Cynulliad Cenedlaethol Cymru

Diolch, Cadeirydd. Good morning, bore da. The Welsh Government plan for health and social care—the new plan—highlights the need for parity between mental health and physical health and there needs to be an equitable level of treatment, care and support between the two. How can we achieve this? There's a desperate need to achieve this, so can you tell me what your plans are to achieve the parity between the two, please? 

I think there are two things, broadly. The first is the conversation about mental and physical health that we need to continue to have to make sure that we're not simply talking about physical health all the time and then mental health once or twice in a year. That's part of the broader importance that we place on it.

And then, secondly, it's the way in which we make choices within the service, of course, as well. When I say, 'within the service', I'm not talking about within the straight service in terms of direct NHS provision, but more broadly in the provision that we know that we need to make with other partners as well. I come to this committee and I regularly factually recount the fact that mental health spending is the largest individual area of spend within the health service, the fact that there's been additional, real increases into the ring fence for mental health as well. And it's then about making sure that that's a continued effort and that we have a focus on outcomes as well. And, again, I expect, when I come to this committee, I'll be asked question about what that really means—so, the money we want to invest in psychological therapy waiting times, whether that actually is real, where the money goes in and whether you see improvements in waiting times—and, ultimately, in the measures that we're looking to arrange and agree with the Mental Health Alliance, in particular, on what outcomes look like.

So, it's not just that we have things about waiting times—and waiting times do matter; they're part of the service—but actually having an outcomes framework that tells us more about whether we are achieving. That isn't then at the most senior or, if you like, complex end of need, but it's got to be: what does that mean throughout? So, it will involve colleagues in education and others, because I recognise that lots of our focus has tended to be on the more specialist end, and we recognise that, actually, we've got to do something about the lower and middle tiers that don't always get lots of focus as well. So, it will be that challenge on times, on outcomes, and whether we can make good the promises we've made about the way our money will be spent.

So, as one in four of us will suffer from mental health issues at some time in our lives—that's 25 per cent of the population—do you think that the budget that you have for mental health is sufficient, considering there'll be such a high demand on these services and the parity between the physical and mental health is—? The gap is widening as more and more people use the services. So, how are we going to achieve this with the increase in demand?

That's part of the reason why we are investing more money into the service. It's part of the reason, actually, why there's been a consistent policy discussion about this, and challenge. That comes not just from the third sector, but it does come from Members in this place and actually comes from within the health service as well, as well as partners, because they recognise that that demand presents itself in different parts across our whole system. I think there are times where the percentage, in terms of trying to extrapolate into the budget, isn't always necessarily helpful, because if you look at where that demand is and how you could deal with it, actually dealing with demand at the lower end isn't necessarily as expensive as the demand at the top end, where it's at its most complex. So, we have to try and understand whether we are spending enough in the right areas or not, and I expect there to be regular challenge about that, which is as it should be.

Okay. One of those is now. Lynne.

If we are serious about parity between mental and physical health, how is it acceptable, then, that we've got people waiting so very long for psychological treatments, and even waiting to access crisis care, which we've heard in this committee, whereas if somebody needed chemotherapy or emergency surgery, they would get it?

Well, that is part of the reason that we're trying to address, because it isn't acceptable to say that people should just wait longer than they should do. It's something that I talk regularly with vice-chairs about, so that there's scrutiny within the system, but also the additional investment we're making in psychological therapies. On the mental health transformation fund, we've taken about £7 million to invest in that, with a focus on community and, indeed, on crisis care as well, because I wouldn't try and look you or anyone else in the eye and say, 'Everything's fine', because it isn't. That's why we're investing more. We recognise there are gaps for us to fill, and to understand, and then to look again at what we're doing. So, I wouldn't tell anyone in this committee, or outside it, that where we are is acceptable. For all the progress we've made, over a period of time, there's still much more to do. So, no, some of the waiting times are not acceptable. We are investing more, and we'll need to see if that investment deliver results that mean that people don't wait an excessive length of time for that support, whether it's going to be urgent at the crisis end, or at the more standard end, because all of those things matter to avoid problems escalating.

Diolch. I wanted to ask you about public awareness of suicide. There are already a lot of existing resources about how you raise awareness. If you look at Network Rail and the Samaritans' Small Talk Saves Lives campaign and the free online resource 'See. Say. Signpost.' So, do you think there will be a case for raising awareness more generally amongst the general public using resources like that, and would the Welsh Government be willing to take a lead in promoting the 'See. Say. Signpost.' training via social media channels, for example?

