feeding it into the system.
I think there are probably a lot of mothers who've been offered, or thought that they may benefit, but it's very clear that they're not going to go, and that information isn't recorded. We know that there have been 12 mothers who have been admitted to acute psychiatric units without their babies. Of the ones who refused, the 15 who refused, we know that six went into the units without their babies, eight had home treatment, and one had a wrap-around service from our community team. What we also don't know is how many women go to home treatment and never go to a mother and baby unit, and don't always even come to the perinatal mental health team—women who come from liaison or on weekends. That data, we know, is probably incomplete. So, I think what we have is an underestimation.
Which is the point I wanted to come back to, really. I accept that, when you've had requests for funding, then, you know how many people have requested funding, but that's not a true reflection of need. If I were a Government Minister at this point and you were trying to make applications for a mother and baby unit for anywhere in Wales on levels of data that were as incomplete as this, I would just say 'no', because you haven't proven your case, despite the work of a committee like this. How come, right at the beginning of this process, when you were asking health boards, 'Come on, we need some robust data here', you didn't press to get that? Because we're still hearing from Swansea Bay that they're only just starting to collect this data now.
And, why didn't Swansea Bay start collecting it as the same time that Betsi did?
We have been collecting it locally, but it is very much dependent on practitioners then pulling it together. The point I was trying to make is what we need is the systems in place so that it comes in naturally and easily, so that part of your assessment and conversations with women is recording their wishes and choices.
We are talking almost five years here.
Even if it's a paper-based system. If you know that WHSCC is going to need this information, you write it down on the back of fag packets and give them the fag packets—seriously. Don't wait for a piece of electronic kit to be invented.
And that work is progressing, and having Sharon in post as the national clinical lead has really got some momentum behind that, and Sharon's driving that work.
Which we do appreciate, incidentally. Okay, just to finish from me, can you just give us—somebody must know why the place in Cardiff closed.
I think there were a number of reasons. Actually, it was a decision that Cardiff and the Vale University Health Board made. So, they made that decision at the board; they didn't consult with WHSCC about the closure. The reasons they made the closure, in effect, was it was a very small unit—I think it was three beds—and there were extended periods of time, significantly, months, where there were no patients in the unit. I think, at the time, there was uncertainty around whether the unit was a Cardiff unit, a south Wales unit, an all-Wales unit, and I don't think it was ever clear exactly how some of the health boards could have had access to that unit. But I do know there were extended periods of time where there were no patients in the unit, and the staff—
And it could have been filled how many times over?
The staff working in the unit were being de-skilled and being taken off to cover other areas of work as well.
And I think that the point that Carl makes is some of those questions were asked at joint committee, and therefore there was a huge amount of scrutiny in terms of the clinical model that Swansea have been proposing, to make sure that the way that staff are used in terms of maintaining their skills and the role of the community perinatal mental health teams is enabled to be able to support outreach and things like that. So, it's really important that the unit is not just seen as an in-patient facility, but it is seen as a facility that can enhance the other perinatal mental health teams across Wales as well.
Okay. You'll have some further questions on that, if you don't mind waiting. Thank you. Do you have one more thing?
Yes, Chair. Yes, I would agree that the creation of a smaller unit, not combined with other functions, is risky because of the very nature of mental illnesses. There is an organicity and a seasonality, so you may have two or three women in demand now, and maybe none for some period of a year. So, it's quite unpredictable in that respect. So, I just wanted to reinforce that position.
Okay, thank you. We've got some questions now on the interim option, from Hefin David.
Can I ask how plans are progressing for the interim six-bed unit at Tonna Hospital to open in spring 2021, please?
Yes, we're all on track to open in spring 2021. At the moment, the work that we've been doing is clearly doing the design works; we'll be going out to tender on that in the next month or two, and we would expect the building work to be starting in August, ready then to be completed in November/December time. So, we'll be able to start being operational and commissioning early in the new year. So, we're progressing well with that from the capital perspective.
I don't suppose you're building very much then, are you? It's quite a small build.
So, it's not a new build, it's a refurb of a suite at Tonna Hospital; a complete refurbishment of that space to make six en-suite bedrooms, making sure we've got full play space, day space, a mother and baby kitchen-type area, external space as well, and there will also be facilities for fathers or relatives to stay over as well, for people who have to travel. So, from a capital works perspective, that's all progressing to time at the moment. Hazel will pick up on the staffing, but we're expecting to recruit to that so that we're fully up and running—
So, you're absolutely confident it's running to time; that's an assurance you're giving on the programme.
At the moment, yes; there's nothing to suggest there's a delay.
Okay. And the staffing?
From a staffing point of view, we're in the process of developing a recruitment plan. We're going to go out very early and try and recruit a consultant and a service manager, and then put out to advert everything else in August when the work starts. So, we want the staff team in early, and we'll be looking at them developing their training and skills development, and also the work plan, so they've got the kind of planning and thinking about how they're going to operate and deliver as a team, to support the development.
