Cynulliad Cenedlaethol Cymru

Yn ôl i Chwilio

Y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon

Health, Social Care and Sport Committee

17/05/2018

Aelodau'r Pwyllgor a oedd yn bresennol

Committee Members in Attendance

Caroline Jones AC
Dai Lloyd AC Cadeirydd y Pwyllgor
Committee Chair
Dawn Bowden AC
Jayne Bryant AC
Julie Morgan AC
Lynne Neagle AC
Rhun ap Iorwerth AC

Y rhai eraill a oedd yn bresennol

Others in Attendance

Antony Metcalfe Rheolwr Ardal Cymru, Y Lleng Brydeinig Frenhinol
Wales Area Manager, Royal British Legion
Dr Ann Luce Bournemouth University
Bournemouth University
Dr Jane Fenton-May Is-gadeirydd, Coleg Brenhinol yr Ymarferwyr Cyffredinol Cymru
Vice-Chair, Royal College of General Practitioners Wales
Dr Kathryn Walters Seicolegydd Clinigol Ymgynghorol, Cymdeithas Seicolegol Prydain
Consultant Clinical Psychologist, British Psychological Society
Dr Rebecca Payne Cadeirydd, Coleg Brenhinol yr Ymarferwyr Cyffredinol Cymru
Chair, Royal College of General Practitioners Wales
Dr Rhiannon Evans Prifysgol Caerdydd
Cardiff University
Dr Sallyanne Duncan University of Strathclyde
University of Strathclyde
Genevieve Smyth Cynghorydd Proffesiynol, Coleg Brenhinol y Therapyddion Galwedigaethol
Professional Advisor, Royal College of Occupational Therapists
Paula Berry Rheolwr Gweithrediadau Rhanbarthol – Canolog, Combat Stress
Regional Operations Manager – Central, Combat Stress
Peter Hewin Uwch Therapydd Galwedigaethol, Coleg Brenhinol y Therapyddion Galwedigaethol
Senior Occupational Therapist, Royal College of Occupational Therapists

Swyddogion Cynulliad Cenedlaethol Cymru a oedd yn bresennol

National Assembly for Wales Officials in Attendance

Catherine Hunt Ail Glerc
Second Clerk
Philippa Watkins Ymchwilydd
Researcher
Tanwen Summers Dirprwy Glerc
Deputy Clerk

Cynnwys

Contents

1. Cyflwyniad, ymddiheuriadau, dirprwyon a datgan buddiannau 1. Introductions, apologies, substitutions and declarations of interest
8. Atal hunanladdiad: Llythyr gan Gadeirydd y Pwyllgor Plant, Pobl Ifanc ac Addysg - 3 Mai 2018 8. Suicide Prevention: Letter from the Chair of Children, Young People and Education Committee - 3 May 2018
2. Atal hunanladdiad: sesiwn dystiolaeth gyda Choleg Brenhinol y Therapyddion Galwedigaethol a Chymdeithas Seicolegol Prydain 2. Suicide Prevention: Evidence session with the Royal College of Occupational Therapists and British Psychological Society
3. Atal hunanladdiad: sesiwn dystiolaeth gyda'r Lleng Brydeinig Frenhinol a Combat Stress 3. Suicide Prevention: Evidence session with the Royal British Legion and Combat Stress
4. Atal hunanladdiad: sesiwn dystiolaeth gyda Dr Sallyanne Duncan, Prifysgol Strathclyde a Dr Ann Luce, Prifysgol Bournemouth 4. Suicide Prevention: Evidence session with Dr Sallyanne Duncan, University of Strathclyde and Dr Ann Luce, Bournemouth University
5. Atal hunanladdiad: sesiwn dystiolaeth gyda Dr Rhiannon Evans, Prifysgol Caerdydd 5. Suicide Prevention: Evidence session with Dr Rhiannon Evans, Cardiff University
6. Atal hunanladdiad: sesiwn dystiolaeth gyda Choleg Brenhinol yr Ymarferwyr Cyffredinol Cymru 6. Suicide Prevention: Evidence session with the Royal College of General Practitioners Wales
9. Cynnig o dan Reol Sefydlog 17.42 i benderfynu gwahardd y cyhoedd o weddill y cyfarfod 9. Motion under Standing Order 17.42 to resolve to exclude the public from the remainder of the meeting

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 09:30.

The meeting began at 09:30.

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

Diolch yn fawr. Croeso i bawb i gyfarfod diweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon, yma yng Nghynulliad Cenedlaethol Cymru. O dan eitem 1, a allaf estyn croeso i'm cyd-Aelodau ar y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yn y lle cyntaf? Rydym wedi derbyn ymddiheuriadau gan Angela Burns. Nid oes neb yn dirprwyo heddiw. Yn naturiol, mae popeth yn fan hyn yn breifat heddiw, onid yw? Mae'r cyfarfod yma'n breifat—. 

Thank you very much. Welcome, everyone, to this latest meeting of the Health, Social Care and Sport Committee, here in the National Assembly for Wales. Under item 1, may I extend a welcome to my fellow Members of the Health, Social Care and Sport Committee in the first place? We have received apologies from Angela Burns. There is no substitute today. Naturally, this meeting is in private today, isn't it?

Mae'n gyhoeddus.

It's public.

Mae'n gyhoeddus, ie, roeddwn i'n meddwl. Mae'r cyfarfod yma yn gyfan gwbl yn gyhoeddus. A gaf i yn bellach egluro bod y cyfarfod yma'n ddwyieithog, a gellid defnyddio clustffonau i glywed cyfieithu ar y pryd o'r Gymraeg i'r Saesneg ar sianel 1, neu i glywed cyfraniadau yn yr iaith wreiddiol yn well ar sianel 2? A allaf i yn bellach hysbysu pobl y dylid dilyn cyfarwyddiadau'r tywyswyr os bydd larwm tân yn canu? Nid oes angen cyffwrdd â'r meicroffonau—mae'r system yn gweithio yn awtomatig. 

It's public; it's not private. It is entirely in public. May I also explain that this meeting is bilingual, and you can use headphones to receive interpretation from Welsh into English on channel 1, or to hear the contributions in the original language amplified on channel 2? May I further inform Members that they should follow the instructions of the ushers should the fire alarm sound? There is no need to touch the microphones—the system works automatically.

2. Atal hunanladdiad: sesiwn dystiolaeth gyda Choleg Brenhinol y Therapyddion Galwedigaethol a Chymdeithas Seicolegol Prydain
2. Suicide Prevention: Evidence session with the Royal College of Occupational Therapists and British Psychological Society

Felly, gyda hynny o ragymadrodd fe wnawn ni symud ymlaen i eitem 2, ac ymchwiliad y pwyllgor yma i atal hunanladdiad. Mae gennym y sesiwn dystiolaeth gyntaf y bore yma gyda Choleg Brenhinol y Therapyddion Galwedigaethol a Chymdeithas Seicolegol Prydain. Rydym wedi derbyn ac yn ddiolchgar iawn am y dystiolaeth ysgrifenedig ymlaen llaw. Mae gennym dri tyst o'n blaenau ni, ac er mwyn y record a allwch chi gyflwyno eich hunain, os gwelwch ei fod yn dda?  

So, with those few opening remarks we move on to item 2, and this committee's inquiry into suicide prevention. We have our first evidence session this morning with the Royal College of Occupational Therapists and the British Psychological Society. We have received and are very grateful for the written evidence beforehand. We have three witnesses before us, and for the record could you introduce yourselves, please? 

Shall I start? My name's Peter Hewin. I'm an occupational therapist, representing the Royal College of Occupational Therapists. 

Hello, I'm Genevieve Smyth. I'm an occupational therapist, and I'm from the Royal College of Occupational Therapists. 

Bore da. I'm Kathryn Walters. I'm a clinical psychologist and I'm representing the British Psychological Society, but I didn't write the submission. I'm an NHS clinician in Wales. 

Grêt. Diolch yn fawr. Mae gennym gwestiynau wedi eu paratoi ymlaen llaw, felly gyda'ch caniatâd ac fel sy'n draddodiadol, fe awn yn syth mewn i gwestiynau, ocê? Mae'r cwestiynau cyntaf o dan ofal Lynne Neagle. 

Great. Thank you very much. We do have questions that have been prepared beforehand, so with your permission and as is our custom, we'll go straight into questions. The first questions are from Lynne Neagle. 

Thank you, Chair. Good morning. The royal college's paper states that

'suicidality has become a unit of currency, tradable for access to services.' 

Can you expand on this point? Is there actual evidence that it's happening, and what are the impacts of that? 

Shall I speak to that? I think the evidence perhaps would be in terms of the number of assessments that are carried out by mental health services in relation to the number of cases that are actually taken on for treatment. There's a significant disparity—it's something in the order of 70 per cent not taken on, 30 per cent taken on, certainly in the team I work in in any case. Very often, what we find is that because of the thresholds and the criteria for access, when referrals are made there is, if I can perhaps say, an over-emphasis on risk in order to speed things up, if you like. When we actually see people, we find out that the real issues that would need to be addressed are different, but because they then don't meet thresholds for secondary care they perhaps get unaddressed. I think one of the things we would want to advocate is the whole early intervention approach, whereby the real underlying issues are dealt with in the first instance, rather than getting ourselves into an unfortunate situation whereby circumstances have had to reach crisis point in order to access services. So, I think that's what was behind that.  

So, when you say that risk is being over-emphasised, that's being over-emphasised by the people referring rather than the patients themselves. 

09:35

Okay, thank you. You also state that suicidal ideation is not necessarily a sign of mental illness, but one of emotional distress, and that the medical model—if you could just refer to that now—may not be appropriate. What kind of approaches do you think we need, then, to put that into place?

I think, again, unfortunately, over a period of many time, we've got into a situation whereby the expression of suicidal ideation is very often taken as a sole indicator of a severe mental health condition, and, again, it takes us down the wrong route. That's not to say at all that people with severe mental health conditions all experience suicidal ideation and require treatment, but, very often, the medicalisation of that, as I've already said, really, takes us down a very prescriptive, paternalistic, 'We do to you' approach rather than one that, actually, is much more collaborative, much more working with the person to try and overcome the underlying difficulties that have led to such a sense of distress that people often—not always, of course—. It's kind of a metaphor, the thought that 'My life is no longer worth living and I want to end it', for 'I feel hopeless; my circumstances are so difficult that I don't know what to do.' And if we could help people know what to do, then we wouldn't be prescribing so many pills and all the rest of it. 

You also refer to the need for a capacity test for suicidality. Can you just explain how you'd see that working, and then maybe BPS could give their views on that idea?

It pertains very much to what we've discussed already. I don't think we're suggesting that this is anything you would legislate for, or anything like that, but it's simply the notion that mental health services are for serious mental health conditions, of course, but as we've already indicated, an awful lot of time is taken up assessing things that aren't mental health conditions. There ought to be a way of distinguishing between when somebody's cognitions are so impaired by a mental health condition that, absolutely, they need to be treated by mental health services, and when it is the situation I described earlier and it's more of a metaphor for distress. And then that gives a way in to say, 'Let's take a different approach: let's look at this in a more sensible, non-medical way.' 

I think there's a multiplicity of risk factors, and although many risk factors that might increase the propensity to suicide have been identified, I don't think there's much positive predictive value about any individually. And I suppose I would want to add my clinical experience as well, which is over 20 years working in mental health services. When I think about the three clients with whom I've worked who died by suicide, not one of them told me they were going to do it. Now, I've been trained in risk assessment, and I'm trained to be more concerned about someone if they tell me they have a plan, if they have the means, than I would be if someone told me they have thoughts. And, yet, intuitively, and not just intuitively in my experience, is that people have never said, 'It it my intention to do so.' So, I think there's kind of a gap. I just think it's really complex.

I read my colleague's report, and I would concur and agree that anything that, I suppose, allows for some of the complexity—. I think there are a huge number of social factors and economic factors, and we know there's a social gradient to suicide as well. So, there is a danger, possibly, that we reduce it to either lifestyle tips, or we tinker with one or two things. I just think it's a huge issue that, in many ways, defies a lot of what we think we know. 

Just a quick supplementary on that point you were making then, Kathryn, about somebody saying that they're going to do it and then not doing it. Is it your experience, then, that people who say they will do it are actually at less risk than those who don't?

09:40

I talk quite often with clients about suicidality. So, many of the people I work with will express suicidal ideation, and I don't think there's any evidence that talking about it increases the likelihood that people will do it. I guess I'm just saying—I'm not sure I'm saying the corollary is true, but I am definitely saying that the three people in my career who have completed on suicide never told me that—

No. And I think—if I think for myself—if I really wanted to do it, why would I tell my psychologist, or my GP, because I would know that that would trigger some kind of intervention? Clinically, I have very open conversations with people at the outset of a session, and we'll talk about, 'What you tell me is sacrosanct, and the only caveat to that is if you tell me that you intend to harm yourself or somebody else, and then I'll have to break your confidentiality.'