Well, look, I'm interested genuinely in the report that this committee provides, and it comes at an interesting time because we're at the midway point of Talk to me 2, and the national advisory group are meeting this week as well. So, all of this is going to come at roughly the same time for us to consider what to do. You know that we already support Time to Change Wales. That's money from this portfolio and the economy portfolio, and that's part of our public awareness raising. But if there are more things we could do, I'd be open-minded about that, as opposed to saying definitely 'yes' or definitely 'no'. We need to see what that is, because some of those things are relatively low level. Sometimes, if you like, with the soft power of politics, you can say 'yes' to something and agree to support something and to endorse it, as opposed to there being calls for additional resources. So, I'm interested in a range of those different things: how we use the money that we've currently committed; what we can do with other partners, and how we ultimately have a more rounded conversation about mental health in the way we do about physical health.

So, you'd be prepared to consider this. 

Yes.

Right, thank you. Do you think there's a case for a specific suicide prevention public awareness campaign, aiming at reducing stigma and encouraging people to seek help, and equipping people to signpost people in distress to sources of help, because, obviously, these are situations that anybody could come across at any time, and do you think that there's a case for trying to promote that more widely?

I think, with any broader public health awareness campaign, when you think about how we're reaching people or the people who we want to reach, part of our broad challenge is—and you'll have this in this committee on a range of different issues—that there's a call for a public awareness-raising campaign, and the space is quite crowded to do that and to think about what is the most effective way to do it. I regularly get asked for condition-specific public awareness-raising campaigns, and the advice that we regularly get from Public Health Wales and others is that, actually, this isn't an effective way to use your resources.

I'm interested, though, in the broader conversation we have about mental health and how suicide prevention is part of that. So, it's a conversation about prevention, but also there is the other side, and that is about how people access support as well. So, I'm trying to be honest with a note of caution about how much we think we could actually achieve in specific campaigns. But if there's evidence that, actually, we think would be a way to help people both to raise awareness so that people feel better equipped and supported to access help if they do find themselves in a position where that help would be useful for them, then, of course, we would think about that. Because you'll have seen the figures as well about the number of people who take their lives, who have had access to mental health services or the health service and those who haven't, and that's part of our challenge: how we reach those, at least 300-350 people—I'm sure you've heard evidence on whether that is an accurate figure or not—who continue to take their lives each year.

Yes. It just seems that this is a crucial area where, if you can step in, it's something that you can actually prevent. So, I hope that's something that you will consider. We do have good examples of the ways in which these other organisations work.

Indeed. If you think about Network Rail and what they're doing, because they recognise that they unfortunately have a range of areas where people go to take their own lives, so, there is something there that is specific about the venue and the access to means. And so you can see how targeted campaigns like that can be really useful, and there's a general campaign as well. I'd just say that if there's going to be a general campaign about suicide prevention, it's not just that we think it's broadly a good idea but how would we do that in a way that would be successful and meaningful when we still have a challenge about broadly raising the public debate and conversation about mental health so that people do feel that they're able to talk about it? Because the stigma is just in one direction—lots of people don't want to talk about their mental health challenges and they're not particularly interested in having a conversation with someone else; other people want to and find it difficult to get help and the response of other people is the problem. So, within that difficult conversation that we know we need to keep on having as a country, because we want to change the position that we're in, where is there a role for a particular campaign and conversation around suicide prevention?

I'm just saying that I am, again, open-minded about it, but I want to understand how we get to a point where we'll make a real difference as opposed to what we're already doing. That's part of the point about having the review and Talk to me 2, the campaign we're already running, and what else we could do in addition to it. It's part of why the report of this committee will be interesting and, of course, the national advisory group are meeting tomorrow, and so the conversation we're having today will also be fed into that and they'll be aware of it when they meet tomorrow.

Moving on to the training of front-line staff, is it the Cabinet Secretary's intention that a multi-agency training framework for self-harm and suicide prevention be adopted in Wales and, if so, what are the timescales for that?

That is one of the items that the advisory group are considering tomorrow actually. So, obviously, I'll be taking account of their advice on what to do and how to deliver that, if it is their recommendation to do so. So, yes, it's an issue that I'm aware of. The National Collaborating Centre for Mental Health is developing some self-harm and suicide prevention competence frameworks and we're thinking about how, then, to take that forward, and that's part of the reason why we have an advisory group to help us to do so.

Right. And again, of course, Network Rail's training for front-line staff is highly commended, so maybe that could be something that could be rolled out amongst all front-line staff throughout Wales.

Yes. Those examples of good practice that already works are really helpful for us. I think it's about how we do something, not whether we're prepared to do something.

And that's what you're discussing tomorrow.

Yes, that's what the advisory group is discussing tomorrow, or part of what they're discussing tomorrow. They have an agenda that is more than one item.

Thank you. 

Thank you. Last week, half of the committee went to the Jacob Abraham Foundation and we had very powerful evidence from quite a number of families bereaved by suicide, and the picture that they presented of the support was not a positive one. Without exception, they all said that apart from the foundation, there wasn't any help for them. And very worryingly, they hadn't been able to get access to 'Help is at Hand Cymru', which is a really excellent resource for people bereaved by suicide, to the point where the foundation had to contact Public Health England and use their version, which, of course, doesn't have the Welsh contact details in it. What's your comment on that level of bereavement support for people bereaved by suicide, and do you think that there should be a proper bereavement postvention pathway, which has been recommended by Professor Ann John in the review of 'Talk to me 2'?