How do you develop a work plan on an interim basis? What does that mean? What does that look like?
There'll be a long-term model eventually, won't there? But the work plan is around how are we going to support these women and their babies within the service we've got, how are we going to work around the kind of hub model—so, what that team staff in the mother and baby unit are going to offer for people coming in, but also going to offer in terms of outreach and trying to support that broader community provision, and how they're going to, I suppose, support the work that we're trying to do around getting consistency across health boards in terms of community provision.
If you're recruiting staff to an interim unit, is that harder to recruit than if you're looking for a longer-term option? How do you deal with that problem?
Recruitment can be a challenge for all of our health staff, and there are some particular areas and disciplines that we know are particularly hard to recruit to. I think it is a challenge on short-term positions, and we're going to have to make some decisions about whether we actually go at risk and offer them permanent posts, which is one way of managing around that, particularly for the hard-to-recruit posts.
But I suppose what's important is the funding. Revenue funding is recurrent and permanent, so we will be recruiting to a permanent service; it's whether the permanent location remains at Tonna. That's part of the work that WHSSC are leading, at the moment, in terms of the options appraisal for the permanent solution.
I think the issue is the fact that the decision in terms of a mother and baby unit is a permanent one, and the decision for it to remain within Swansea Bay is a permanent one. So, therefore, the staff who are employed into an interim solution would, in one sense, morph into it being that permanent solution. I guess that, during that recruitment phase, Swansea Bay will make it clear to the staff the position in terms of the longer-term proposition for the service.
And what does short term and long term mean to you? What's interim and not interim?
Some of the key issues: obviously, the unit will open next year, but before we get to that point we will be doing a piece of work through the joint committee looking at permanent options. It may be that, if we do decide to go with a permanent solution that's a new build, clearly the service will continue until that's ready. It may be that we decide that the interim option does morph into the permanent solution. So, that work—[Inaudible.]
Sorry, I missed that because Dawn was coughing. Can you repeat that?
So, the work still needs to be done to determine the permanent solution, whether it is going to be a new build, or actually whether Tonna Hospital will become the permanent solution.
Right. I thought you said that. Just on that point, if the interim option becomes the permanent option, is it built to a spec that would otherwise have been built had it been intended to be a permanent option in the first place?
Yes, it is.
It meets the standards that we've identified for a mother and baby unit. Clearly, there are differences between the two options, and that will form part of the decision-making process for the permanent option. But it does meet the core standards that are required for a mother and baby unit. The other thing is that, in support of Swansea Bay, we have identified funding to allow this area of recruitment to take place, and training for the staff so that they can be ready to hit the ground running as soon as the unit is operational. The other thing is, with the interim unit, what we've decided to do is to expand the space so that the local community team can be co-located with the unit. Because one of the interim options was not going to allow that to happen, but we've confirmed that will happen.
So, if it meets all the standards of a long-term option, why is it an interim option? Why isn't it just the solution?
I think that work still needs to be done. The original agreement with stakeholders, the consultation and the original announcements from the Minister were looking towards a new build, but clearly there is a process that we are going through to determine is the difference in quality, is the difference in costs and standards—can that be delivered through the Tonna site?
So, can I put it to you, then, that the question you're asking is: let's find out how it goes. Is that basically what—?
No. I think, obviously, that may play into it, but I don't think that is the question. I think the joint committee of the health boards have asked for a piece of work to be done to look at the best permanent solution, irrespective of where we are.
But this might be it.
It may be. It is one of the options.
But you'll only know when you find out after it's up and running.
Carl, you just said that standards can't be delivered through the Tonna site.
Yes, standards can.
No, they can. Sorry.
They can, yes.
I don't understand why it's any different to a permanent option.
There's an option appraisal piece of work that's being undertaken, led through WHSSC, and that will be completed. So, I just want to say, it's not a case of wait for it to be open, wait a year, then do a bit of, 'Let's see how it goes'; the option appraisal work is being done now, and the expectation is that that goes back to the WHSSC joint committee in the next couple of months. So, that will be looking at: should the permanent solution remain at Tonna or should the recommendation be that it would be a new build, wherever that may be, and I suppose where we've put forward previously would be at Neath Port Talbot Hospital, and as Carl said, the elements that we'd be looking at would be value, cost-effectiveness and access. I think access is quite important, as well. So, those are all of the issues that are being taken forward through the option appraisal at the moment, and we will know the outcome of that within the next couple of months, I think, isn't it, Carole?
We’re hoping to get that piece of work completed to go back to joint committee in May.
Okay, thank you. Suzy, you had a supplementary on this.
Yes, thank you. You mentioned the Baglan site then as a possible permanent—. Was that looked at during the investigation for—?
Yes. Not for the interim, but as the permanent—. When we’ve been doing the work on the business case about whether it should be an interim or a permanent, the Neath Port Talbot site has been looked at.