Thank you. Final question from me: the royal college highlights the value of meaningful occupation and activity in suicide prevention. In what ways do you think we could further promote that, and is there a role for occupational therapy in dealing with the devastation that's left behind after suicide bereavement?

Yes, sure, in both cases, really. We're just about to launch our mental health campaign reports about occupational therapy next week, and the themes of those reports are very much the issues that we've been talking about this morning. So, it's about the complex sets of social problems that people face, and, actually, people need good housing, they need a meaningful life, they need good connections, with good friends, they need good-quality work, and these are the protective factors that we know decrease people's risks. So, actually, certainly for some of the people who you're talking about, these are the things that we feel occupational therapists can deliver on, and help sort the roots of emotional distress. I mean, people are living in poverty—they don't have that sense of meaning and purpose, and we all need that sense of meaning and purpose. And that comes through lots of different ways—our roles: employment is a key issue. So, certainly, one of the things that we're highlighting in our report is early intervention for young people, and, certainly, we think occupational therapists offering particularly students and young people more support is absolutely key. That has improved in the past years, but, actually, I think, if you can get occupational therapists working with young people sooner, that can help at that point—it's a crucial, difficult transition point for young people. For people who are not in employment, we can help people get back into meaningful employment. We can keep people physically active, and we can help intervene early.

So, I'll give you an example. One of the examples in the report is there's a group of clinicians working in the north of Wales, offering a service called Healthy Prestatyn, and there the occupational therapists are offering early intervention for people with anxiety and depression, and it's so they don't have to be referred on to more expensive secondary mental health services. So, there's a group of people who need more than they can access in primary care, but they don't need referral on to psychiatrists, and that's where the occupational therapists are bringing their expertise. So, certainly, I think that's our strength—it's about social determinants, and how we address those social issues.

Diolch yn fawr. Mae'r cwestiynau nesaf dan ofal Rhun ap Iorwerth.

Thank you very much. The next questions are from Rhun ap Iorwerth.

Bore da i chi. Yn dilyn ymlaen o hynny, cwestiwn ynglŷn â beth sy'n digwydd ar ôl i risg gael ei adnabod, ac ar ôl i ymyrraeth gael ei wneud. Mae tystion blaenorol wedi dweud wrthym ni pa mor bwysig ydy hi fod yna ofal dilynol, ar ôl yr ymyrraeth gychwynnol, ond rydym ni wedi clywed bod yna anghysondeb yn y delivery yna o ofal dilynol. A ydych chi'n cytuno bod hynny'n broblem, a sut mae mynd i'r afael â hynny?

Good morning to you. And following on from that, a question on what happens once risk has been identified, and once intervention is made. Previous witnesses have told us how important it is that there is follow-on care, after that initial intervention, but we've heard that there is inconsistency in that delivery of follow-up care. Do you agree that that's a problem, and how do we tackle that?

I certainly would agree that there is inconsistency. I think one of the problems that we have is that—and, again, I know I'm coming back to this issue about the medicalisation of the problem—actually, medical solutions are not quick fixes; no tablet that a psychiatrist would prescribe acts immediately—you're talking about several weeks. No talking therapy acts quickly. And yet, if the threshold or the Mental Health Act 1983 isn't met, then the way services are configured now, we have a bit of a vacuum, really, in a lot of cases. And I suspect that's where the inconsistency is being identified. Again, I would argue that we need more in the way of support at that point, but also much earlier on before you get to that point, because, unfortunately, it's this threshold business again—things have to become critical before people can access services, when it would be better if we intervened earlier.

09:45

Yes, and I'm sure that early intervention absolutely is something that would be desirable, but once that intervention, from your point of view, has been made, it's what happens afterwards as well and whether there are deficiencies in that. I don't know if you have thoughts.

I guess it depends how you define 'intervention', because for me, clinically, an intervention could mean working with someone for an extended period of time, and I would say that, often, I think what helps to keep people safe is making meaningful relationships. Our basic needs are to be connected, valued and safe, and I think often, certainly in some in-patient settings, we've moved towards the idea of safety and containment in the physical environment, so we've moved the means by removing ligature points, but I'm not sure we've given as much attention to the value of meaningful connections for people who find themselves in those environments. So, I think if you're talking about an assessment in a community mental health team as an intervention, I would generally hope and expect there would be some kind of follow-up from a team. By the time someone arrives though my door, I'm likely to be seeing them for an extended period of time, and a huge part of what we do is about building a relationship. But in truth, that doesn't happen that quickly, but actually even giving people the hope of that, I think—

Yes, it's about giving people the hope of that, and knowing, in a sense, that they're being held in mind by services—that they're being thought about. I do think that the pressure, often—. We know that, often, targets shape the behaviour of services, and I think a lot of mental health services are probably firefighting because of demand and because of pressures, and to some extent you turn your attention to where a target is because that's what organises you.

One other question on a group of people who are far too reluctant to come to your door or anybody's door, and that's men, especially middle-aged men, who are at a higher risk of death from suicide, and there's clear evidence that men are reluctant to seek help. Do we need new ways of encouraging men to seek that help—to hear those or take on board those messages, and are there examples of good practice out there that we can follow?

I could talk about some great examples that took place in Scotland, probably 10 to 15 years ago, by a psychologist called Jim White, who was running a primary care intervention. He knew that most, or many of the men in Glasgow, which is where he was working, wouldn't give any thought to a leaflet or may not even attend their GP surgery. So, they thought really clearly about where people were and they did things like put that information on beer mats and put them out in the pubs and they put posters at the height of the urinals, because that's the only time that some of these men might actually read something. So, yes, I think it is worth thinking creatively about how you target communities or groups of people who are either disenfranchised, or who have disenfranchised themselves, from accessing mental health services.

Yes, I'm in agreement with that. If you think about the Men's Sheds example, in my experience of working with exactly that group of men, sometimes it was difficult for them to access a formal talking therapy session, but what they would do is an activity together, and doing things side by side with peers was the way to start to mention that there was some difficulty or some problem. So, I think it's about building community-based opportunities for men to do meaningful activities. My other half—his main love is cars, so all of his social networks and structures are around cars, for example. So, it's about thinking about that male culture and how we think of these normal things that men do, and how we get out that message out via those normal activities about the fact that it's okay to talk—sometimes life is hard and we struggle and we need to talk about it.

09:50

I've got a particular concern, I must say, about the agricultural community, especially as they move on to a period of coming under intense stress over the next few years as well. It's about targeting that group in ways. It's a very lonely existence to be a small farmer.

I used to work in Powys and there was some work done by colleagues around suicidality in Powys and very rural areas, and it's almost a perfect storm of some of that isolation, really strong cultural values that would dissuade people from opening up, and also having access to means. So, yes. But I think also physical health can sometimes appear as a trope or a smokescreen for mental health, and we know middle-aged men are not also that good at even going to their GPs, but that's probably a bit more acceptable than turning up to a mental health service. So, I think something about acknowledging that there's much more of an overlap and a link between physical and mental health as well.

So, identifying not just at-risk groups on a high level, middle-aged men, but micro-identifying sub-groups would be a useful recommendation, perhaps, from us, in order to be able to target them.

I do think so, but I do think actually there's value in targeting middle-aged men, because they are— in the statistics, they're the peak group. Interestingly, talking to your point as well, they've done some very interesting work in Northern Ireland in the farming communities there where they've helped the farming communities and disenfranchised young people by linking them up. So, it was occupational therapists going to the farmers and saying, 'We've got some young people who can come and volunteer on your farm,' and it's almost like building family units that for some reason haven't existed, and it benefits both parties. It's like a social intervention that's helping both sides.

Mae'n rhaid i ni symud ymlaen, achos mae yna nifer o gwestiynau i'w gofyn. Fe wnawn ni symud ymlaen i gysidro hunan-niweidio rŵan, ac mae yna gwestiwn gan Caroline Jones.

We do have to move on, because we've got a number of questions to ask. We will now move on to consider self-harm, and a question from Caroline Jones.

Diolch, Cadeirydd. Good morning. I wonder if you could tell me the ways in which you think the management of people who self-harm could be improved in order to reduce suicide risk, and have you got any evidence of effective interventions for self-harm?

Well, we have an example in our report of a young person who was self-harming. She had had lots of different types of interventions, and actually she was living in a rural area, her parents were busy, and actually what worked for her was trying to get back to the core of who she was as a person and what was meaningful for her. Her background was as a sporty individual and she'd stopped doing all of those things because she was depressed. So, actually, she needed someone to spend time with her to find out what was at the core of her as a person and help her get back into it. Sport was her thing, so that's what worked for her, but that actually lessened her self-harming behaviour because she felt that meaning back in her life, and actually that became another coping strategy. So, when she was feeling distressed, she didn't feel she had to harm herself; she could go for a vigorous jog or those kinds of things.

So, it is obviously a very personal and individual feeling. So, do you think the resources are there to treat people for the time element that they need? Do they have the time that they need to talk about these individual issues and personal issues, do you think?

I would certainly say that in the team I work in, as you've just described, the majority of the work is around firefighting and it is around assessment and there is a huge lack in terms of the time you're describing there.

So, have you any evidence of effective interventions? I know you've mentioned one; have you any more evidence of others?

I have. There's really quite strong evidence from RCTs, randomised control trials, on the effectiveness of, especially, DBT—I'm sorry for the acronym—which is dialectical behaviour therapy, which uses components of cognitive behavioural therapy that you may be familiar with, but also takes more of a mindfulness approach. I ran and led a DBT service in south Powys up until about two years ago, and the evidence really is strong for it. I would make the claim it is potentially life-saving treatment for people.

It's not especially cheap. A course of DBT would take probably a minimum of a year, and it's quite intensive, but it aims to help people look at three core components: how they tolerate their own distress, because often what leads people to self-harm is an overwhelming sense of distress that can't be coped with; how they increase their effectiveness inter-personally, so we help them to communicate better, to express their emotions; and also how they learn to regulate and identify their emotions. Because what we often find is people—. They're not even really aware of what emotions are, or they'll say, 'I only experience anger' and they've just not had the experience of being able to delineate different emotional responses. So, DBT, definitely, with an adult population, there's really strong evidence for.

The evidence is a little bit more equivocal for adolescents, but I think there's generally a lack of RCT evidence for adolescents. There are many services in Wales that offer DBT but, unfortunately—and I am going to say this—I think part of the issue around mental health services is there is not the parity of esteem between mental health and physical health services. So, I recently have experienced the death by suicide of the 15-year-old daughter of good friends of mine in Cardiff, and I have permission from her parents to talk about this. She was due to receive DBT six to eight months before she died, and the clinician who would have been her one-to-one therapist went off sick—which is not uncommon in mental health services—and there was just no cover. She couldn't access it, and I do find myself wondering if someone were referred for chemotherapy whether they would find themselves in the same position. And the difficulty, I guess, is we're always in the position that it's hard to say unequivocally what we have prevented from happening in mental health services. It's back to that complexity. But it does distress me that we struggle so much. There are services where people go on maternity leave and there just isn't cover, and I'm not sure that exists in the same way in physical health services.

09:55

Do you, as professionals, feel that you've got the tools to assess suicide risk and do you feel you have the training as well?

That's a very good question. We do, but, as my colleague has just said, it is such an inexact science, isn't it? I mean, the Wales applied risk research network training that Welsh Government rolled out around risk assessment is very good, but it's very much focused on assessment, and actual interventions and what you then do is much, much more limited. When you take that in conjunction with the fact that risk assessment in itself is by no means an exact science, then it does leave one feeling a little at sea, which, I think, is perhaps what you're alluding to.

I'd agree. I feel very comfortable sitting with people clinically and talking about suicidality. I'm not sure I would say I could predict on the basis of my experience and those conversations. There'd be very little predictive value that I'd put my name to as to whether I would say they were likely to complete an act of suicide, and I'm not sure anything can tell us that.

Well, I think there's training in terms of helping people to have compassionate conversations around it. I think there's a lot of stuff that can be done around helping people to talk about their distress, but I'm not sure if we could ever train people to be clear that we can predict suicide.

Right. And what about GPs? Do you think they have the tools to, well, have the compassionate conversations?

GPs are often constrained by shorter appointments, aren't they? Is it that the average is 10 minutes? I'm looking to the Chair.

Yes, seven to 10 minutes. So, I think, you know, again, these are—. It could feel like a very clunky conversation to try and shoehorn that in with someone in the first couple of minutes. I definitely think—. I think we know from the data that about a third of people who die by suicide have had contact with their GP, a third have been in mental health services, and about a third have had no contact with any health service. So, it's not simply a mental health or a primary care issue; it's a much wider societal issue. But I think I would say anything that helps people to treat people with compassion. We also know that, when people have self-harmed or made previous attempts, that does increase their risk. So, I guess if someone's presenting to their GP and that’s known, that might be able to trigger a different kind of conversation.