There are, I guess, three things there. The first is that I do recognise that we need to do more around bereavement support. So, yes, I recognise that we need to do more on the first point.

Secondly, I'll deal with the specifics about the postvention pathway. Again, we're getting advice from the advisory group, but I would be very surprised if the national advisory group did not recommend taking on the learning from England in understanding what we want to do here in Wales. It would be kind of odd if I said, 'I think we've got more to do on bereavement support' and to then say, 'but I'm not interested in what's taking place across our border'. So, yes, I'm interested. I know it's one of the recommendations and I expect that to come forward from the recommendations not just from this committee but also from the national advisory group as well. 

The third is the experience that you recount from the Jacob Abraham Foundation. I met both the mothers a couple of years ago and we did talk about 'Help is at Hand', and at that point, they described some difficulties and they said that they would've found it useful, because they didn't have access to it at the time. So, I'm really disappointed to hear that there are still families out there that are describing that they don't have access to it. Last night when I was preparing for this meeting, I Googled 'Help is at Hand Wales' and I found it was within the first two results. But I guess the problem is that if you don't know that it's available, then you can't access it. So, I think we need to understand from those people who've not had the support that is available how we do that and what would've mattered to them, because it's different for different people—but to understand, if you're looking for support, how do you look for it and then to make sure that people like the Jacob Abraham Foundation have got ready access to hard copies as well as online versions. 

Yes, I think that's the point, really: that people don't want to go Googling things when they're bereaved by suicide. What we need is front-line staff—police officers, people in A&E—who give this in hard copy to families, so that they can read it when they can face reading it.

You see, from the conversation I had with them nearly two years ago now, because we did then relaunch 'Help is at Hand' in June 2016, I had understood that there was going to be greater—. We had a different range of people who said that it would be useful for us, and so I'm really interested in hearing about where people are saying that they don't have access to it—

I've never met anyone who has been given it who has been bereaved by suicide.

Well, that's why I'm interested in the individual stories of those people. Because we, of course, want to listen to people who've gone through this. We can't expect to improve the position if we're not prepared to listen to their experiences. So, I'm definitely interested in not just the general report from the committee, but in terms of those people who are prepared to share their experiences about where they were and where it would've been useful, because we need to understand where that isn't getting, rather than saying, 'Look, we've got copies of this in hard copy and they're available'. And the fact that people are contacting Public Health England is actually a problem, and it's a significant problem for me, because there are copies available in Wales. I don't understand how they haven't had access to it, and I want to, to be able to do something about it.

Sorry, Lynne, but before we go on, Dawn has got a question on this point.

It was on that point, because there were two things about that. One is that, over and above the point that Lynne has just made about the individuals not being able to access it, the organisation, the Jacob Abraham Foundation, weren't able to access it. They contacted Public Health Wales, and they were not able, as an organisation trying to help bereaved families—they couldn't get copies of it either. Public Health Wales, apparently, were very unhelpful. So, that's the first thing.

But the other point I just wanted to make was that I met recently with the police in my constituency, on the back of our visit to the Jacob Abraham Foundation, and they said that they would find it enormously helpful to have that resource available, because one of the consistent reports from that group of bereaved families was that the police arrive to tell them that a member of their family has taken their life, but because no crime has been committed, the police have no further involvement, and they leave them. They're just left on their own, and they've nothing. When I was talking to the police in my constituency, the point that they made is that the police often leave those circumstances feeling awful themselves because they don't feel there's anything they can do, and they said that it would be enormously helpful to them if they had access to resources so that, when they know that they're going to a family to give them this news, they could say, at the same time, 'Look, when you're ready, have a look at this, this might help.' At the moment, that's not available.

Part of my disappointment at hearing that is that that was part of the conversation that I'd already had. I'm really disappointed to hear that the Jacob Abraham Foundation contacted Public Health Wales and they were unhelpful, because this resource is not a secret and we want it to be available. The reason that we updated it in June a couple of years ago was to update it and to make sure that it was available. Now, for all the groups like Samaritans that perhaps have copies of that resource—we know those aren't the only places that people go. The police were one of the organisations that we talked to, including mortuary staff, as well, where people go to identify bodies, and understanding about—. So, there are a range of different points that I thought we were going to cover in making the resource available. The fact that people are recounting to you that it hasn't been is really disappointing, and I want to understand how we actually do something about that. So, we'll go away and look again at why we think that is, and, actually, we should contact the Jacob Abraham Foundation as well to make sure that they know how—. We'll get them copies and make sure that they know how to get copies in the future as well, should they need more, because that—. The disappointing thing for me is that it shouldn't take a committee inquiry for that to happen.

Well, expect some recommendations. Lynne.