Because just to turn Hefin’s question on its head, really, obviously, a considerable amount of money will be put into the Tonna site. It could be empty in a couple of years. I'm presuming that the money wouldn't be wasted on the basis that it'll become a more solid community provision. What’s its alternative use once you've been through this process? I don't need a long answer, because it’s not directly related to the inquiry, but—.
Well, clearly, we'd want to make the best use of the facilities that we've got and the capacity that we've got. So, we haven't looked at what we might use that space for if the permanent solution ended up being somewhere else; we haven't done that bit of work yet.
Okay, because I think we'd all be nervous about a double spend on this. But, thank you very much.
Siân, you had a question on this.
Yes. What happens if we find that the north Wales solution just isn't coming through and that people aren't actually coming down to the interim solution? Wouldn't a permanent solution then have to be in an another location, outside of the Swansea Bay health board; somewhere where access is more equitable for everybody across Wales? I don't know who that is a question for—it’s not a question for you, it’s a question for WHSSC, probably, is it?
The decision, to date, is that the unit will be in south Wales and that Swansea Bay will be the provider of that service—
The permanent one as well.
The permanent one as well. Clearly, the north Wales issue has changed, and we will need to have some further discussions about what solutions we can have for north Wales—
Because the north Wales situation has changed, does having the permanent location in Swansea Bay change as well?
I think some of the work that we did early on on the options—we got 1000 Lives from public health to look at travel distances from the whole of Wales. Wherever you place a unit in Wales is going to be challenging, but I think the evidence was that the Neath Port Talbot area was one of the best placements for access from public transport and from all parts of Wales, but recognising that there is an issue for north Wales, north Powys, et cetera, and north—[Inaudible.]—even, as well.
Because we’ve heard this morning that there is a need for four beds in north Wales, to serve the women of north Wales.
That isn't what our earlier evidence has shown, so, clearly, we need to go through and expand on that. Our early evidence and everything the case has been predicated on was that we’d expect two beds for north Wales, so our discussions with NHS England were based on that, and that was in line with the epidemiology and the level of demand that we’ve seen in south Wales.
Sorry to go on about this, but that was based on the evidence of how many people were actually accessing MBUs, rather than on the 15 who refused to go.
No, that was based on pure epidemiology data and information from NHS England.
I would like to reassure the committee that we are not in a different position. I think if you take strictly the population in the recommendation of the Royal College of Psychiatrists, it’s 0.25 beds every 10,000 births. So, if you look at our births, we need two beds for north Wales. Our proposal of four beds is more based—first of all, considering the inclusion of north Powys and the needs of north Powys because of the geography, and secondly, the clinical needs. The Royal College of Psychiatrists recommendations are based on the very end of acuity and respect for mothers, but we believe that, following our experience in perinatal, and following consultation with our clinical leads—and Dr Schmidt can expand if she wishes—that other mothers will benefit from an admission locally. And hence, maybe, if there is an opportunity to develop perinatal services including a mother and baby unit in north Wales, ideally, we would like to have four beds. But again, it's not a position that is in contrast with the previous WHSSC position, and I want to be very clear, because if we reduce strictly to the college guidelines, yes, two beds is the demand for north Wales.
Dawn, I think some of the questions have been covered. Is there anything you feel hasn't been covered?
I was just going to ask you about permanent options, which I think you've covered. I think the question that still remains slightly unanswered is the cost-effectiveness of running this parallel process of having an interim unit that clearly is going to have to be funded and then a permanent unit that is going to have to be funded, and whether all of that was taken into account in terms of running with this dual process, and whether you believe that that was the most cost-effective approach.
The actual cost of running the permanent unit and the interim unit from a revenue perspective is going to be very similar, so there won't be much of a difference. The main difference, obviously, is if we have a new build as a permanent solution with significant capital investment required, and that will feed into the options appraisal that the chief execs will be presented with by WHSSC.
The revenue costs, as Carl said, are the same. It's the capital.
And the staffing costs.
On the staffing costs, there's a very slight difference in terms of covering night shifts. But it's the capital costs that are the difference.
And timescale, you were saying—you talked about a couple of months before a decision is likely to be made on the permanent solution. Is that right?
Yes, I think you were expecting to take it to—
Yes. We are hoping to take a paper to joint committee in May.
Okay. And I suppose the final question on this is following on from Siân Gwenllian's question about the interim solution for north Wales, and the permanent solution for north Wales is still, from your perspective, an arrangement with England. Is that still where we're going?
That is the case at the moment, yes.
For both permanent and interim options, north Wales will have access to whatever services are in south Wales, but given the geography, there are issues. But there may be some patients from north Wales who either choose or are that ill that they need to be sectioned, who will access the unit in south Wales. If they can't or don't access that unit, they will continue on the current arrangements, which is trying to access beds through NHS England.
Okay. Seeing as that option is going to be made available to women in north Wales, will there be a Welsh language facility incorporated into the offer in Tonna?
Yes, absolutely. We've got the Welsh language standards and the expectations of the health board, so we would absolutely include that. We currently do have Welsh speakers within our community perinatal team, and we'd have to seek to take that into consideration in terms of recruitment.