10:00

Yes. Can I just ask about support for people bereaved by suicide? We've had evidence that we should have an all-Wales postvention pathway, with the aim of ensuring more consistent support for individuals following a suicide, and also in organisational settings such as schools. Is this something that you would support?

Yes, I would. I’m a school governor. So, the school in which my friend's daughter died is also the school that my children go to. Pastorally, they did an excellent job in the immediate aftermath of learning about the death, but there was no—. They were relying on their own expertise and I think they did all that they could in that situation. But, yes, I think something that feels—. I guess it's to try and diminish the likelihood of there being a bit of a postcode lottery, isn’t it? It's to try and ensure that there is a basic, minimum standard of care that people could be offered, especially for bereaved parents, families, friends.

Especially given the fact that being bereaved by suicide is a major risk factor for suicide.

Absolutely. There definitely needs to be more support for people who are going through that bereavement. Certainly, it was my experience that, quite often, I would work with family members, and the family member had taken their own life even 20 years ago. The ripples last for so long and are so profound. They needed more support 20 years ago, rather than ending up working with me 20 years later.

It was just really whether you felt that there was a need for any kind of public awareness campaign. It’s one of these things, isn’t it? It's almost one of the last taboos, isn’t it—suicide—in terms of us talking about it publicly. I know we are in Mental Health Awareness Week, and we've had quite a lot of publicity about speaking out and saying things, but actually we still seem to be quite reluctant to talk about suicide. So, I'm just asking, really, whether you feel that there is a need for a public awareness campaign, and, if so, who should we direct it at?

Yes, I do think there is a need for that. We’ve already said that a certain number—quite a high number—of people who take their own life have not disclosed that to anyone, and I think one of the main reasons they don’t disclose is because of stigma, because it's hard to admit that you’re struggling. And there's shame attached to admitting you're having those thoughts and feelings, and how people are going to react: 'Am I going to be sectioned? Am I going to lose my children?' So, there’s a great deal of fear around that. We will only address the shame and the fear if we start talking more openly about it. And I will come back; I know we've previously discussed that group of men—middle-aged men. I do think that's a particular group we need to think about in terms of talking and stigma.

So, you would advocate more of a targeted awareness approach, or—

Yes, I would, personally.

Turning, finally, to matters pertaining to the media and internet, Jayne.

Thank you, Chair. Yes, I was just going to ask you about social media and the internet, because we hear lots of things, bad things, and how difficult a role they can play in things like this. Is there a positive side to social media and internet that could be used, whether that’s getting the message out or, particularly, e-tools?

Certainly, I recommend quite a lot of apps to clients. I work, generally, with adults of working age, but anyone who works with adolescents will know that they're much less likely to perhaps read a book than they would be to look at an app. So, I think there's definitely scope. I think it’s a mixed picture. We know that social media can play a huge part in people’s experience of feeling excluded or bullied, especially, again, around adolescence. But there are also—. It is a platform. I suppose it's a platform that can be used both ways.

I think that social media has the potential. We can use it more for a public health approach to try and—. It’s being used very well in other countries around other forms of public health approaches, and I think we can use it more to spread positive messages about asking for help and sharing and talking about how you're thinking and feeling. It's not a shameful thing. In fact, we know the rates of people actually experiencing suicidal thoughts and feelings are much higher than, generally, people admit. So, I suspect it's actually quite a common experience that some of us in the room have probably experienced but we don't talk about it. And that's what needs to change and social media can do that. There have been some brilliant campaigns about other things—so, for example, other public health issues like skin cancer—and they've been using social media to push messages to people when we know they're moving into risky times or risky transitions. So, we could do that; the technology is there. It's harnessing it.

10:05

Great. Do you have any final comments about what you think we could prioritise? We've talked quite a lot about different things today, but are there any final thoughts you have or any things we should prioritise as a committee?

I still think there is a key issue about employment. We know that people who're unemployed have a higher risk of suicide. We know that there are good interventions that can help people get back into employment. We know it can't be any form of employment; it's got to be good-quality employment. So I actually think the role of employment, as a protective factor, is not addressed enough and that we should be doing more around employment. Because, if you look at the wider determinants, there's a link between education and employment, so, if people do well in their education, they do well in employment. There's a link between that and poverty and all the wider issues—housing. So, I think if we could crack employment for those who want to work, it fits with regeneration of areas, it fits with prudent healthcare. I think that could be our secret weapon. And, particularly, for a lot of the men I've worked with, they're not in employment—something's happened and they've lost their jobs. So I still think that that is a crucial point for that age group, because, for that age group, that is your main meaningful identity—you work—and for men to lose their jobs at that point in their lives—. I think that's a real pressing issue. So, I would go for employment.

I wanted to ask something else, really, to BPS. Shall I do it now?

Well, have you got any other thoughts on—? We're going to be producing a report with recommendations, so feel free to invent one of them.

Well, for me, it's still the parity of esteem issue. But also I'm interested in services that try and adopt a zero-suicide initiative and I'm not aware, in Wales, that we do that at all. Some people have heard that as zero tolerance to suicide, but it's really trying to be more proactive and almost trying to identify and care for all the people who may be at risk of suicide, rather than reacting to people when they present in crisis. And I think that's kind of where we're at. So, there are a number of issues around that, such as removing the means and giving people easier access to crisis care. But I just think even though many of us would say, if we're honest, we're not sure if we could ever get to zero, we should be striving to. If zero isn't the appropriate target, what would be? There's an economic cost, too, to people we lose by suicide, and I'm not sure if you'll hear evidence around how that's quantified, but that's significant as well.

Yes. It's £1.6 million, it's estimated, for every suicide, it costs. I just wanted to ask Kathryn—it's about parity of esteem, really. Are there any issues you think we should be addressing in our recommendations specifically about the way services are delivered in terms of things like waiting times for psychological therapies? As you know, there's no target for waiting times—

There is now. This is exercising my professional life a lot. Welsh Government have given more money for increasing access to psychological therapies in the last five years, really, than I can ever remember at any other point in my professional life. Having said that, I really think there's a phenomenon that we almost increase awareness of services and people come. They keep coming. And I think we've seen that in primary care where there was a tier 1 target and, certainly in my health board area, the number of referrals to primary care increased by 40 per cent for the mental health services. I know that colleagues spoke to the Children and Young People's Committee around CAMHS services, but I think it's the same thing. There's this idea that our services are focused at the top of the iceberg and there is a whole lot of unmet need that we may start to uncover and identify the more we offer services. So, obviously, it's intolerable that people wait the length of time they do for accessing psychological therapies, and I'm really grateful for the new moneys, but I'm wary that we may find ourselves in a similar position, even though we've had more investment, because more people will just come forward. At the moment, there are services where GPs won't even bother referring people for psychological therapies, then we get into the issue around prescription because it's quicker and it's easier. But I think there's still a huge amount of demand. And the middle-aged men, but people who are socially disenfranchised—the way our services are set up makes it really hard for them to come and see someone like me at nine o'clock on a work day. So, I think there's a lot we have to think about.  

10:10

By happy coincidence, we're launching our mental health campaign reports about occupational mental—

It's going to be launched next Tuesday here in the dining room. We're going to have some people who've used mental health services at the session, so you're all invited; we'd love to see you there. The four themes in the report are: helping young people with mental health problems in education, helping people with mental health problems get employment, improving physical health of people with mental health problems using sport, using physical activity, and early intervention—so, a lot of the things that we've spoken about today. So, we hope to see you next week.  

Grêt. Diolch yn fawr. Dyna ddiwedd y sesiwn dystiolaeth yma. A allaf i ddiolch yn fawr iawn i'r tri ohonoch chi a hefyd am y dystiolaeth ysgrifenedig ymlaen llaw? Byddwch chi'n derbyn trawsgrifiad o'r trafodaethau yma i wneud yn siŵr eu bod nhw'n ffeithiol gywir a'ch bod chi'n hapus efo nhw. Ond, gyda hynny o ragymadrodd, a allaf i ddiolch i chi unwaith eto? A gaf i gyhoeddi i'm cyd-Aelodau y cawn ni egwyl am bum munud rŵan i gael y tystion nesaf i mewn? Diolch yn fawr. 

Great. Thank you very much. That brings us to the end of this evidence session. May I thank all three of you very much and also thank you for the written evidence we received beforehand? You will receive a transcript of the discussions this morning to check for factual accuracy. Having said that, may I thank you once again and let my fellow Members know that we will take a break of five minutes before the next witnesses come in? Thank you.  

Gohiriwyd y cyfarfod rhwng 10:12 a 10:20.

The meeting adjourned between 10:12 and 10:20.

10:20
3. Atal hunanladdiad: sesiwn dystiolaeth gyda'r Lleng Brydeinig Frenhinol a Combat Stress
3. Suicide Prevention: Evidence session with the Royal British Legion and Combat Stress

Croeso nôl i bawb felly wedi'r egwyl yna, wedi'r sesiwn dystiolaeth gyntaf o'r bore. Rydym ni'n symud ymlaen rŵan i eitem 3 ar yr agenda, gyda pharhad efo'n hymchwiliad i atal hunanladdiad. Mae'r sesiwn dystiolaeth yma gyda'r Lleng Brydeinig Frenhinol a Combat Stress. Rydw i'n falch iawn, felly, o gyflwyno ac o groesawu, yn wir, Antony Metcalfe, y Lleng Brydeinig Frenhinol, a hefyd, Paula Berry o Combat Stress. Rydym ni wedi derbyn ac yn hynod ddiolchgar am eich tystiolaeth ysgrifenedig ymlaen llaw, ac, yn ôl ein harfer, awn ni'n syth i fewn i gwestiynau. Mae yna res o gwestiynau gyda ni, a ddim gymaint â hynny o amser, ond mae yna ddigon i'w drafod, rydw i'n siŵr, ac mi wnaiff Lynne Neagle agor y cwestiynau.

Welcome back everyone after that break, following the first evidence session this morning. We now move on to item 3 on the agenda, with a continuation of our inquiry into suicide prevention. This evidence session is with the Royal British Legion and Combat Stress. And I'm very glad, therefore, to welcome and introduce Antony Metcalfe of the Royal British Legion, and also Paula Berry from Combat Stress. We have received and are extremely grateful for your written evidence beforehand, and, as is our custom, we will go straight into questions. We do have a series of questions and not that much time, but there is plenty to discuss, I am sure, and Lynne Neagle will start for us. 

Thank you, Chair. Good morning. Research suggests that the overall suicide risk amongst armed forces veterans is no higher than the general population, but that there may be an increased risk among certain groups, such as younger men, females, those who haven't served as long. Can you give us your perspective on what you think the trends are, and whether there are any particular areas we should be focusing our attention on?

Yes. We've done some research into the suicidaility of veterans who have left the military in the UK, and some of the particular groups that are at increased risk are those who are early service leavers, so who have done less than four years serving in the armed forces. Another increased risk group is those who are unemployed. So, echoing my occupational therapy colleagues from the session earlier, not finding meaningful employment, finding a role, finding an identity for those people who are leaving the armed forces certainly puts them at increased risk of suicide. And, interestingly, another group that we've identified that is at increased risk is actually those taking less than five years to access services, which indicates that they are suffering from—they're perhaps in more crisis. So, the longer that somebody leaves it before they access help, they usually would form their own kind of resilience, they might find their own coping mechanisms, but those who are presenting to services earlier are presenting in crisis with more complex issues, and therefore they're at more risk of suicide. 

I agree with what Paula's just said. The Ministry of Defence figures do show that between 1998 and 2017, there were 309 suicides and open verdicts that occurred amongst UK regular armed forces personnel, but, overall, the suicide rates across all three services have fallen since the 1990s, and we have managed to debunk some myths around more service personnel died via suicide in the Falklands than actually were killed in combat, for example, which is a very important message to get out as well. Suicide rates in the regular armed forces are lower than in the general population. Some elements of service life may give some protective factors against suicide. For example, we know at the moment that, in the general population, suicide is the biggest killer of men between the ages of 35 and 45, if I remember rightly. In the armed forces, that's different. Maybe it gives some protective factors around longevity of workplace, for example, comradeship and other areas as well.

There are some data limitations. I believe that the MOD doesn't currently collect information on suicide rates among veterans, for example, but we do know, from the 2009 Manchester research that Paula talked about, that there are risk factors if you're a young man, if you've served in the army, if you had a short length of service and you're a lower rank—that traditional sort of early service leaver category, for example. The potential causes of that may be around stress of transition to civilian life, maybe seeing the army as a way out of some negativity in your past, but then it not being that and then you leaving and then thinking, 'Actually, where is my life moving on to?' I know there's lots of work at the moment around what they're calling the ACEs—adverse childhood experiences—and looking into that detail, into people's backgrounds as well. 

So, I think, overall, it is positive, but there are some areas of concern in certain sub-groups.

10:25

Can I just clarify? When you say there's a difference for people serving in the army, do you mean as opposed to the other services?