In terms of resources, the review of 'Talk to Me 2' recommended that this work now needs to be resourced in Wales. It's resourced in England and Scotland, but there's no dedicated resource in Wales. In view of the shortage of services for people bereaved by suicide, will you consider giving specific funding for suicide bereavement, and particularly for suicide bereavement support groups in Wales?

Yes, I will consider it, and I need to think again about how that's done, because lots of—. Support that's currently provided isn't always directly provided through the health service, of course; lots of it is third sector support. So, I need to think about how that's provided and how that's done. We provide direct grants for the third sector to provide services. Local health boards do that, and I need to think about whether that's something that we would ask local health boards to do and to deliver in partnership with the third sector, or would we do that at a national level, or not. Again, I expect there'd be recommendations from the advisory group that we'll then need to take account of and then respond to, obviously, as well. So, the report of this committee and the advisory group recommendations—. Because, again, going back to the start of this round of questions from you, recognising that we do need to improve bereavement support services, we'll obviously need to think about the funding of those in doing so, as opposed to just saying we can be smarter and more innovative, because that's often a way to say, 'Let's do something without spending any money on it.' So, we need to think about how we do that, and I expect that there will be calls for more funding and targeted funding that we can demonstrate is making the difference people want it to, rather than disappearing somewhere and you can't actually identify what good that money is then doing.

A final question from me. The committee's been told that suicide prevention activity in Wales should be co-produced with those with lived experience of suicide. How do you think we can deliver that kind of co-production, working not just with people directly bereaved by suicide, but front-line staff who have been affected by it as well?

Well, that's one of the things we've tried to do more broadly in health and healthcare services: actually listening to the voice of people with direct experience, whether they're staff, carers or individual people and families affected. So, in terms of taking forward not just the recommendations of the advisory board, we want to think about how we actually make sure that we are listening to people and they've got a voice in what we're saying. So, the fact that you pointed out that you've met a group of families who don't feel well supported, it's not just a message for us, but there are people who are prepared to talk and who we should be prepared to listen to, and given that we're going to talk to the Jacob Abraham Foundation after this, there's a group of people there—. And also, I'd like to see how it is taken forward in the Wales Alliance for Mental Health work as well. I meet that alliance on a regular basis, and how this issue is taken up—. And to be fair, the Samaritans have raised issues through that alliance, but it's for us to try and make sure that we're continuing making sure we do listen to the voice of users and carers in a range of work we already do. But I want to make sure that that's visible and people understand that—so, even if they are not the families involved, that they're confident there are other families with direct lived experience who have had an impact on how we're trying to design and deliver our system. So, I think we need to demonstrate not just how that's done, but then to be able to set out in which areas people have had a direct influence on the work that we're doing, as well as each point that we review it as well. Because it isn't just a one-off, I accept; you can't just say, 'I talked to families and I listened to families three years ago, therefore, everything's okay'. So, it has to be a regular part of what we're doing. When we talk about continuous engagement, this is one of the things we're talking about. So, when we review other frameworks as well on mental health generally, on substance misuse, on a range of areas, we want to listen to the voice of carers and users. It will be the same in this area as well.

I will make the point that while some members of this committee were visiting the Jacob Abraham Foundation last week, others of us—I'm looking at Angela—were visiting Tir Dewi, which is a very similar charitable organisation, and coming to the same actual conclusions about the lack of information. I don't know whether you want to—?

[Inaudible.]—in terms of saying that we'll talk to the Jacob Abraham Foundation, I would be interested in a conversation with that group too about their experience and what they haven't had access to, and what they would find useful as well, because I think it's important we're prepared to do that proactively.

It's not just what they haven't had, though, Cabinet Secretary; it's also about the complete lack of understanding that is around the service provision for people who have had a family member take their life and what has happened, especially in farming communities. I think it would run true to other areas where you haven't just lost a loved person, but you've lost the leader of the business, or you've lost the extra pair of hands on the farm, you've lost the succession planning, you've lost everything. So, the family don't have a chance to deal with the grief. What came across very strongly was that they had no chance to deal with grief because, actually, tomorrow morning, those cows need milking, the sheep need putting out, the hay needs taking in, the crops need sowing, and all the other things. And I think that you could probably take that and lift it from farming to anywhere where you have people who have a small venture with sons and daughters, or husbands and wives, or whatever it might be, when one suddenly is taken away in such a tragic way, then that pressure on that family is doubly intense. And, of course, the inspection regimes still roll on pitiless in their objectives that they have to meet, and it's incredibly difficult. And when they turn around for support, they just cannot find it. I've yet to meet somebody who's gone, 'No problem, we had bags of support when this awful event happened to us'.

I don't have anything to add in terms of the previous question, because it's the same challenge in a slightly different context. But there's still a challenge about the support that we expect to be provided, and how we need to understand where people have not had access to that support, even though there are resources available. That's really difficult.