Okay, thank you. Can I just ask about the paper that Swansea Bay submitted, which described a perinatal hub model? Can you just tell the committee a little bit more about how that would work? But can you also clarify whether that is intended to be the model for the permanent solution, the interim solution or both solutions, please?
So, the plan would be that it would be the model for both solutions. So, our clinical teams have spent a lot of time considering the models and thinking about it, and the thinking is, in terms of their expertise, that the mother and baby unit would provide significant expertise for mothers who are really, really ill and need that admission. But also then it provides opportunities for that team to support the wider parts of the pathway—so, the community teams—to develop research and become a bit of a specialist unit. Well, they are a specialist unit, but to use those specialist skills to the best of their ability so that they're supporting all parts of the pathway.
So, what that would probably look like in practical terms is that you'd have members of the team who, within their individual work plan, would have outreach roles and would support different areas, whether that's research or whether that's supporting supervision and development or education and training of other parts of the system, like midwifery services. It would be a whole range of things, but primarily focusing on research, education and training and looking at supporting some of the work that Sharon's doing around trying to get that consistency in those national pathways.
Okay, thank you. Siân, do you have anything else to ask on this, or the one on the Welsh language?
Wel, mae’r cwestiwn ynglŷn â chael defnyddio’ch mamiaith pan rydych chi mewn sefyllfa fregus ofnadwy, yn enwedig pan rydych chi eisiau siarad yn eich mamiaith efo’ch plentyn a’ch bod chi mewn sefyllfa sydd ddim yn caniatáu hynny, dwi’n falch eich bod chi’n mynd i fod yn edrych ar hynny. Mae hi mor bwysig i gael y staff, nid jest y safonau. Dyw’r safonau, cael arwyddion yn y Gymraeg, ac yn y blaen, ddim yn mynd i—. Beth sydd angen ydy bod y fam yn gallu siarad yn uniongyrchol yn Gymraeg efo aelod o staff. Mae hynny wedyn, wrth gwrs, yn codi cwestiwn ynglŷn â pharhau efo’r trefniant o anfon merched i Loegr—. Dydy hwnna jest ddim ar gael yn fanna o gwbl. Dydy’r math yna o gysylltiad ddim yn bosib, yn amlwg, sy’n rhoi pwyslais mawr ar geisio cael datrysiad ar gyfer y gogledd. Mae’n bryderus iawn bod hyn i gyd, rŵan, yn arafu lawr. Dwi’n meddwl bod Betsi—. A ydych chi’n edrych ar fodel a allai caniatáu inni gael y ddarpariaeth yma yn y gogledd? Rydych chi’n sôn yn eich tystiolaeth chi y byddech chi’n fodlon edrych ar fodel ar gyfer y gogledd. A fedrwch chi jest sôn ychydig bach am hwnna cyn inni orffen?
Well, the question regarding using your mother tongue when you are in a very fragile situation, especially when you want to speak to your child in your mother tongue and you’re in a situation that doesn’t allow that, I’m happy that you are going to be looking at that, because it’s incredibly important to have the staff, not just the standards. Having Welsh signs isn’t going to do it. What you need is the fact that a mother can speak directly in Welsh with a member of staff. That then, of course, raises a question about continuing with the system of sending women to England. That’s just not available there at all. That type of connection isn’t possible, which puts great emphasis on having a solution for north Wales. It’s very concerning that all this now is slowing down. Are Betsi looking at a model that could allow us to have that provision in north Wales? You mention in your evidence that you would be willing to look at a particular model for north Wales. Could you just tell us a little bit about that before we finish?
Thank you for the question. I’m very pleased that you ask. I completely agree with that. Although the arrangement that we currently have is sufficient, I don’t think it’s satisfactory. One of the reasons is the language, but it’s not only that, it’s distance, it’s proximity to familiarity and to a familiar environment. So there are a number of reasons. We, in Betsi, had quite a lot of discussion on how the perinatal services may fit with the direction of travel for the strategy. And just in very broad terms, the direction of travel is very much in line with the Welsh Government’s direction of travel, which is care closer to home and prevention. So, this is what we want to focus on in developing our services, including perinatal.
So, we are putting significant emphasis on community care and primary care. We want to start from the first time, in this case, a mother hits the GP or primary care services and how we can deliver something at that point without waiting for the illness to get to the point where you need an acute admission. So that is what all our strategy is about. Probably, you are familiar with the partnership work that we are developing—the I CAN is one example, in collaboration with the voluntary sector, but it’s not the only one. When we talk about partners, we’re talking about the independent sector and, of course, our extended colleagues, including primary care.