Mainly because of the tempo of operational tours, for example. This is me speaking personally, as a veteran myself; I served from 1994 to 2006. It may be due to some of the trades in the army, compared to the trades within the navy and the RAF, which have slightly more technical backgrounds, for example. So, the recruiting methods for people coming into the armed forces—. But it is certainly a little bit higher in the army than the other two services.

Diolch yn fawr iawn i chi. A allaf i ofyn i chi pa gamau sydd yna i adnabod problemau iechyd meddwl tra bod pobl yn gwasanaethu yn y lluoedd arfog? A oes yna gamau pendant iawn i adnabod ac i ymyrryd pan fod angen gyda phroblemau iechyd meddwl, tra'u bod nhw'n gwasanaethu?

Thank you very much. Could I ask you what steps are in place to identify mental health problems whilst people are serving in the military? Are there specific steps in place to identify and intervene when that's necessary, when people are serving?

Yes. Obviously there is mental health—departments of community mental health services—within the MOD. There are lots of campaigns—to reduce stigma, to encourage people to discuss their feelings, lots of peer support, there's lots of promotion around camaraderie. There's certainly more opportunities, I would feel, within the armed forces to discuss mental health issues. There is quite a rapid access to community mental health teams within the military—they've got psychology, psychiatry, nursing. There's certainly opportunities to do that. The difficulty is, obviously, addressing the stigma and the shame and the guilt of somebody actually coming forward to do that. I think the campaigns that the MOD have run—there's certainly the armed forces helpline that is provided by the MOD and Combat Stress, where there's a 24-hour access for serving personnel to access a helpline, which will provide support and advice and guidance. I think it's really about raising that awareness that it is okay to come forward, making sure that's done from the senior ranks to the junior ranks. That tends to be where the difficulties are found, in those more junior ranks—younger, more isolated. So, that needs to come from the top, and we certainly had some real spokespeople in the MOD who are serving, who have come forward with their own experiences. So, for me, it's certainly around peer-led. There's the trauma risk management programme, which kind of looks at people's experiences, and also training those front-line personnel to spot in their colleagues, or the units that they are managing, things like depression and anxiety, anger, and certain traits of trauma-related illnesses.

And as a supplementary—maybe you can address both—do you know whether there's data available, some effective data, on how that contact is happening within the armed forces?

I must admit, personally, I think what Paula said is absolutely bang on. We are seeing a lot of increase—. If I look back, when I left in 2006, if I can be honest, I think it was probably very, very poor. You know, the bar was where you went to get drunk and discuss things that happened, and it wasn't about discussing your emotions and your feelings. You know, Big White Wall, for example, and the 24-hour Combat Stress helpline is really important. But also, as Paula said, leadership by example on these issues is also really, really important. I mean, before I came to this role, I was working for Mind and running Time to Change Wales, for example, so I understand the power of people voicing lived experience in the workplace, to get over these issues. I think you have seen increased issues around training and awareness, but that needs also to be matched with actually recruits, and anybody of any rank thinking, 'If I do disclose this, it's not going to impact onto my career path', for example. So, it's fine saying these sorts of things, but actually you're thinking, 'Hmm, it might stop me getting my promotion to sergeant'—or captain to major or something, for example. So, in principle, yes, but it needs to be backed up by an actual more open and awareness culture within the whole military environment.

The MOD collects data around serving personnel, but unfortunately don't collect any data really around those who have left the services, and that tends to be where we're finding the issues. But certainly the MOD will give you the efficacy of the TRiM programme, how many people have contacted their DCMH services, how many people have been medically discharged because of a mental health disorder. So, that's certainly available from the MOD.

10:30

Are armed service personnel properly prepared, in the context of mental health, for discharge, and moving into the civilian world, do you think?

I think that's very difficult. So, you're talking about transition, and I think that somebody who is transitioning after four years of two operational tours, or more operational tours, who has come from a very disadvantaged background and who probably had some real pre-service difficulties, maybe around childhood trauma, substance misuse and involvement in the criminal justice system, going into the military for four years and then transitioning—that's very different from somebody who is transitioning after a 20-year career, where they've been a more senior rank and then coming out to something that's very stable. I think that, in terms of transition, a lot of focus is around employment and housing and where you're going to go afterwards and what you're going to do. There's not a great deal of, 'What you might feel later on'—

I think there's absolutely room to do more of that, and there certainly has been improvement and certainly it is around, 'If you are feeling like this, this is where you can access support', but that tends to be after you've left and maybe when you're in crisis. So, we found that people are presenting to Combat Stress and other organisations much sooner than they historically did. So, a few years ago, it was 10 to 11 years after leaving the armed forces that they would present to an organisation like ours. What we're finding now is that, especially around Iraq and Afghan veterans, they are presenting five years, and sometimes much sooner than that, after leaving the armed services. So, obviously, something is happening in that transition period to encourage people to access support when they need it in a much shorter time, but I still think there's definite room for improvement in identifying those people who are transitioning out, who may then experience difficulties.

I think the career transition partnership has definitely got better over the last 10 years. There's the legion's campaign where there are gaps in those who can access CTP, such as early service leavers. But it is a personal decision—it's not compulsory. And actually, if your unit or battalion is then posted away on operations and you've signed off and you've got eight months left, and you go on a six-month operational tour, that's going to really derail some of your plans around transition. It does impact on to younger service leavers as well. If you are settled and you have been in the army for 22 years, and you're a senior rank or sergeant major, you might be living off base, your partner might be working, for example, and your kids are in local schools—you might have made that mental jump from being service personnel to a civilian already four or five years ago. If you'd gone into the army at age 17, and it's always been the way out for you from a negative background, and it hasn't worked out or you've done your four years and decided to leave, there is that danger that you will get sucked back into that previous environment you might have been in before.

I know we want to move on to what happens after leaving the armed forces, but with your permission, could I just disturb the timeline and just jump back to pre-recruitment? How much mental health assessment is done at that stage?

The screening questionnaire has been debated several times—should we screen people who are wanting to join the armed forces for any kind of mental health disorder? My particular thoughts are that no, we shouldn't, because actually serving in the armed forces gives you a massive amount of positivity and resilience, so for those people coming from disadvantaged backgrounds, to screen them out and stop them accessing the armed forces—

We can't be doing it to screen them out; it's to screen to see who needs help as they go through.

Absolutely. I think that that's the debate. If you've found somebody who is going to potentially experience difficulties, if those people weren't accepted for the armed forces, you'd be doing them a massive disservice, because actually for a lot of people, joining the armed forces gives them tonnes of resilience and tonnes of positivity—it gives them opportunities that they would never experience. And actually their army career—I'm an army wife, so I refer to the army a bit more—gives them massive potential for development.

Once again, talking about personal experience, the regiment that I served in recruited from Glasgow and Liverpool and the guys in my tank crew would say, 'It was the military, prison or the streets', and they've seen lots of their friends go down some of those negative paths. Once again, asking these questions is fine, but are people going to give a truthful response? It's like the work we've done with employers around mental health awareness. If you put a question on, 'Have you had a mental health issue before?', people aren't going to put it on their CV, for example, or job application, for fear of not getting past the sift. So, I wouldn't want it to be seen as a negative barrier to people joining the forces, because actually, as Paula said, the military can be the making of lots of these individuals and take them away from that path.

10:35

I don't think I'm talking in terms of, 'Have you had mental health problems?'; it's going through a process with them and trying to identify where there might be some issues that they'll need to work with them on as they go through their career.

Yes, so that it doesn't become a negative issue for them later on, or a barrier and them thinking, 'I shouldn't put this down, because it's going to stop me getting past basic recruit training', for example.

Diolch, Rhun. Symudwn ymlaen felly i'r cymorth ar ôl rhyddhau. Caroline, roedd gyda ti gwestiwn.

Thank you, Rhun. We'll move on therefore to post-discharge support. Caroline, you have a question.

Diolch, Cadeirydd. Do you think that sufficient focus is given to the armed forces veterans in the Welsh Government's suicide prevention strategy 'Talk to me' and in its broader 'Together for Mental Health' strategy?

I think there's some similarities between the general population and veterans. So, we're talking mostly men, we're talking mostly around that age range, mostly those with vulnerabilities, certainly those who are abusing alcohol or have been engaged with criminal justice services, and employment is a massive thing. So, I think some of the themes around the strategy are pertinent to veterans anyway. I think that some of the little sub-groups that we've got—those veterans who leave the services early, those veterans who are unemployed—general campaigns and general strategies will certainly assist those. I think obviously the commissioning of veterans' mental health services at the moment falls just within community-based services that are psychologically led.

My personal view is that there is a place for residential treatment of veterans with mental health issues, and certainly from a more multi-agency or a multidisciplinary team. My psychology and OT colleagues earlier on spoke about the need for a multidisciplinary approach, not just based on a medical model, not just looking at psychiatry, not just psychology, but a range of services, to include things like peer support and substance misuse. So, I think that generally the strategy does veterans no disservice, but actually there are certain things that the Welsh Government could pay particular attention to.

It's great to see that the armed forces are referenced in 'Talk to me 2', but we'd like to see them referenced as a larger, broader group, not just the armed forces but also veterans and spouses, for example, as well. I think strategy is absolutely brilliant, but strategy needs to be backed up by resources and by action and by outcomes, for example. Echoing what Paula's just said, we have a great potential here in Wales to do some really good stuff. I know Neil Kitchiner's Veterans' NHS Wales has had some funding issues, but it's a very good and well-regarded service. The work with the Change Step peer mentors, supporting and holding the hands of those individuals who are on a waiting list, for example, is a great example of good collaboration. We don't hold on to veterans ourselves in the legion, we work closely with SSAFA, with Help for Heroes, with Combat Stress. Talking personally, I think, hopefully, in Wales, you can get things done because of the closer relationships we can have within the devolved boundaries, if I can use that term. So, it's great that you've got a strategy and it's great that you've got plans, but those plans need to be matched up with resources and outcomes. 

That leads me on to my question, actually, which is about access to timely and appropriate mental health services. Do you have information about how well veterans are able to access mental health services in a timely fashion, and particularly the NHS Wales veterans services?

Accessing services from Combat Stress is simple—it's one phone number, it's a telephone helpline. Our helpline is run by Connect Assist, based in Cardiff. Immediately, when that veteran contacts us, we have triage nurses, so they will do an in-depth assessment, including risk, and that then is directly referred into a multi-agency team, which happens within that week. We have the discussion, we look at the assessment, and then the next steps are allocated. Sometimes, that might be input from psychiatry or psychology, another piece of the assessment sometimes, but usually that veteran is then put on a pathway, and that is either 'suitable for trauma work' or 'not suitable for trauma work'. Then, there's a period of stabilisation, whether that's substance misuse or liaising with our colleagues on welfare issues—

Sorry, Paula—I think, obviously, Neil is a better person himself to speak about Veterans' NHS Wales. But, I know, because we work very closely with Neil and his clinicians, that since 2010, they've had just shy of 3,000 referrals. We've also long campaigned for additional investment to support Veterans’ NHS Wales, which I know the Welsh Government have been very good at supporting them with, along with the money that Help for Heroes gave to support the change step peer mentors to go into those health boards where there were longer waiting lists. So, I think it's our ability to listen to the need and to help support that need, for example. 

I'm sure there are issues around certain waiting lists in certain areas, but I believe that the additional funding put into place has addressed those issues. But once again, taking a referral is a very personal step. Some individuals will want to access residential care that Combat Stress provide, for example. Other individuals are very happy to access therapy services that Veterans' NHS Wales provide, for example. But it's a very, very personal decision about what the right service is for that individual. 

10:40

And I guess it's not every every veteran that's going to come through Combat Stress.  

No, absolutely not, or the RBL or SSAFA or anybody else. 

And it's a very personal choice—[Interruption.] Sorry, Paula. I think one thing that's also important to me, and this is one thing we've campaigned hard on since the covenant has come into place, is about making GPs understand—and other services and local authorities as well—the need to make the ask: 'Have you served?', 'Are you a veteran?' because sometimes veterans won't want to acknowledge themselves that they're a veteran and, therefore, they can leave the surgery after an appointment never knowing that Veterans' NHS Wales is available to them, or Combat Stress is available to them as well. So, making the ask and raising that issue is very, very important.

I'm going off on a tangent here a little bit, but I think at the moment that's why we're really, really pleased that the funding has come in to support the armed forces liaison officers across the various local authorities in Wales, because that's embedding the covenant into the day-to-day running of the local authorities while before, to be honest, it was a bit patchy, because it was down to individuals driving that thing forward. So, I think the AFLOs provide a very good opportunity to build on that resource and understanding of what's out there for veterans. 

I was going to ask about that, but in terms of primary care and whether you think there's sufficient knowledge within primary care actually. If somebody's being directed through Combat Stress, then there's obviously a red flag, isn't there, that this is a veteran, but for people who have come through a different route, is there that awareness within primary care that veterans could be at particular risk? 