Expect some recommendations coming your way.

Well, it's very difficult to hear, but we need to do something about it.

Absolutely.

I briefly touched earlier on the mental health transformation fund, and the £7 million that's been invested, and the plans—[Inaudible.]—about how they want to use that. We've made clear that we expect them to be focused on improving crisis care services and also community services as well. So, it is part of what we expect to see improvement on.

On your point about GPs not being able to access contact with specialist health, I'm interested in how consistent an issue that is, because my understanding is that GPs should be able to contact the duty officer with queries, and they should have a prompt call back if there is a need for psychiatry input.

I'll explain that one of the things that became clear was that there was no direct link that the GP could have with a psychiatrist, for example—a direct contact.

May I say, as a result of some very tragic incidents some years ago, the system for accessing emergency care has been streamlined. So, across Wales, a GP can get an appointment for a patient in an emergency situation within two hours [Correction: four hours], or in an urgent situation within 48 hours. The GP does that by ringing the relevant community mental health team and asking to speak to the duty worker. That duty worker will take the history from the GP, so there's no need for a letter, there's no administrative delay. Having spoken to the GP, more often than not the response is: 'I will see your patient within the two hours [Correction: four hours].' Alternatively, they may say, 'I need to speak to the psychiatrist.' They will then go and interrupt the psychiatrist in the clinic, come out and ring the GP back.

I think there have been problems in the past, but I think there have been significant steps to address those problems.

That doesn't sound like what we heard is actually happening on the ground. That may well be how it's meant to work, and there are GPs close to me here who might have an opinion on that. But we can feed back quite clearly that that is not how—

I am a GP, and only last Friday I accessed emergency care for a patient in just this way. So, I'd be very interested to hear of problems where people can't access that, because they would be very significant incidents and would need to be investigated.

Okay, that's interesting. No doubt, again, we will provide all the clear evidence that we've been given during the course of this inquiry. Sorry, you wanted to add to that.

To be fair, if that evidence—there's no need to wait for a report. You could go weeks. I'd want to understand that sooner rather than later, and not wait for the report to be agreed. So, the details that you have, I'd like to see them passed on so that they can be looked at.

Another issue: access to psychological therapies. Professor Keith Lloyd of the Royal College of Psychiatrists told us that waits for psychological therapies can be in the order of 18 months, and with pretty solid evidence that these kinds of therapies can be very effective, obviously those kinds of waiting times don't really help with early diagnosis and early treatment. How do you respond to that, and what plans do you have to improve access?

We're investing a recurrent £5.5 million to help improve psychological therapies. Health boards are expected to submit plans for use of those, which will align with the advice and guidance provided within the next month, so by the end of July. The point about this is to improve access to care, because, as I responded to Lynne Neagle earlier, I wouldn't try to say that all of the current waits are acceptable. We recognise there's improvement that is required—not just desirable, but required. That's why we've committed to invest a sum of money, and, again, not just in this report, but I expect in more general scrutiny, you'll want to ask more questions about it, and also the plans—have they arrived, has the money gone out, and what difference is that starting to make? Because each of those figures is a person.

But it's not just not really acceptable—18 months for therapy that can really nip a problem in the bud and give somebody a real opportunity to deal with the issues that they have is so far off the mark. It's not a matter of tweaking, is it, really? 

No, but then I'm not suggesting it's a matter of tweaking. We wouldn't be investing that sum of money with plans required for improvement if we thought it was just a matter of tweaking. And even a relatively limited number of people waiting that long is a problem for that person, for the family in the context they're in, so that's why there's a real challenge about not just there being more money, not just there being more investment generally within the service, but actually wanting to see that made real. 

So, like I say, I won't tell you today that everything is fine and you can be confident that all will be well in the future, so don't ask me again. I'm expecting to come back and have questions and to expect to be able to provide answers about how far we've got and how much further we still have to go as well.   

Lynne, on this point. 

Just very briefly: do you think we're training enough psychologists because the clinical psychology training places—what is it, about 25 in south Wales, 25 in north Wales, I think, which isn't a lot of psychologists coming forward and, obviously, some of them go and work elsewhere anyway? 

Psychology, I think, is one of the areas that is one of our speciality areas in taking forward ‘Train. Work. Live.’, because we recognise that we don't just want to have all those places filled, but then we've got to think about how we want to keep people as well. So, my personal view on how many people—I always think it's dangerous for Ministers to have personal views on individual staff numbers, but, actually, that's why we were creating people like Health Education and Improvement Wales, to give us a view on how many people we need, how we train them to make sure that the quality of training is good, but also how we keep them as well. 