If we narrow down to the perinatal services, we are not very far away from the position of our colleagues in Swansea Bay. We want to extend our community services—if we had the funding, we would like to extend our community services. We are prepared to offer the committee an option appraisal of the gold standard, or some options for how perinatal services can serve our population in north Wales, and we are having dialogue with north Powys, for the reasons I mentioned before. Also, talking to Dr Schmidt, we are prepared to pilot a new model of care. For example, it’s been mentioned in discussion with me about a day hospital that can serve perinatal mothers, where they can have access during the day, in a safe manner with their baby, and that can be used both whether they are home with an acute illness or whether they are an in-patient as an acute in-patient, so they still have some contact with the family. We are happy to develop a more specialist home treatment team, for example, similar to what Hazel mentioned, in the sense that, of course, the specialist may be retained at that level but the outreach with mainstream services. But, fundamentally, at the minute perinatal services are really fulfilling the basic function, so the very end of the spectrum, because of capacity and demand. So, it’s as simple as that. And it’s a very small team serving a large geographical area. This is what it is.
And in regards to an option of developing a permanent solution for a mother and baby unit in north Wales, now that the discussion with England has taken a different direction—or it seems to have taken a different direction—I think it’s a possibility that we can explore alongside WHSSC. As I said, we mentioned four beds, based on the criteria that I mentioned before. That is a possibility, but I don’t want to enter into too many details until we do the work because it would be perhaps unfair. But one of the ideas behind it is exactly what you mentioned, incredibly, to perhaps consider the west part of north Wales because of the Welsh language and the proximity, and the access from the rest of north Wales as well. But I think it’s premature to get into this level of detail. However, I can say that considering the current maturity of internal governance that we have in service redesign, we can offer some option appraisal in regards to a permanent solution for north Wales.
I do just think we need to remember about where we started. We did explore various alternatives to how we could deliver mother and baby services for Wales. And I’m not saying that we can’t revisit or things have changed, but there was clear evidence from the Royal College of Psychiatrists, the evidence from the Cardiff and Vale experience, the expertise of having the staff to run the service, and we did test with our clinical networks, and the clinical evidence was they didn’t support the development of small units. Because one of the options was to actually have three or four units around Wales with two or three beds, but the clinical evidence was that wasn’t supported. So, we would need to revisit that in light of that.
Yes, but at least you’d be willing to have that conversation and look at a new model, and pilot something that could be quite innovative in north-west Wales.
I think as well—. Sorry, Chair. It’s also really important that in line with the new service, we will be putting out a new service specification for the provision of a mother and baby unit, and that will be based on the evidence. It will be based on the royal college standards. So, we will be working very closely with Swansea bay in terms of the development, making sure that that service specification will go out to consultation before the new service is up and running. So, any service that WHSSC would commission, we would expect it to meet the service specification or have areas where health boards would be able to put alternative plans in place.
And is that for interim and permanent?
It would be for both, yes.
Okay. Final question, then, from Dawn.
Yes, it’s just about the interim unit that you say is likely to be up and running next year. So, at the moment we’re still sending mothers to England for in-patient care. You talked about the problems that you’ve got with NHS England in the north-west. Are you satisfied that the general provisions that you’re able to offer to women in Wales in England during this process, before we get to the interim one, is still robust?
I think it’s as robust as it can be at the moment. The changes in England, obviously, are affecting this new development, but what has been positive is that there is more capacity in England because they have developed new mother and baby units. So, in theory, access to services should be at least as good as it has been in the past. We probably do need to also point out that we have had a period of exceptionally low demand and low requests over the last six months, and we have had periods where no Welsh patients have been in mother and baby beds.
We'd also know that, with the development of specialist perinatal mental health teams in NHS in England, they too have seen a fall in the demand into their mother and baby placements. Therefore, we do know that they have additional capacity within their services in order for us to be able to access those mother and baby units.
It's probably worth just to add in as well that when mothers and babies do go to England, our community perinatal teams do reach in and keep in contact. It's not ideal because of distance at times, but they will try to go to a ward round within the first couple of weeks. They will have weekly contact, and they will go to the discharge meeting. So, there is a level of in-reach into the service.
I understand. The reduction in demand, Carl, that you talked about—. I know that you said that this is entirely unpredictable anyway. You never know from one month to the next, and even one year to the next. But, is that partly to do with the community outreach type of work that you are doing, which has prevented in-patient admissions, or—?
I think, generally, that is what normally happens. So, we have experienced that with CAMHS services as well. As more investment has gone into community, potentially, the demand for tier four in-patient beds has reduced as more support is available. But, clearly, there is a real issue about this cohort of patients, about geography and their ability to travel to access services for family and other reasons. So, I think that that's the sort of unknown here—the demand. Even if we knew what the exact demand was, you couldn't guarantee that they would all access the service because of the issues that we've already discussed.
I think that the work that we did initially with mothers with lived experience—. What they said is that they wanted to be cared for safely, and they wanted to be cared for by people who had the specialist expertise. That's what we heard from each and every one of them.
Okay. Well, we've come to the end of our time, so can I thank you all for attending and for answering the committee's questions? You will be sent a transcript to check for accuracy following the session, but thank you again for your time this morning. The committee will break until 10:50.
Gohiriwyd y cyfarfod rhwng 10:43 a 10:53.