Yes, I think it's better, and there are certainly opportunities to improve that. So, we've been doing lots of training with GP trainees recently. So, getting 40 or 50 GP trainees into a room with our colleagues from Help for Heroes, Blesma, Blind Veterans UK and almost doing a crazy veteran-focused speed dating exercise, where we do some presentations and we let people ask questions, because I think sometimes the way to access Combat Stress or the RBL or Help for Heroes is that you need to be a veteran and there's some misunderstanding about the terminology we use about the word veteran. What does that mean? Who can access services?

So, I think there are huge opportunities for improving things in primary care. I think it's very difficult, especially around GPs. They are pressured to prioritise everybody, from women and children and this, that and the—. So, to actually then prioritise knowing a little bit about veterans, especially around mental health, is a big ask. We need to make that very simple. A lot of veterans will not say, 'Oh, by the way, I am a veteran.' A lot of veterans don't identify themselves with that word. GPs will often not ask and certainly it's something that doesn't get floated. 

But what we have got as well at the moment, which was formally launched last year, of course, is the new veterans gateway service, being run out of Nantgarw, which has our call centre and Mind's call centre and Combat Stress, and that's just bedding in at the moment and is just approaching its one-year point. I think that's a real example of multiple third sector collaboration, not just from the armed forces charities, but from Shelter, from Mind, from the Samaritans, because there is a lot of confusion out there about what services veterans and their families, or the neighbour who lives next door to an elderly veteran, can access. By phoning the veterans gateway you'll get clear, concise signposting to the relevant organisations.

And that's the next point I was going to ask you about actually. It's about the joint working of all the various agencies with the NHS, the third sector, whatever. The gateway is really the key from your point of view— 

Yes, absolutely, to bring it all together. 

—to ensuring that all of that works more effectively together, but it's still quite early, isn't it? 

It's early days. It's only been going a year or so and, to be honest, we're not seeing many direct referrals via the veterans gateway, because people know our services, people know SSAFA and people generally know of Combat Stress. But I know that organisations like the Forces Pension Society, for example, Blesma and some of the smaller military supporting charities, when somebody phones up and says, 'My brother, these are the issues I've got', they're very skilled and have highly trained call-centre advisers who can either answer their questions there and then or can put them through to these other agencies and link them in. So, it's helping veterans and their families and the communities to get through that plethora of armed forces charities out there. 

10:45

It doesn't negate the need for local links though, I think that's the thing. Certainly in Wales, Combat Stress will have regular meeting with Veterans' NHS Wales to ensure—. You know, they're clinical meetings; they're about, 'Do we refer on?' So, going back to your point about access to services, we need to make sure that we continue to do that. So, the commissioning of veterans' mental health services, there isn't any commissioning in Wales for in-patient services; there isn't any. So, veterans in Wales do not have equitable access to in-patient residential specialist PTSD treatment. They do in Scotland and they have in England for the last eight years. But actually, there isn't that. So, there's a real need for those local links to be made so that we make sure that we don't lose individuals.   

Jayne—although your question may well have been covered by your colleague next door to you. 

That's okay. No, I think it sort of has. It was just around—the health committee did a report in 2011 on PTSD and they identified a lack of awareness of veterans' right to priority NHS treatment, particularly around mental health. You've touched on it with GPs, but do you think that's improved enough or to some extent? 

I think it's very difficult. So, I think the majority of veterans don't present with PTSD, we know that; they present with common mental health issues: depression, anger, substance misuse, anxiety. There is a lot of focus on PTSD and certainly there is a percentage of veterans presenting with complex PTSD, which appears to be rising. King's will tell us—the research is telling us that it's going up. I think what we need to do is ensure that people in primary care are asking the question, because then it will just trigger something else. So, if somebody is presenting with anger issues, substance misuse and low mood, to ask, 'Are you a veteran?', will just link them in or get them to move along that pathway, rather than seeing them as someone who's just presenting with his current mental health disorders, but someone who could access Improving Access to Psychological Therapies or other care services. I think sometimes GPs—not necessarily just GPs, but all primary care staff—by not asking that question, it sort of closes a door off already where veterans could access specialist services, whether they be commissioned services or charity services or whatever. If they don't ask that question, then they're not giving the opportunity, but then they're not guaranteed an answer if they do ask it. I think that's the issue. 

I think that's our experience as well. It can be patchy at times. Some are aware—some GPs and local services will be aware, but once it gets down to it, you know, it's front-line training and awareness, and also sometimes turnover of staff in some of these positions as well. You can't just go in once and do it and expect them to know it. It's got to be constantly refreshed. That's why we're quite excited about this new training package that the AFLOs are bringing in across local authorities, but it is a bit patchy. We'd like to see greater improvement around access to primary care.  

Have you got another question, because I've got a question otherwise? 

With my GP hat on, obviously as GPs we see most of our patients in a given calendar year, however a significant percentage, we never see for years. One of the issues though, as GPs, is that we have no medical records from the time people spend in the army or the navy. In fact, we have no written knowledge that these people that we haven't seen for years have been in the armed forces at all. When we ask, we don't get acknowledgement of asking the question. So, in terms of how we can better find out when we have veterans in our care, one of the major statements that we want from our point of view is the fact that, no.1, we don't know that these people are veterans because there's absolutely nothing in the records, so nothing is going to inspire us to say, 'Oh, by the way, are you a veteran?', because it's not a usual sort of question. But there's also nothing in computer records or in paper records that would say MOD or anything. In fact, when we ask for something like that, you just cannot have it. I'm just looking for a way forward in that sort of conundrum. 

Personally, I did a freedom of information request and asked for my medical records, so I've got mine at home. So, you can be proactive and bring these things into your first appointment with a GP. I think, once again, it's down to asking the question. We're campaigning hard nationally for the census to be changed, so you understand where the veterans and serving population is based, because at the moment we just don't know. We're campaigning hard as well with the education committees to change the questionnaire that, every year, the schools do with their pupils. Are you from a veteran or are you a service family? And, I think, once again, it's about very simple things, just asking—. I know GPs are hugely busy, but the receptionist—. If somebody comes in to register for the first time, asking them. Have a poster up, saying, 'If you are a veteran, please step forward.' But once again, it can also be down to things around expectation management. Just because you're a veteran, also it doesn't mean that you'll get access to all the services that you want straight away as well.

10:50

And I think, sometimes, it's about having those non-verbal cues, or picking up on those non-verbal cues. Having a veteran-friendly environment, so, maybe some leaflets from the legion, Help for Heroes or Combat Stress. Picking up on some of those things and that's certainly what we talked to our GP trainees about. If someone is sitting in front of you and they present—you know, not to stereotype veterans—but they're early and they're dressed smartly, and they might have a veterans badge. Certainly, those little things. But I don't think there's any simple way of doing it. My husband, when he left the army, writing out for his medical records—he had to go in and tell his GP. He wouldn't have gone in for any other reason. He needed to access some surgery for his knees. A lot of veterans won't just give you that, especially if they are going to come and see a GP or other professionals for any issues where there may be stigma or shame attached to it. They would possibly not say that anyway. It's really difficult, especially when the systems don't talk to each other.

Well, yes, absolutely, because there's an absolute refusal to give GPs those MOD records, even when there's a clinical necessity sometimes. 

We struggle getting medical records. 

We shall have to leave that one for another day, then. Great, thank you. I think that's the end of our questioning for this session. So, thank you very much indeed. Can I further say that you'll receive a transcript of the deliberations to make sure that they are factually correct. You can't, obviously, change your complete world view of things based on that, but at least make sure that they are factually correct. So, thank you very much, both, for your evidence beforehand and for answering the questions. And can I tell my fellow Assembly Members we'll have a break now before the next evidence session, which is by Skype? So, it will take some setting up. So, we'll be back here at 11:10. Thank you.

Gohiriwyd y cyfarfod rhwng 10:52 a 11:15.

The meeting adjourned between 10:52 and 11:15.

11:15
4. Atal hunanladdiad: sesiwn dystiolaeth gyda Dr Sallyanne Duncan, Prifysgol Strathclyde a Dr Ann Luce, Prifysgol Bournemouth
4. Suicide Prevention: Evidence session with Dr Sallyanne Duncan, University of Strathclyde and Dr Ann Luce, Bournemouth University

Croeso nôl i sesiwn ddiweddaraf y Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru yng Nghaerdydd. Rydym ni wedi cyrraedd eitem 4 rŵan, a pharad efo'r ymchwiliad i atal hunanladdiad. Mae'r sesiwn dystiolaeth yma gyda ffrindiau o ddwy brifysgol sydd ddim gyda ni; rydym ni yn nwylo technoleg amgen, fel petai, ac rydym ni'n cael y sesiwn dystiolaeth yma drwy Skype.

Felly, os gallaf i ofyn i Brifysgol Strathclyde gyflwyno'i hunan. Rydym ni wedi colli'r cysylltiad efo Dr Sallyanne Duncan o Brifysgol Strathclyde. A hefyd, os gallaf ofyn i Brifysgol Bournemouth gyflwyno'i hunan. 

Welcome back to this latest session of the Health, Social Care and Sport Committee here at the National Assembly for Wales in Cardiff. We have reached item 4 now, and the continuation of our inquiry into suicide prevention. This evidence session will be with colleagues from two universities who are not actually with us; we are using alternative technology for our connection, and this evidence session is via Skype.

So, if I may ask the University of Strathclyde representative to introduce themselves. We do seem to have lost the connection with Dr Sallyanne Duncan from the University of Strathclyde. So, may I ask Bournemouth University to introduce herself?

Hello, everyone. My name is Dr Ann Luce, a principal academic in journalism and communication at Bournemouth University. I've written extensively on suicide over the last 12 years, and have actually written a book around the Bridgend suicides, which was published in 2016.

Diolch yn fawr. Rydw i'n gweld bod y llun yn ôl o Brifysgol Strathclyde. A ydym ni'n gallu clywed oddi wrth Dr Sallyanne Duncan? Helo. Na. Rydw i wedi gwneud y pwynt o'r blaen ynglŷn â'r angen am rhagor o bwerau yng Nghynulliad Cenedlaethol Cymru, felly rydw i'n credu fe wnawn ni barhau ymlaen, ar hyn o bryd, efo Prifysgol Bournemouth, a mwy na thebyg bydd Prifysgol Strathclyde yn gallu ymuno fel mae'r signal yn dod trwodd.

Mae'r cwestiynau cyntaf yn y sesiwn yma o dan ofal Lynne Neagle. Lynne.

Thank you very much. I can see that we have the image from the University of Strathclyde. Can we hear from Dr Sallyanne Duncan? Hello. No. I have made the point previously that we need more powers here at the National Assembly for Wales, but I think we will continue with Bournemouth University, and hope that our representative from the University of Strathclyde can rejoin us once the signal comes through again.

The first questions in this session are from Lynne Neagle. Lynne.

Morning. Could you just tell us a little bit, please, about how you feel the issue of self-harm is dealt with in a school setting—it's our understanding that there isn't any consistent guidance—and whether you've got any comment on that?

I would say that self-harm—. Yes, there doesn't seem to be a consistent model of talking about self-harm in schools anywhere in the UK. I think there are probably some hubs of good practice that are going on, but, to my knowledge, there's no one set of guidelines that schools could be using to talk to young people about self-harm. 

Thank you. If I can just go on to the issue of suicide reporting and how that will have an impact on audiences: what evidence is there that that can cause suicide contagion?

Well, there's quite a bit of evidence out there. We have the Werther effect that says the more suicide is reported, the more suicides that you'll actually have. However, I take issue with this evidence, and have done for quite some time. There's some evidence around vulnerable people being influenced, but I think we need to be very careful about cause and effect. There's a correlation, and correlation is not indicative of causation. So, there's no actual evidence that reporting suicide causes suicide. If that was the case, every time we saw a suicide story, or every time we would see a murder, for instance, then that would mean another murder would go with it. That cause and effect argument is what we call in the media and journalism studies field the hypodermic needle theory effect, which is kind of a syringe for passive audience lemmings, in a sense, but that's not actually the case. I think the media does play a role in suicide and in, also, suicide prevention. I think there's actually quite a bit of evidence that's emerging now around the Papageno effect, which my colleagues in Austria published back in 2010. That says that the media can actually contribute to preventing suicides and that it actually can have a positive effect in helping people cope in adverse circumstances. So, I think the impact we have on audiences isn't as strong as you might think or might be right to believe, especially by colleagues who work in the medical field or in the psychology field, and that's with no disrespect to those colleagues, but a lot of people—there's been no real audience research that's been done on the impact of suicide stories on the audience. So, we're, kind of flying blind on that one. 

11:20

Thank you. Dr Duncan's paper suggests there may be greater risks with online news content, with the immediacy and easy facility to share via social media increasing the risk of copycat suicide. Can you expand on these comments and whether there's anything that we could suggest is done to mitigate the risk? 

Sorry, is that still for me? 