Obviously, in the nursing and midwifery field, we've got bursaries and we've got the opportunity to work in the health service to be taken up to receive that funding. We've got different incentives to get people in, and also, as you know, in GP speciality training as well, we've got opportunities to keep them for a period of time after. So, we do need to think about not just numbers, not just incentives to come into the system to train, but, actually, what we want to do to try and keep people, because this is a general shortage across the UK. So, what I don't want is that we train lots of people to go and work in other parts of the health system. England and Scotland will be having similar conversations as well, so we have got to think numbers but also outcomes, and what that means in terms of our staff number as well. And it is one of my many anxieties about the future of the service.    

Okay. Rhun. 

Hopefully, earlier intervention with enough trained professionals can avoid crisis and the need for crisis care in many cases. In matters of crisis, though, your transformation fund—you tell us in your written submission that it is aimed to increase access out-of-hours and 24-hour access to mental health professionals for individuals in crisis and at risk of suicide. Do you want to tell us a little bit more about that—what your hopes are for what the transformation fund can do in that area?   

We've already invested £2.7 million to extend the crisis team in Powys for children and young people, so it's 12 hours. And our expectation is that we want that to be 24 hours, and for it to be available seven days a week. So, that's about what partners are currently doing in terms of how the work is taken forward now, and also what the future looks like as well, because we don't centrally sit down and say, 'Within my office or within advisers directly working for me, we decide a direct central model', because you do need to take account of what crisis care will look like in different parts of the country, and physically what that looks like as opposed to the quality of what that is.  

So, we may have things that are slightly different as they match, appropriately, different parts of the country. I know I regularly say that we have too much variation across our health system, and that it's just about local practice, not good practice, but this is an area where you have to understand and you need to understand what looks different to be appropriate to that part of the country. So, it's about how quickly that transformation money is used. As I've said for the third time now, crisis care is part of the £7 million transformation fund for mental health that we have, and it's then about being able to describe not just the story of it, but then to be able to say, 'And here's what "better" looks like across the country.'  

Okay. I'm conscious of the time, so—

Yes, so am I, obviously, and we need to get a little bit more agile now, and I'm looking to my agility queen, Dawn.  

I will be very quick. Just on people being discharged from in-patient care, Cabinet Secretary, the 'Together for Mental Health' delivery plan talks about a follow-up within five days, and yet we've heard, actually, that the peak time for suicide risk on discharge is about three days. So, one question is (a) do you think the current standards are being met and, secondly, do you think there is a case for reviewing 'Together for Mental Health' to introduce a three-day target rather than five?

Part of our challenge in understanding how current targets are met is the reality that our information technology systems are not optimal, and so to be able to give ourselves all the assurance we would want, you'd want that to be systematised. We're moving towards having an IT system—the Welsh community care information system, which is often referred to as 'WCCIS', which is one of those acronyms that people don't understand unless they're in that part of the service. That won't be in place until 2021, but that will mean that we'll have a way to more accurately understand what our system is delivering. The current target is being reviewed because we've heard that evidence as well. And so, in taking forward the next delivery plan for mental health, we may well have change in that target and that expectation, because we've heard that evidence too. I forget which body has made a recommendation—we've got recommendations to consider about that as well. 

Two more fairly quick questions, Chair. One is around the confidence that clinicians have about sharing patient information in cases of suicide or self-harm. Do you think there's a case for strengthening the guidance to professionals around this? We've heard that, sometimes, the families and parents are the last people to know that their family member was at risk, and that there's a reluctance by professionals—a confidence issue rather than a reluctance to actually share information. Do you think there's a case for strengthening the guidance to professionals?

Yes, you are right. About three months ago, Papyrus wrote to us—. Young people who have taken their lives—. They asked us to circulate the accurate form of the guidance. So, as the General Medical Council states, you shouldn't share information, but even the GMC is quite clear that if it's in the patient's interest that you should share information, you should do so. So, Papyrus asked us to share that interpretation in order to get more consistency, but you're right to highlight it as an issue, and it is something that we need to continue to work on because, still, there are misconceptions about patient confidentiality—when it applies and when it doesn't apply.

And does that also apply then in terms of sharing information across agencies?

Absolutely, yes.

And that would link in to the point you were making, Cabinet Secretary, about improving the ICT systems as well, so that that information can be shared. 

Yes. So, Powys, Bridgend and Merthyr already have WCCIS in place, and every authority that has adopted it has recognised an improvement in the way information is shared between partners, and that benefits the citizen. The challenge is how quickly we roll that out across our system. There is still some reluctance in different parts of our system, but we've just got to be able to get on and do it, frankly. It's one of those once-for-Wales choices we need to be able to make and implement, because the inefficiency isn't just financial, the inefficiency is then delivered in patient outcomes and experience. 

Okay, thank you. Thank you, Chair.

Okay. Jayne.

Thank you, Chair. Last month, representatives of the regional suicide prevention forums described inconsistencies in the make-up and operation of the forums and called for a greater central steer from Welsh Government national advisory group, particularly in relation to membership, reporting structures, and also training. Do you think that would help?