The meeting adjourned between 10:43 and 10:53.
Welcome back, everyone, to our second evidence session this morning. I’m very pleased to welcome Sharon Fernandez, who is the national clinical lead for perinatal mental health with the NHS Wales Health Collaborative; and Joanna Jordan, national programme director for mental health at the NHS Wales Health Collaborative as well. Thank you both for attending this morning, and thank you, Sharon, for the paper that you provided in advance.
We’ll go straight into questions, if that’s okay, and the first questions are from Janet Finch-Saunders.
Thank you. Good morning, both. Sharon, when you took up your position, what were the main challenges you faced and what do you see as your main achievements since taking up the role?
I started as the national clinical lead in January 2019. I’m not sure I’d refer to them as challenges, but there were obviously things that I needed to look at and identify. I felt that it was needed for us to pause, reflect and look at where we were at.
So, in order to be able to do that, I spent time setting up some workshops. We had three workshops throughout Wales, and I made a point of going out and meeting stakeholders. I met with stakeholders in Powys, in Mind's Mums Matter groups, Pre and Postnatal Depression Advice and Support, and Action on Postpartum Psychosis. From that, we gathered lots of information. We spent time theming that and what you’ll see from my paper is that we identified four clear areas that needed to be looked at.
So, we identified them as the four Ps. So, that was the need to strengthen partnership working, it was also the need to think about, which was in the recommendations, an all-Wales pathway, looking at performance, data collection and people, which was around training and supervision. So, those were the key challenges, I suppose, if you want to refer to them as challenges, that we needed to look at and we needed to focus our time and energy on, and that’s what we’ve been doing over the last year.
In order to be able to do that, we needed to prioritise, because I’m sure, if you start thinking about it, the amount of work that needed to be done was overwhelming. I was keen to focus on strengthening the foundations of the work that had already happened, and doing a little bit of underpinning. So, very much, for me, it was focusing on the building up of relationships. I’ve spent a lot of time and energy over the last year identifying key stakeholders, engaging with them and connecting, but also connecting wider across Wales, because my thoughts are that we will have strength in numbers and we can only make these significant changes if we’re working together.
So, the focus very much has been on partnership working. So, that was encouraging each of the health boards to ensure that they had a multi-disciplinary and a multi-agency steering group up and running and that we had third sector voluntary organisation representation and was very much about service user voice. We’re at a point now that, next week, we will have, in each of the health boards, a steering group, and that needed also to have representation from each of the services across the pathway, because what I was very much wanting to do was to ensure that we look at the whole pathway approach. So, what we’re taking on is a huge transformational change of a whole system. So, ensuring there was midwifery, health visiting, primary care, adult mental health, CAMHS, specialist teams involved in that.
The other thing that had happened, or what staff wanted to happen, was that they wanted to come together as professional forums. So, we’ve set up a number of professional forums over the last year. We come together bi-monthly. So, we are meeting regularly with the specialist midwives, the health visitors with a special interest, mental health practitioners within the specialist teams, specialist team leads, more recently with the psychologists and next month with the psychiatrists. So, that gives them a safe space and time really to reflect on maybe the challenges within their particular area, on the opportunity, sharing of good practice. So, we’ve been doing that.
And then, I’m working very closely with Sarah Witcombe-Hayes from the NSPCC maternal mental health alliance. She has one day a week now as our Welsh representative for the maternal mental health alliance. And we have a date to facilitate a workshop for third sector and voluntary organisations, because what I was mindful of was that we had some, we had a small number of third sector organisations that we work very closely with, but there are many more out there that we need to do more work with and we want to bring them together, and the plan is then that we’ll have a stronger service user voice.
But I’m also keen to work with our communities and what’s already there, so building upon the work of the maternity service liaison committee and we're already linked with the engagement and community leads in each of the health boards, so that we can get out and hear the voices of people within our communities that may not necessarily have accessed services but may have needed them. So, that’s the work that we were doing last year.
Okay. How is the role of the clinical lead—? I think you’ve answered the next one I was going to ask. How is the role of the clinical lead monitored? And what budget resources are attached to this role?
Okay. So, obviously, I’m reporting directly to the national clinical lead [correction: the national programme director for mental health]. I meet monthly with Welsh Government colleagues in the mental health and vulnerabilities team and I report quarterly, provide an annual report, and then we’ve recently set up the board. That is in its infancy, but I will be reporting to the board on a quarterly basis.
Okay. There is mention, and you’ve endorsed it again today, about the engagement sessions that you’ve held with stakeholders, established groups and forums, and you’ve met with service users. What information has been gained through this? How satisfied were the services users with the services available to them? And, as was emphasised in the earlier session about data collection, how are you then making sure that what you learn and what you pick up is not lost?
And I suppose that's—. Within the workshops—although that was the majority of staff—it's the anecdotal information at the moment that we've been working with. What was coming back from the service users and the staff are really no surprises to me—I've been working in this area for 20-plus years. The same themes come up all the time.