Yes. Well, we were pleased to welcome Strathclyde, and then, unfortunately, we've had to say goodbye to Strathclyde, so it's Bournemouth. [Laughter.]

Yes, so—. I'm sorry, could you repeat the question? So, it's around online—.

Yes. In view of what you've said about reporting maybe not being a direct cause and effect thing, Dr Duncan's paper suggests that there might be a greater risk with online news content because of the immediacy and the easiness of being able to share it. 

Definitely. Yes, we are seeing that, and, actually, that kind of ties into something that I'm hoping we'll talk about a little bit later in the session around media reporting guidelines. What we're finding is that journalists, in an online environment, probably are not adhering to guidelines as much as they would in a printed product, for the simple fact that it is immediate and it's to try and get the story first and to get the images out there first. So, there does seem to be a bit of an issue around online reporting that really needs to be investigated.

Some colleagues here in the UK actually published in—I believe it was the British Journal of Psychiatry just last year about a project they did looking at online media reports and looking at how Samaritans guidelines were applied, and what we actually found—or what they found, rather—was that out of the 229 schools that they sampled in a one-month period, 199 of them failed to comply with at least one of the guidelines. The top three that they failed to work with were—. The first one was there was no support references, which we know—it's just not good journalism practice, whether or not—. We know there's an impact, and there's a preventative measure there, but they're not putting those support references: so, a link to the Samaritans or a link to Papyrus to say, 'If you're in need of support—'. They also failed in terms of method. We know that method should not be explored or explained in extensive detail, but this sample of stories actually indicated that that was not the case. And then the third thing that journalists were doing incorrectly in that study was speculating about the reasons for suicide, and that's something that I explored quite extensively during my work around the Bridgend suicides. We actually found that to be true as well. So, those top three things are things that journalists need to be doing, especially in the online sphere. 

Dr Duncan, can you hear us now? This last question was based on your paper on online news content and suicide risk.

Is this a question for me?

Yes. It was just about the point that you were making in your paper that, actually, there's more of a problem with online reporting of suicide because of the immediacy and the ability to share things quickly. 

Yes, I think that that's going to be a growing problem because there'll be more online content than print content in the future, but I think it's also an issue that journalists have to be aware that they are sharing very quickly. I mean, there is a pressure on them to get information out very quickly and to ensure that they are keeping on top of social media and promoting stories. So, what I have suggested there is that perhaps they need a little bit more vigilance. Instead of tweeting or posting on Facebook, they should stop, think and then act—so, even just building in a few seconds of reflection before they actually do that, and that's perhaps something that the guidelines should address in the future. 

11:25

In terms of guidelines, Jeremy Hunt has recently indicated that he's looking to be a lot tougher with social media and online companies. As far as you're aware, are there any plans to tackle this particular issue about the handling of suicide and self-harm online as part of the UK Government's plans?

I'm not aware of that specifically. My research mostly focuses on the media's use of social media and death and trauma. I think we have to make that distinction between responsible journalists using social media and ordinary users using social media. I think it would be incredibly difficult to bring in guidelines that affect ordinary citizens, so I'm not entirely sure how anything like that would work, unless it's the tech companies themselves that are going to be held responsible for the content.

Good morning. Could more be done to raise awareness of media guidelines on reporting suicide among journalists?

This is actually something that Sallyanne and I are working on at the moment. We are in the midst of a study where we are asking journalists whether they're even aware of the media guidelines, which is one of the bigger issues that we face. We tend to see that reporters will typically engage with Samaritans guidelines. Most journalists are aware of their editors' code of practice or code of conduct, but overall there's low and inconsistent use of guidelines. We know that that's a problem that we have to overcome. So, Sallyanne is trying to determine what those issues actually are—why they are not aware of them and why they aren't using them to better effect. My own hypothesis on this is that there are too many sets of guidelines. Just off the top of my head, I could probably name you nine or 10 in the UK alone, and I think that's probably quite problematic.

Yes. I kind of declare an interest as a member of the National Union of Journalists. And actually I was presenting the BBC morning news programme during the time of the Bridgend incidents. I think I can concur that there's a problem here. I don't think I was ever given training. Certainly, as you mentioned, the Samaritans guidelines and so on are there, but how do you encourage journalists that this is a matter that is worth them taking sufficient note of that they do turn to these particular guidelines and respond to them? Strathclyde first, then, perhaps. Thank you.

I think it's one of the pressures that are on journalists. I think that most journalists want to be responsible. They don't want to contribute to someone's death or to cause anybody any harm, but they act within several constraints these days. Time pressures are a huge difficulty for them, and they are working in newsrooms that are staffed by very few people and often very young journalists. So, I think the editors and the news managers have to take responsibility here, and most of them do try to do that, but, again, they're under time constraints. So, possibly, we need to go right back to the start of journalist education, and from the day they enter into a university or a further education college course, we need to be making them aware of these issues and they need to be responsible reporters, because it's a very difficult thing for them to deal with on their own.

11:30

Maybe that highlights a problem. I, for example, never went through any formal training on being a journalist, and I think lots of people would be in a similar situation, so it's a matter of continuous professional development as well, I guess.

Yes, I would agree with that, but again it needs innovative methods because journalists don't have a lot of time to devote to this sort of thing.

Yes, I would have to agree with everything that Dr Duncan has said. In addition, I would say that it probably becomes a more global approach in some ways as well in the sense that, as a society, we have to be okay about talking about suicide, so, it needs to go back to schools where mental health and suicide and self-harm are discussed at school. And, with that education, it's just a natural progression into journalism education. Dr Duncan and I are also working on another project right now, talking about, or asking journalism students, their perspectives on suicide before they go into the newsroom. Some of those early findings are quite spectacular in the sense that 72.5 per cent of them never heard about suicide on news days when they were actually in working newsrooms learning their craft, and 92 per cent of the students who were in our sample actually came back and said that when they went on placements, which is pretty standard practice across higher education—92 per cent of them never even had suicide mentioned to them in a newsroom. 

I think one of the other issues that you face when you're in a newsroom—I, myself, also never had training when covering suicide and covered quite a few suicides before being bereaved by suicide and then recognising, 'Oh, hang on, I shouldn't have reported in that way'—. But I think that because newsrooms are so—they've been cut down so much and we are dealing with fewer journalists who are running and reporting the news across newsrooms in the UK. I think one of the other issues that we're facing is that time issue, but they just don't realise that they're causing harm. So, I think it's the lack of understanding of what can actually happen for someone who's been bereaved by suicide.

Ocê. Gan symud ymlaen, mae'r cwestiwn nesaf o dan ofal Julie Morgan. 

Okay, we'll move on. The next question is from Julie Morgan.

Dr Duncan's paper, as we've discussed previously, talks about the adherence to guidelines and the fact that they're not monitored in any formal way as they are voluntary. Some stakeholders do monitor media reporting of suicide and will contact the news outlets to challenge their reporting, but is there any way that this could be strengthened so that they could be challenged more?

I think this is possibly a role for the regulators, the Independent Press Standards Organisation, IPSO, and IMPRESS, although, again, they are voluntary organisations with limited powers. It depends what they're going to do with that monitoring as well. If they're mainly looking for bad practice, then I think that could actually have quite a negative effect on journalists' understanding of suicide. I'd like to see them looking for best practice as well as poor practice so that there are examples of how journalists should report suicide and the benefits that that can bring. I can't see any other organisation that would be able to monitor on a significant scale, and I go back to Dr Luce's point that this really needs a global approach because we have to remember that, where there are high-profile suicides, it attracts the international media as well as the national media, and some of the worst practices that we see, not just on suicide reporting but on death and trauma, come from the international media. So, it really need someone who can take a good grasp of the situation. Having said that, I wouldn't want this to be a statutory monitoring service, because I think that causes its own problems.

11:35

In some ways I agree, in some ways I disagree, with Dr Duncan. In the Republic of Ireland, there's an organisation called Headline. It's a media monitoring unit for suicide, mental health and self-harm. I believe—the last time I checked it was funded in part by the Government, and in part by the media industry. It was a piece of strategy that was created over a decade ago now, and what this media monitoring unit does is it monitors every media outlet throughout the Republic of Ireland. It actually points out that best practice, but also then points out to newspapers, television programmes et cetera really, really bad practice. They run training, because they go into newsrooms, and actually train our journalists on how to better report suicide. They've had some really good results from that. Literally, what you see is, if you look at the reporting of suicide in the media in the Republic of Ireland a decade ago and look at it today, there's a night and day difference. So, I think they have a really good model that could be adopted elsewhere—in somewhere like Wales I think it would actually probably work quite well. I don't know if it's something that could work across Wales, England, Scotland and Northern Ireland because the journalism practices are so different in each one of the regions. So, it would mean that people would have to come from different segments of the country and actually make this a priority. But, in Ireland, they were having some major suicide issues several years ago, and they've really been able to turn around some of our media reporting through using Headline.

Thank you, Chair. My question, really, is about, given that these are guidelines and they are voluntary, to what extent could any effective action be taken if the guidelines are breached—the guidelines or the code of practice?

Well, the simple answer is that there's not anything that can be done if there's a breach, but what we tend to rely on, with guidelines, is that—. We work from the standpoint that most journalists are decent human beings. They want to report the story as effectively and responsibly as they can; they're not starting from a position of harm. They may cause harm as a result, but that's not a deliberate act. Therefore, I think what we're using guidelines for is to point to them that this is the way that the research shows that reporting should be done. It's a means of giving them a template of where to go with the reporting, rather than leaving them to struggle without any help whatsoever.

Yes, I would agree with all of that. Yes, they're voluntary guidelines. The biggest thing you'll hear from journalists—and anecdotally I've heard it myself—is 'Who are you to tell me what to do? I'm a journalist', and I think that's a quite standard response that you find. Even when we say to journalists, 'Why are you not using guidelines?', it's, 'Well, I know my job. I know what I'm supposed to do'. So, it's about building a bridge between guidelines and the actual working practices in the newsroom. When you actually start looking at the academic literature that's out there around suicide and media, there's only myself, Dr Duncan, and maybe one or two others who are actually from the media itself that are conducting this research. So, the research that's been conducted, while it's valid research, it doesn't have an understanding of the production practices that go on in the newsroom, so, journalists, you can understand—and rightly so—they're quite indignant when they have someone coming up to them and telling them how to do their job. So, I think it's about better communication with journalists and actually talking to them perhaps on a peer to peer level rather than, you know, a Government telling you what to do or a medical charity telling you what to do. I think there has to be an even playing field for this to actually work.

11:40

Just following up Dr Luce's comments about the organisation, Headline, in Ireland, I'm just wondering whether there are any examples that you've got of that kind of partnership working going on with journalists or news outlets anywhere in Wales, or anywhere in the UK, actually.

Not really.

No, not to my knowledge. I don't know if—. Dr Duncan may have some examples from Scotland, but I can't think of any.

The examples I'd use are Choose Life, which is our suicide prevention initiative in Scotland, and also See Me, which is a mental health charity. Both of these informally work with journalists to monitor the reporting; so, they will monitor coverage, particularly See Me, and, if they come across something that is negative or derogatory or stigmatising, they will contact the news desk and try to work constructively with them to see how they could report in the future. And that informal relationship seems to work quite well, but it's not established as a monitoring service as such; it's part of what their work is as a national charity. But they are taking steps towards that, and they' are trying to be much more constructive in the reporting.

Y cwestiwn olaf gan Jayne Bryant.

The final question is from Jayne Bryant.

Thank you. I just wanted to touch on the influence of tv and radio programmes. ITV recently have been praised for sensitively handling a suicide on Coronation Street, and the actor was also then praised for how he engaged with people on social media following that. So, there's some good practice there. Is there more that could be done by producers and broadcasters to promote suicide prevention messages alongside dramas where suicide is part of the storyline?

Yes, I think there's always more that they can do. If they're planning that as a storyline, they should definitely be contacting the various charities and organisations that deal with suicide, and they should be talking about approaches and a way that they could film the storyline. I think the aftercare is absolutely essential as well, because we know that people now engage in conversations on social media as they watch the programme, and then afterwards, but I would emphasise that this probably should go on for longer than just the 24-hour cycle after the programme. There need to be support mechanisms in place to deal with these sensitive topics that are going to go beyond the lifetime of the programme because, after all, we've got to remember that we do have iPlayer and on-demand tv and things like that as well, so people might not be watching it within the actual time slot. So, those links and those conversations need to go on afterwards.

Yes. I also thought that the representation on Coronation Street was actually—I felt it was very well done. The thing that struck me most about it was how they engaged with the family and friends, and how they were able to accurately depict the pain that results from a suicide. Even the language that they were using within the programme: 'He killed himself. He's taken his own life.' These are all excellent steps towards helping to destigmatise a really sensitive social issue. I agree with Dr Duncan that this needs to continue. When someone's bereaved by suicide, it just doesn't stop overnight or even in a couple of weeks. This needs to be a longer storyline where you see Aidan Connor's father's interactions over the next year, the next two years, the next five years, and that's where we need to be moving going forward.