It could do, and that's one of the things the national advisory group will consider. In all of this, there's that balance in how you say to local groups, 'You understand the part of the country you live in and are responsible for and you need to design something appropriate', and how much we say, 'You have to work within a national framework.' But I'm interested in what the advisory group have to say about greater consistency and the engagement and involvement of different people who should be in the same room at the same time. 

Okay, thank you. We know that suicide is a leading cause of death among people under the age of 35 and the leading cause of death in men under the age of 50, and there's no specific funding for suicide prevention. So, what consideration have you given to making further resources available to fully implement 'Talk to Me 2' to ensure that suicide prevention can be sustained beyond the life of this current strategy?

Well, that was part of the point of having a mid-point review of 'Talk to Me 2', to understand how much progress we've made. There are positives about the progress we've made, but also there are clear signs of where progress is yet to be made as well. So, we talked earlier about funding for bereavement support services, but we need to think about what that looks like across the whole picture. So, that will be part of what I'm expecting back from the advisory group, with recommendations about what we then need to do. And, of course, we then have to respond to that. So, I know that funding is always a question we have to consider—about where to put our money to deliver a return that makes a difference with and for people. So, yes, we will have to answer questions in responding to recommendations from the advisory group and the mid-point review about what we're then prepared to do, and of course expect to be held accountable for that.

I'd just like to move on to a couple of the at-risk groups. We've had written evidence from the National Confidential Inquiry into Suicide and Safety in Mental Health, which highlights that 70 per cent of mental health patients have a history of previous self-harm, and studies have shown that the risk of suicide, following self-harm, is particularly high, and a specialised psychological assessment is key in determining that future risk. What steps are being taken to ensure that NICE guidance on management of self-harm is consistently implemented across Wales?

I think Ainsley may be able to—.

Sorry, I forgot to say, on the issue of investing in different areas, in a previous question, we have actually invested money with third sector partners in some of those areas, particularly men's access to mental health. So, we've invested in a range of things in our section 64 grants with Men's Sheds, but also work with Samaritans too. So, there is direct funding going in, but we need to see whether that's adequate or not. That's a point I should have made, sorry.

In terms of self-harm, I think, a lot of the time, self-harm happens outside of services. So, there are a lot of people who self-harm who may not actually come into contact with services. So, there's a lot of work going on in the space of working with the third sector, some of the programmes that are—they're working with students and so on around developing coping strategies, because self-harm is often used as an outlet to cope, as opposed to being necessarily an indication of a suicide attempt. So, the psychological therapy investment within services will help to provide support as well for people who are in contact, and it's only 28 per cent of people who go on to take their life that do contact services. I think there's a lot of focus on that area as well because the self-harm rates have been rising, so what is that about, particularly with younger people. So, we're listening to the advisory group in terms of their advice on how we start to address some of that. Agencies like Samaritans are heavily involved in that space and give us guidance in that area on how to improve.

And, just as a general point, women are more likely to self-harm; men are more likely to take their own lives. So, there isn't a direct link, but it's one of the risk factors that we want to understand.

Okay. We've also heard that psychological assessments are only being carried out in around 60 per cent of cases. So, you know, there is a bit of a concern, obviously.

I don't really recognise that, and I—[Inaudible.]—in particular. I'm trying to understand how robust a figure that is, and what that means for our services, of course.

Okay. Perhaps you can take that up. I've just got another couple of questions, actually. Just following on from that, just around substance and alcohol misuse, we heard some evidence last week at the Jacob Abraham Foundation that we went to around substance misuse as well, and the link there. What further progress needs to be made in developing integrated care pathways for those co-presenting with substance misuse and mental health issues, to reduce the risk of suicide in that particular group?

We've already developed a service framework, coming from an announcement that I made previously—I think when I was a Deputy Minister—about co-occurring mental health and substance misuse. And so we've got a framework to implement now as well. We need to understand how that's being implemented as well, because, again, we know that substance misuse is one of the risk factors in this area as well.

And, just finally, on university students, we've heard that, in recent years, there has been a steady increase in the number of student suicides, and several universities in the UK have experienced that—a number of student suicides within a short period of time. We've heard some evidence as well around students who have perhaps gone away to university, not in Wales—perhaps in England—and they've come back and had difficulty in registering with their GPs, because they've had to register in England. And when they've presented feeling suicidal in Wales, that history isn't replicated, so that the GP doesn't know the history. So, what is the Welsh Government doing to respond to the significant increases in suicides among university students.

The point you raise about students studying in England, registering with a GP and then coming back and finding it difficult to re-register and access primary care was one that I am interested in, about how we just make it easier and make that whole system work for that person. So, I definitely want to be able to take that forward. 

Of course, we're interested in working with the university sector on understanding how we best support our young people who go to university, wherever that is. It is some time ago since I was a student officer, but I'm aware that universities themselves have direct services, as indeed do most student unions in the higher education sector certainly—but to understand what we need to do to get alongside those services too. But, as a general point, the university students are at less risk than the rest of the population of a similar age and actually there is a greater incidence of suicide within our communities who don't go to university than do. So, we want to understand what we need to do in universities, but I don't want to forget the fact that, actually, we have a greater risk and a greater number of people taking their own lives among those who don't go to university.