Going forward, everything needs to be underpinned by the service user voice. So, the things, again—I'm sure there wouldn't be surprises. Some were sharing that they've had experience of excellent care. More recently, we've had letters in from people that say, 'We couldn't have done without the specialist team services.' But on the other spectrum, we're getting people that have said, 'I needed care in a more timely manner. I didn't get what I needed.' And this is, I suppose, the ethos of what I'm trying to do, and that's ensuring that we're developing services going forward that are providing the right care at the right time by the right people, and that those right people—the staff—have the right skills, knowledge, support, and supervision to be able to do that work.
So, how are you ensuring then that that feeds into the overall data information collection requirements, really? And how then are you ensuring that that's shared amongst others? Because I know from various pieces of work that I've done that there's a lot of people gathering data, and it becomes very precious and people don't always share it as well as they could.
Over the last year as well, one of the main things that we've been doing is setting up the network, which will be that place where all this information is taken to. So, as part of that network we've set up the perinatal mental health board. We've also set up, or we've reviewed membership of the existing all-Wales perinatal mental health steering group. What I felt was needed was that we just needed to make sure it was a group that had representation from all those service areas and from the board. So, we've got the national clinical steering group up and running, and we've re-established the community of practice. So, these are all places where the information goes to.
During the conversations that I have, things will come up. One of the things that's come up more recently is about the support that they're offering 12 months plus. So, for me, again, I've been doing a lot of work around benchmarking, just so that we can get a bit of a clearer picture of where we're at. So, when these things come up, I'm talking to my Welsh Government colleagues and asking if they could be included within the data that we're routinely collecting. I appreciate that data collection is absolutely a priority, but at the moment that stays with Welsh Government because there have been so many other things to do.
We did start looking at how we could shape data collection in July—we had a workshop and we've had a meeting before Christmas. What became apparent to us is that we need to have much more clarity around what the pathway looks like, so that we can then start really doing the work around shaping the data collection.
Thank you. Where perhaps you've received not so favourable responses and where you've felt action was needed, what action have you taken on those cases?
There's a particular situation I'm thinking of, but that was just making sure then immediately that that person was safe and that they knew how they could raise their concerns. But, again, it's working with the team. And as much as I am a person who would want to do everything yesterday, we need to take a systematic and measured approach to all of these things. So, if they've been immediately of concern, as a clinician, I have an opportunity to raise those concerns or make sure that they're safe. But it is taking it back and it being mindful of the theme, so that we can address that in what we're developing.
Would you say that you have sufficient co-operation from other organisations and professionals to allow you to carry out your role effectively? Or are there any gaps?
No, I think I've been really fortunate. I don't want to speak too soon, but I've had open doors where people—. We have the most amazing, passionate, skilled group of clinicians, et cetera, within Wales, who I think have just been sitting, waiting—it's not just about me; we're a whole team—for the leadership to be able to move the services forward. So, it's been really positive. Each has had different starting points, and we have to be mindful of that, and there are different journeys, but we're all heading in the same direction, which is really, really positive.
And what do you consider to be the current level of awareness of perinatal mental health issues amongst the public and professionals, and is further work needed in that regard?
As I said, I've been working in this area for 20-plus years. I think there's definitely much more awareness if you use social media. There's lots out there, and we try to—. I'm not so great on it, but I have colleagues who are much better, so they're sharing what we're doing. I think there's still work to do, but that's the work of the network, to look at how we can continue to raise the profile. More women and families are willing to share and to talk about it, which is great. We're starting to reduce the stigma around it. We're making it acceptable to say, 'It's okay to say you're not okay', which is brilliant.
Again, we'll be doing work with Sarah Witcombe-Hayes around all of that. I know that Sarah, as part of her role with Maternal Mental Health Alliance, will be looking at awareness days, and again what we want to do is get to a point where we're sharing this across Wales: each team takes a role in—. It's about using social media or any platform to be able to use it as an opportunity to raise awareness of mental health.
Thank you. We've got some specific questions now on the clinical pathway and equity of provision from Hefin David.
Can I just pick up—? You've already mentioned the clinical pathway, and recommendation 12 of the report that we produced said that we needed an all-Wales clinical care pathway. Are you identifying, then, that significant progress has been made?
Yes. So, again, it was definitely—. Yes, it was a recommendation, but that would have been something that I was looking at anyway. I don't know if you're aware I was working in Powys—I'm seconded from Powys—and we had already started looking at a fully integrated care pathway. You look at all the evidence out there, that's what it's suggesting.
So, what's happened—and this is what I'm saying about the practitioners that are incredibly passionate and go above and beyond—is that, naturally, health boards seem to be leading on pieces of work anyway. So, Hywel Dda colleagues have taken the lead on drafting up this fully integrated care pathway. I was with them yesterday; it's coming along very nicely. So, our plans are to be able to share that more widely.
We've got a community of practice event on 19 March, but it will go out for consultation and for comment from that point onwards. The plan would then be to test that change. So, Hywel Dda have agreed to do that for about six months because we want to make sure that, if there are any issues, that we need to address them, and then we are planning to have a conference in November where we will share it further.