I think there's just something that we also need to be careful about in terms of, tomorrow, we have the second season of 13 Reasons Why being launched on Netflix, and I'm actually really quite the fan of 13 Reasons Why in terms of what they actually were able to accomplish in talking about suicide and self-harm and rape and bullying with young people in the first season. But one of the conversations that opened up after these dramas is the fact that guidelines should be applied to them. I would just caution that, because reporting guidelines are for simply that—they're for reporting; they're for journalists to report suicide. What we see on television or dramas or soap operas, these are fictional representations of something that's very real in society. So, I think we have to be careful. There's a line where we can start censoring what in some circles would be considered art, in one sense. But I do think that suicide can be depicted in a very responsible way and actually open up a conversation about suicide. I think that's what both 13 Reasons Why and Coronation Street, a year later, have actually been able to do.

11:45

I was just about to touch on that drama as well, but I wondered if you thought that perhaps some work should be going on in schools, knowing that that's coming up again. Do you think that that's something else that could be done to form discussions at schools?

I think definitely. Young people, we know, are watching shows on Netflix. We know that they're bingeing on shows on Netflix and I don't find that there's anything wrong with that. I plan to view 13 Reasons Why 2 myself this weekend, but I think the conversation around suicide, self-harm, rape and bullying and the other social issues around how boys and girls should treat each other in a school, those conversations should be had in school, and I think they can be had in a very responsible manner. 

Now, what we found with the Bridgend suicides, when Bridgend started happening—and I know it was quite a reaction for everybody—schools, in some cases—. You know, the South Wales Echo covered the fact that schools were saying, 'No, we can't talk about it. We're afraid that more suicides are going to happen', and I really think that we ought to be having those conversations. They're hard [Inaudible.] conversations to be had, but I think if we're being provided with an opportunity, where young people are watching this programme, why not tie it into a lesson on reading the book by Jay Asher and then let's compare and contrast literature to actual drama; let's talk about the issues that are emerging and how they influence your lives and how they impact your friends' lives and let's have some honest-to-goodness conversations.

Ocê, diolch yn fawr. Rydym wedi rhedeg allan o amser am y sesiwn dystiolaeth yma. A allaf ddiolch yn fawr iawn i Dr Sallyanne Duncan o Brifysgol Strathclyde a Dr Ann Luce, Prifysgol Bournemouth? Diolch yn fawr iawn i chi am eich gallu i ymateb i'r cwestiynau mewn ffordd mor aeddfed a threiddgar, a hefyd diolch am eich amynedd a dyfalbarhad, wrth gwrs, wrth i’r dechnoleg weithio yn llai na delfrydol y bore yma. Mi fyddwch chi’n derbyn trawsgrifiad o’r drafodaeth er mwyn i chi gallu gwirio bod e’n ffeithiol gywir. Ond, gyda chymaint â hynny o ragymadrodd, diolch yn fawr iawn i chi am eich presenoldeb ar Skype y bore yma. Diolch yn fawr.

Okay, thank you very much. We've run out of time for our evidence session. May I thank Dr Sallyanne Duncan from the University of Strathclyde and Dr Ann Luce from Bournemouth University?  Thank you very much for your ability to respond to our questions in such a mature and insightful manner, and thank you for your patience as the technology worked in less than ideal ways this morning. You will receive a transcript of the proceedings so that you can check it for factual accuracy. With those few words, thank you very much for your attendance via Skype this morning. Thank you.

Thank you for the invitation.

5. Atal hunanladdiad: sesiwn dystiolaeth gyda Dr Rhiannon Evans, Prifysgol Caerdydd
5. Suicide Prevention: Evidence session with Dr Rhiannon Evans, Cardiff University

Diolch yn fawr, ac, i weddill y pwyllgor, rydym yn mynd i fynd ymlaen yn syth, yn nhermau amser, i eitem 5, gyda pharhad efo’r ymchwiliad i atal hunanladdiad. Mae’r sesiwn dystiolaeth yma gyda Dr Rhiannon Evans o Brifysgol Caerdydd. Rydym ni wedi derbyn tystiolaeth ysgrifenedig ymlaen llaw, yn naturiol, ac felly, gyda’ch caniatâd, awn ni’n syth i mewn i gwestiynau sydd gan yr Aelodau dros yr hanner awr nesaf. Felly, fe wnawn ni ddechrau efo Lynne Neagle.

Thank you very much, and, for the rest of the committee, we will move on immediately to item 5 and continue with our inquiry into suicide prevention. This evidence session is with Dr Rhiannon Evans from Cardiff University. We have received your written evidence beforehand, and therefore, with your forbearance, we will move straight into questions from the Members for the next half hour. So, we'll begin with Lynne Neagle.

Thank you. It's good afternoon, now, I think isn't it? You've drawn a distinction in your paper between self-harm and suicide. Can you just tell us a bit more about how you feel self-harm is dealt with in schools? I don't believe that there is a consistent approach, but are you aware of any consistent approach? And, just a bit more information on that, really.

Of course. I just want to say thank you for the invitation to come. Just to quickly note on the differentiation between suicide and self-harm, a lot of that—just as an academic point—in American literature, they tend to differentiate between non-suicidal self-injury and self-harm with suicidal intent. In the UK, there's been a drive towards not making that differentiation, because it suggests that self-harm is independent of suicide, but actually, what we can see is that repeated self-harm can escalate towards suicide. So, we think it's useful to talk about it within the same discussion, really, and keep those joined in that way.

With regard to school-based practice, at the moment, in the response I provided, we did a large-scale survey and interviews with schools in Wales and in south-west England. What we found was, actually, a lack of consistent approach, but, perhaps more importantly, a lack of an approach at all. So, my own expertise is primarily on mental health—prevention and promotion—and what we see is schools consistently responding and being quite reactionary to an instance of self-harm or suicidal ideation within schools, and also they tend not to discuss it in an open manner within the school context. They try and manage individual disclosures or detection, and the primary practice is to construct it as a safeguarding issue, so it then gets escalated through the school to the safeguarding officer, maybe the headteacher, if that's the most relevant person, and then schools tend to seek external expertise in order to address that particular individual. So, it tends not to be a school-level approach; it's managing the individual.

11:50

Do you think the fact that it's escalated in that way—you seem to imply in your paper—is actually a barrier to young people coming forward?

So, I think there are two important issues there, and I don't really know a concrete answer to either of those. There's some research to suggest that students, perhaps, don't come forward because they're concerned that the issue will escalate—that, in some cases, they want to be able to talk to their teachers in an open manner without knowing that that then might get passed on to their parents, or it might then go to the headteacher.

I think another concern we have—we don't perhaps have the research there that we need at the moment, and we are doing a research study to this effect at the moment—is—. This week, I met with some of the clinicians at the university hospital in the emergency department, and they'd expressed some concern with how quickly things escalate from an individual in school disclosing that they might have engaged in self-harm behaviour or be suicidal, and then the natural progression, in some cases, is to take them to the emergency department. The clinicians suggested that that was quite a frightening experience, particularly if they're between 16 and 18. They might be on the cusp of adult provision, so they might end up with adults, or, alternatively, they might be with quite infant-level problems. So, there's not really a place within emergency services for adolescents, but also they're often surrounded by people who can make their distress worse. So, we do see a real issue with the very quick escalation, really, of responses to them. But that's not to say in some instances it's not appropriate.

To what extent is the fear of talking about self-harm and suicide actually a barrier in schools?

So, in our study, we explored that—about what the barriers were. So, the biggest barriers we had were things like time and resources. The other thing that came up a lot was lack of teacher training. Teachers feel really unsupported in this; they don't have any—well, they very rarely have any training. So, only about 50 per cent of teachers said they'd ever had a discussion or any help around self-harm. The fact is, they're being forced to deal with it, because that's where the disclosures often are or where they detect it. So, there's a fear for teachers that if they deal with it, if they say the wrong thing, that it might lead to someone dying by suicide. So, there's a real concern there about their own response to it.

But there is a broader issue about not wanting to talk about self-harm within the school context. They're worried about contagion, they're worried about behavioural amplification, so that they might, in talking about alternative coping strategies, end up talking about strategies that young people might not know about and that they might then employ to engage in self-harming practices. That's one of the reasons why they keep it quite individually focused, responding to individual self-harm, rather than an open, preventative approach where they discuss self-harm with the wider student population.

Do you think that there should be a push to have more open discussion of self-harm and suicide, and do you think that there should be guidance issued to schools and teachers on that?

There are a few different things about it. So, I think, firstly, we actually don't know that much about the idea of self-harm contagion. There are some studies to suggest it's perhaps not as extensive as we might suggest, but a lot of the evidence tends to be more around contagion through online media, rather than, perhaps, in everyday school settings. So, I think that's a piece of work we're looking to do in the future, of trying to ascertain whether, actually, when we talk about self-harm with young people, that does encourage them. There's also a complex thing around—young people who engage in self-harm tend to be friends, or connected in the same peer groups. So, to disentangle that at the moment is a little bit difficult for me to say. But I think one of the things that came out of the study, and we talk about it a lot, is actually whether the discussion or the focus needs to be self-harm, or whether it needs to be a much earlier prevention approach within the school. The schools want much more investment in mental health promotion and intervention.

I think, in the last couple of years, there was a study published internationally that was around Youth Aware of Mental Health, or the YAM programme, which was mental health promotion and intervention, and that was shown to be effective and showed an impact on suicidal ideation and suicide attempts. So, we don't necessarily need to be so orientated to self-harm and suicide within the school setting necessarily; we need to really be focusing on mental health promotion and the well-being of young people.

11:55

Wedi gorffen? Rydym ni'n symud ymlaen at y gyfres nesaf o gwestiynau, sydd ynglŷn â chyflwyniadau hunan-niwed mewn lleoliadau gofal iechyd, ac mae Rhun ap Iorwerth yn mynd i ofyn y rhain.

Finished? Okay. We'll move on to the next set of questions, which are about self-harm presentation in healthcare settings. Rhun ap Iorwerth will ask these questions.

Jest yn dilyn o'r hyn yr ydych chi wedi'i ddweud yn eich papur, rydych chi'n credu bod gweithredu canllawiau NICE yng Nghymru yn rhywbeth sydd ddim wedi cael ei astudio ddigon. Eglurwch mwy wrthym ni am hynny.

Just following on from what you said in your paper, you believe that implementing the NICE guidance in Wales is something that hasn't been studied enough. Can you tell us more about that?

I was going to say, 'I can't speak Welsh, so I don't know how I'm going to answer'. I don't know what I was going to do. [Laughter.]

So, obviously there's NICE guidance about what should happen when an individual presents at hospital with self-harm, and that's for over-eights, so there should be treatment for medical injuries, a psychosocial assessment. So, there's a set of pathways, and that is recommended, but studies show that that's not happening. So, psychosocial assessments are probably only delivered in about 60 per cent of cases.

I don't know. I think the Talk to Me strategy again has flagged up the fact that they're not being delivered consistently in Wales, and Public Health Wales have picked that up in their suicide review as well—that it doesn't seem to be happening. I don't actually know why that is.

We are doing some research at the moment with one of the new CAMHS crisis liaison teams. So, they were set up—and there's one that sits in the university hospital that is specifically targeted at improving the conduct of assessments with children and young people. I think that was an issue—that they weren't being necessarily delivered with that population. So, that's intended to mitigate that risk of them not happening. It should be on-site that they should be delivering those assessments with children and young people when they present to the hospital. We're trying to explore within that what's the experience of that: are young people more inclined to take up those assessments? Because there's a risk that an individual can just leave the hospital of their own volition before these assessments are conducted. So, we're trying to explore how we increase the uptake of those assessments.

So it might be useful for us to make a recommendation or to consider a recommendation in that area.

Yes. Firstly trying to monitor their conduct, but trying perhaps to explore a bit more comprehensively where this pattern's in practice and why some teams or some hospitals might not be undertaking them.

To take a step back, the guidelines—you're happy with the guidelines? Do you think the guidelines have it right?

They're pretty comprehensive, and there's evidence to show that individual aspects of that guidance are shown to reduce repeat self-harm. So, yes.

What about primary care settings and the management of self-harm in those settings, apart from in hospital?

I think it's the issues that have been consistently raised, particularly about the CAMHS teams, about access, about thresholds. These are well-rehearsed considerations. There have been increased efforts to resource them, but we're yet to really see whether that happens. I know that there's been the announcement of increased investment for the piloting of the CAMHS professionals within schools, to try and improve relationships between schools and the CAMHS professionals. We don't know really what the evaluation is going to be of that and whether that might improve relationships between, particularly, schools and the CAMHS teams. But I think people have expressed issues about whether the number of young people who have been referred to CAMHS—. How do we decipher who are the most appropriate referrals, and how do we allocate that resource most appropriately? Are there cases where the resource isn't necessarily needed, and we can manage those cases much earlier on? I guess that brings us back to some of the school-based stuff. Are referrals sometimes occurring because, within school settings or family settings, people don't really know what to do? So, I think there's a lot of unpacking that we still need to do there about managing those relationships and ensuring the most appropriate referral pathways between the services. 