Caroline, your next question has partially been answered, or have you got a different twist to it?

No, I'm fine; happy with that, thank you.

There we are. We'll move on then to internet matters. Rhun.

Yes, just quickly, the internet and social media are often demonised in this context, but I wonder what your thoughts are on the positive roles that can be played by various online platforms in suicide prevention. 

Social media is a challenge that we didn't have to deal with, growing up, and in many ways I'm grateful for that, but the opportunity to share information online is obviously an opportunity for delivering health and care services in a wide range of areas, including here in mental health support. We've had correspondence from NUS Wales—one of my old organisations—looking to improve what's available online, and we know that there's a potential there to deliver a service that is not just cost-effective, but actually is useful from the citizen's point of view about how they want to access a service as opposed to having to physically attend somewhere. So, it is definitely something that I'm interested in us taking proper advantage of, and, again, how we do that in a way that is consistent as opposed to a piecemeal initiative in different parts of the country.

And investing in it directly perhaps, because of a lot of this stuff might be done by charities and various other groups.

Yes, we'll need to see how that's done.

We have invested in a roll-out of computer internet-based cognitive behaviour therapy for people aged 16 and over with an all-Wales approach, following a pilot in Powys, and we're also scoping ways of looking at what is the best evidence and most reliable and effective programmes for children and young people under the age of 16. So, we're currently working with a number of partners to determine what are the best programmes that are available in terms of online self-help and considering whether a similar approach in Wales, to roll out one or more of those, would be appropriate. 

What are the early outcomes of the pilots?

So, there are several programmes that NHS England, for example, endorses. There are also some local apps. So, for example, in Wales, they've developed an eating disorder app, where young people can assess their eating habits to decide whether or not there's a risk that it's an eating disorder to get advice about whether to seek help. That was something that was developed within one of the health boards in Wales; it's currently being piloted and it's looking very promising. So, I think we'll be considering both what we have learned from other areas in the UK, but also some of these new innovations that are coming up locally and elsewhere, before committing to one or another to fully see what the best decisions are in those areas.

Ocê. Diolch.

Okay. Any other questions? Rhun.

Yes, I wouldn't mind asking just about the suggestion that there could be more work done on locating community psychiatric nurses in police control rooms. It's shown to be an effective triage model in terms of responding to people in crisis.

Yes, I think it's one of the things that Alun Michael, the south Wales police and crime commissioner, is particularly interested in and, actually, some police forces have invested some of their own resources to develop them. Actually I met with Alun Davies and chief constables and police and crime commissioners at the start of this week, together with people from the fire service, who were interested in not just how the blue light services work with each other, but more generally those services, and one of the regular challenges that police forces face is in dealing with mental health. So, it's one of the things where actually we've made some progress, but there is still more for us to do. How staff are located is part of that, whether that's deliberately in large-scale investment in the same control rooms or not, and, in the evidence from south Wales of what that means, there may be choices for all of us to make broadly across the public services, and not just about trying to shift money between police and the health service, but, yes, it's definitely an area that I'm aware of and interested in. Again, I'd like to see somewhere that there's a model that we can say that consistently should be the right thing, because, obviously, those police employees who are handling calls coming in will need to be supported as well.

Okay. Lynne.

Yes, just very quickly, obviously, you've responded to the children's committee's report on mental health, which has called for guidance to be issued to schools on talking about suicide and self-harm, and we're debating that next week, which is fine, but I just wondered if you wanted to get anything on the record in this committee because that has been a strong theme of the evidence that we've heard, that that should be a priority, really, and that talking about suicide doesn't cause suicide—on the contrary, it makes those conversations possible to prevent suicide.

Yes, I've heard the evidence and the debates, and I think there is something about how we normalise conversations, including around suicide. Lots of people that I've met—. In terms of thinking about some of the conversations I've had myself outside of public life about trying to get to a position where people are more readily likely to have a conversation to avoid a problem rather than actually saying, 'Let's not have a conversation because I find it difficult', and normalising that conversation at earlier parts in life, you can see the value in doing so. What I don't want to do is to try and provide a commitment about how the curriculum and how space in school is used when, actually, that's not just about the lead of another Minister, but it is a whole Government conversation. It would potentially involve the resources that we have in health being used as part of that as well—so, not just about the pilots we're running on the child and adolescent mental health services, about providing resilience, saying, 'Well, what do we want that to deliver and achieve?' And as those start, from the autumn onwards, I think we'll have more learning that isn't just going to be about the end of the two years, but understanding and learning, 'Well, how is that changing the nature of the conversation?' as the pilot runs, and then, more generally, 'Is that delivering the change that we want it to?'