So, public sight would be 19 March, you said?
Yes. It may come out before. Just bear with us. We've got a community of practice event on 19 March where we want to take it to the wider perinatal audience, but then, absolutely, it's there for comment, and I'd gratefully receive comments from people around it. It's a needs-led approach. So, it's focusing on levels of need.
Can I just come to the health boards in perinatal mental health services and the variance that we've discovered through the course of our inquiries? Do you think that has improved recently?
Absolutely, yes, and part of the preparation for coming here was to have a better understanding of where we're at because, again, even over the last year, things have changed. So, when I say we've got five and a half health boards that are meeting the royal college standards, we've got one health board that just because there was a natural turnover of staff that had prioritised that, we now have a new specialist team lead in that health board and they will prioritise reaching the standards by June. And then I'm working with the other health board, and, again, they recognise that as a need and their plans are to have met the standards by June.
So, which are those health boards that need the most improvement?
It isn't about most improvements. I think what we need to acknowledge is that when the money was given to health boards, each of the specialist teams set themselves up slightly differently. So, what we're trying to do is standardise the function and the form of the specialist teams.
Which health board needs the most standardisation of function?
It's not about that. So, Cardiff and Vale will be meeting—. This is about meeting the age criteria, okay? So just as was mentioned before, this was about demand and capacity, and so what we're doing is looking at the function. So, it's a complex picture, isn't it? There are a lot of factors that need to be thought about.
But isn't it inevitable that if different health boards have different forms and functions, then certain patients will see a difference in service?
Absolutely, and the work that I am doing is to address that. So, one of the areas of work that we've absolutely recognised needs work and what we've been doing over the last year is to think more around the function of the team, so what is the criteria. So, making sure all the health boards are working towards meeting the Royal College of Psychiatrists's standards around criteria. So, we're almost there and by June we'll be there with that, so they will all have very clear criteria for accepting referrals.
So, would that mean in practice, then, if I'm a patient in any part of Wales, I'll see a uniform service from that point in time?
That is absolutely the aim, yes.
So, that's for the age criteria. The work that we will be doing next year—
When you say age criteria, you mean—.
You'll see in my report, the royal college's standards say that specialist teams should be accepting direct referral up to six months and following consultation after six months, so that's the piece of work we're looking to do for that. With regard to uniformity, that's the work that we will be doing over the next year, so that each of the health boards are now working towards meeting the Royal College of Psychiatrists's standards for community mental health teams, so that by the end of March 2021, we should be in a position where, wherever you are in Wales, you will be getting the same level of service.
So, you said, Sharon, that all of them were meeting those standards bar one—
For the age—
Right. So, not for the Royal College of Psychiatrists.
As I said before, I would have loved to come in and say, 'We'll do this all right now', but we've got to take a measured and paced approach about it, so we've been looking at the function, so the criteria, and how what we're doing is comparing against the royal college standards, mapping out what that function will look like and making sure we go through a process that everybody's agreeing that that's how it will be.
So, the concern would be: are all health boards meeting those standards at this point in time?
The Royal College of Psychiatrists.
Not all of them.
So, which ones are? [Interruption.] Well, let's deal with the Royal College of Psychiatrists first, I think. I'm getting confused.
So, I think it is probably the case that no health board is yet meeting all the royal college standards, and that would not be the expectation at this stage in the development of the teams. The requirement is that they work towards that by next year, so that is what Welsh Government has set as the outcome, and it's a key part of Sharon's role to support health boards to get there. But it would be surprising if they were all meeting all of those standards at this stage. They've been in a period of development. They are quite exacting standards. They're quite complex. There's a whole series of them, so there may be some, such as the age criteria, that may already be there or thereabouts. There will be others that they're further away from. So, the plan is to work with health boards to bring them all up to the standards for next year. So, I think that is the expectation from Government, and what health boards have signed up to do.
Some health boards, though, are meeting those standards faster than others. Is that the case?
They may be meeting some of the standards faster than others. Other health boards may be meeting other standards faster.
Okay. And is it then fair to say that the direct consequence will be a less patchy service by that date that you've set next year?
That's the whole aim.
That's the aim.
By meeting those standards.
Absolutely. What we want—I see my role as coming in and leading the work that needs to standardise. I absolutely expect, and so do clinicians, that wherever you are as a woman in Wales, me and my family will receive the same care and the same level of care. It may be that it's done slightly differently in that we may have one third sector supporting a piece of work around here and a different third sector there, but the aim is—and this is the whole point of the pathway—that we are absolutely standardising and saying, 'This is what is expected at these times.'
Are those royal college standards new?
No. They've been updated.
They're being updated at the moment, actually, so they may change slightly.
It was one of the recommendations, wasn't it, that you've made?
Yes. And the Minister told us in February that it was a priority for all community teams to meet the all-Wales perinatal mental health standards by March 2020. Are they all doing that now?