12:00

Mae'r cwestiynau nesaf o dan ofal Dawn Bowden. 

The next questions are from Dawn Bowden. 

Thank you, Chair. I just wanted to look at the situation in care settings now. I know you did a study last year around that, and it identified that suicide attempts are probably three times more likely by a child in a care setting. What data do you have about self-harm and suicide in care settings? Do you have that or not? 

So, that was a systematic review, so they were international published studies. In terms of the Welsh data, we have—. I think historically in the UK, the quality of data around social care, particularly in regards to children and young people, has been relatively limited, and part of that is because of the transience of the population. So, for example, in the secure anonymised information linkage databank in Swansea, where they do all of the data linkage, there have been moves to link in more social care data. A colleague of mine has got a study at the moment trying to ascertain a lot of the mental health risks of individuals with ACEs and individuals who are care experienced, to know the certain risks associated with those different types of childhood experiences. So, we actually know very little even about basic epidemiology of that population. 

So, we have the school health research network, our university, where we routinely survey young people, and that has a large foster care sample.  That's probably one of the most comprehensive surveys we have at the moment about the experiences of care-experienced individuals, and even from that we could ascertain that key determinants of well-being in care-experienced individuals are relationships with their peers and relationships with their teachers. So, we're trying to develop intervention around that, which taps into that data. But in terms of the more suicide and self-harm outcomes, there's not really much data. 

No, and I think you kind of touched on it there in just some of that—that some of the main contributory factors would be related to possibly issues prior to a child going into care, or their experiences while they're in care. What are the contributory factors? 

So, again, that's complex because we don't have a lot of longitudinal studies. There is a Canadian study that suggests that the risk of suicide attempt at the point of entry into care is higher than when an individual's been in care, which would suggest that being in care is a protective factor for a lot of young people. And a lot of it is that the reasons that a young person might go into care are known risk factors for suicide and self-harm. So, maltreatment is a big factor. Maternal mental health issues are a big factor. A young person might go into care because they themselves have mental health issues. It's been shown that individuals in care are probably four [Correction: five] times as likely to have a mental health condition than those who aren't in care, and that's a significant risk factor for those outcomes. So, there's a complex array, probably primarily of pre-care experiences, that contribute to those outcomes. 

So, carers that have dealt with children that have self-harmed or tried suicide have got a huge amount of experience in that area. Do you think we could be doing more to utilise their experiences for future children coming into care? Would that be—?

The study we did worked with carers, and it's quite interesting because in the role of corporate parenting they said they fell between being a professional and then being the birth family, and they've got an expertise that isn't necessarily privileged within decision making. And with suicide and self-harm, perhaps rightly so, there are predominantly medical discourses that surround them, so we talk about them in medical terms, and their sense is that there are a lot of sociological or social dimensions to these behaviours that they understand because they live with young people every day. So, I think they were saying they just wanted a stronger presence, perhaps, around decision making or knowledge exchange, to understand why is it that individual has engaged in self-harming practices, and what might be the best course of treatment for them. So, it's just giving them a little bit more of a voice, perhaps a bit more of a professional standing in this area.  

So, what further support and training in this area do you think that carers probably need?

12:05

I think there's probably two things there that we need to think about. The first is very practical training about supporting young people. A lot of them said that they'd never had any training at all. They tended to be in a cluster of foster carers. An individual might have died by suicide and then there was some postvention training. But in terms of actually supporting the day-to-day of living with a young person who engages in self harm, thinking about alternative coping strategies, things about managing stress and resilience to try and prevent the escalation to the point of self-harming—those sorts of everyday skills to live with that person. 

But I think also it's thinking about the professionals that work with foster carers and residential carers. So, the Fostering Network have been doing some work about trying to integrate training into social workers' or even clinicians' training about what foster carers and residential carers do, and how they might use their expertise to inform planning of care pathways. 

Hapus, Dawn? Dyna ni. Yr adran olaf yw materion yn ymwneud â'r rhyngrwyd a chyfryngau cymdeithasol, ac mae gan Julie Morgan gwestiwn. 

Content, Dawn? Fine. The final section is issues in relation to the internet and social media, and Julie Morgan has a question. 

Thank you, Chair. Obviously, I think a lot of concern has been expressed about the internet and social media and the way it is sometimes used. But do you think there is scope for a positive way of using the internet and social media to help deal with these issues?

Yes, absolutely. I'm sure I'll just echo what a lot of people have said, but, again, it's complex. We know from some of the samples and studies that have been done that individuals tend to actually use the internet a little bit more for help-seeking around self-harm and suicide than they do actually for looking at sites that promote it. So, it is used quite a lot in a helpful way, but the issue is that studies show that when individuals are already engaged in self-harming practice, or self-harm with suicidal intent, they tend to use the internet for methods, and in ways that then perpetuate or contribute to those behaviours. 

So, we did a study about how young people use online imagery as part of the ritualistic practices of self-harming—that when they felt they were coming up and starting to feel they wanted to self-harm, they might go on the internet and look at images of other people who engage in those practices. It sometimes became a competitive thing about the depths of cuts or the extents of scars and trying to replicate that. So, it's certainly got a problematic usage for individuals who are already engaged in self-harm. But I think if we take a step back and think about the wider use of it, a lot of people are using it in a positive way, and there's definitely scope for online interventions, both in terms of internet, but also app-based interventions that young people might interact with to try and increase positive help-seeking. 

Are there are any sort of targeted interventions via social media?

Yes. So, there's sort of guidelines about content warnings. Particular platforms will have warning guidelines. And there has been a move towards mindfulness interventions and that sort of thing online. I'm not sure—. We did a systematic review and evidence was mixed, and the sort of evidence I've seen since has still remained quite ambiguous about what actually works within that area. There's still a long way to go. That's not that helpful, is it? I don't know. 

Has much research been done on this? Not much, then, presumably. 

I don't think we're there yet in really knowing what works. 

There are apps for adults though, aren't there, like suicide prevention apps? So, you're not aware of anything similar for young people. 

I think there's some stuff being developed, but I'm not quite sure of specific ones, sorry. 

Dyna ni. Mae'r cwestiynau wedi dod i ben. Diolch yn fawr iawn i chi am ateb y cwestiynau mor raenus, ac hefyd am eich presenoldeb y bore yma, ac am y dystiolaeth ysgrifenedig ymlaen llaw. Ymhellach, byddwch chi hefyd yn derbyn trawsgrifiad o'r cyfarfod yma i allu gwirio bod beth ddywedoch chi yn ffeithiol gywir, a'n bod ni wedi cofnodi'r peth yn fanwl gywir. Felly, gyda hynny, diolch yn fawr iawn i chi.

Ac i'm cyd-Aelodau, byddwn yn torri nawr am egwyl, a'r peth cyntaf fydd yn digwydd yn yr egwyl yna yw y byddwn yn cyflwyno ein hadroddiad ni ar gyffuriau gwrthseicotig. Felly, mae yna ymrwymiad cadarn i bob Aelod o'r pwyllgor yma fynd yn syth drws nesaf heb fynd i unrhyw le arall yn y cyfamser. Diolch yn fawr iawn. 

That's it. I think we've come to the end of our questions. Thank you very much for your excellent answers, and also for your presence this morning and the written evidence we received beforehand. Further to that, you will receive a transcript of this meeting to check for factual accuracy, and that we have recorded it in full detail. With that, thank you very much. 

Fellow Members, I'd like you to know that we'll take a break now, and the first thing that will take place during that break is that we will present our report on antipsychotic medication. So, there is a strong commitment from all committee Members to go immediately next door, and nowhere else. Thank you very much. 

12:10

Gohiriwyd y cyfarfod rhwng 12:10 a 13:18.

The meeting adjourned between 12:10 and 13:18.

13:15
6. Atal hunanladdiad: sesiwn dystiolaeth gyda Choleg Brenhinol yr Ymarferwyr Cyffredinol Cymru
6. Suicide Prevention: Evidence session with the Royal College of General Practitioners Wales

Croeso nôl i'r sesiwn ddiweddaraf o'r Pwyllgor Iechyd, Gofal Cymdeithasol a Chwaraeon yma yng Nghynulliad Cenedlaethol Cymru. Erbyn nawr, rydym ni wedi cyrraedd eitem 6 ar yr agenda a pharhad o'n hymchwiliad i atal hunanladdiad. Mae'r sesiwn dystiolaeth yma gyda choleg brenhinol y meddygon teulu yma yng Nghymru. Felly, mae'n bleser gennyf groesawu hen ffrindiau, Dr Rebecca Payne a Dr Jane Fenton-May, ill dwy o goleg brenhinol y meddygon teulu. Rydym ni wedi darllen pob math o dystiolaeth ymlaen llaw. Wedyn, gyda'ch caniatâd, fel sy'n arferol, fe awn ni'n syth i fewn i gwestiynau, ac mae'r cwestiynau cyntaf gan Jayne Bryant. 

Welcome back to this latest session of the Health, Social Care and Sport Committee here at the National Assembly for Wales. We've now reached item 6 on the agenda and the continuation of the inquiry into suicide prevention. This evidence session is with the Royal College of General Practitioners here in Wales. So, it's a great pleasure to welcome old friends and colleagues, Dr Rebecca Payne and also Dr Jane Fenton-May, both from the Royal College of General Practitioners. We have read evidence beforehand. So, with your permission, as is customary, we'll go straight to questions, and the first question comes from Jayne Bryant.

Thank you. A key theme in the evidence that we've had so far is the need to improve training for suicide prevention for front-line staff. It was felt to be particularly important for those identified as priority care providers, such as GPs. What way do you think suicide prevention training for GPs and other primary care staff needs to be improved?

If I start from the beginning of the patient's journey, the first point of call is very often the receptionist, or else, a call handler in the 111 or the out-of-hours service. So, there needs to be training available to these team members. And very often, the health boards offer protected learning time. So, many health boards will run their own training. The whole practice will shut for an afternoon. Often, the out-of-hours will take over and that gives a real opportunity to provide training to the entire practice team. So, that could be one possible way to do it. Once they've got through to the next level of professionals that they will see, it could be a GP, or we're also seeing a huge number of other professionals coming to join us in general practice: people like paramedics, different types of nurses, physios, and other professionals—pharmacists, for example. And one of the things we've been pushing for is that anybody coming to work in general practice actually has general practice relevant training. Because if you're a nurse, you could have done your advance nurse practitioner course in the hospital and never really come across the huge variety of different things we encounter in general practice. So, we're very, very keen that anybody coming in to join the team has bespoke training relevant to that context.

Then there's a need for update training, because GPs will cover suicide prevention and mental health as part of their GP curriculum, which they're examined in order to become a GP, but all of us forget stuff, things change. It's important to stay up-to-date. And, again, there's a variety of different ways this can be offered—again, through the health board continuous professional development afternoons. But, it's important to note that the recent workforce figures showed that a third of GPs are currently not working as traditional practitioners—so, not working as a salaried or a partner GP—so don't have a link with a local practice or sometimes not even with a local health board. And it's absolutely vital we catch those people too, which health board training afternoons don't always do.

So, other options for that would be through the deanery—they run some courses for GPs. And then there's a variety of medical update organisations. I recently did a day's training updating me on everything I needed to know that's changed in the last year and they had a really excellent section on suicide prevention. There are online options as well to deliver training. As a royal college, we've got various tools and resources that people can work through. So, there are loads of training out there. The important thing is to make sure that people have enough time to access it, because I know you're well aware of the pressures on general practice and our colleagues need to have protected time for learning. Jane.

13:20

Can I just emphasise, firstly, the problems of the other members of the primary care team and the learning in mental health things? Because most practice nurses will have been through physical training for adults in nursing and although there are some mental health components to that, they are not basically trained in mental health issues. And I know that my practice nurse, when I was in practice, was very experienced but felt that she had limited experience of mental health issues in patients. We have nurses and other people seeing a lot of the chronic care patients, and those patients actually are at fairly high risk of having mental health problems, so we need to make sure that that is part of the training for the practice nurses. It's difficult to get practice nurses into training, so we need to emphasise that. And the newer members of the practice team equally need that kind of learning.

One of the problems is you can have as much training in how you manage people with suicide risk, but, actually, what you need to be able to do is have an ability to discuss the issues with them in a compassionate way and that is much more about experience and learning on the job rather than going to a course or reading a toolkit or something like that. And the kinds of patients that you see presenting in general practice, who might be suicidal, very often aren't telling you that they're suicidal. You have to probe, they come several times with some odd complaint and you need to be aware and have that sixth sense that often GPs have that there's something else behind this patient that's coming. And as we know, a lot of patients don't even come near the general practice when they have mental health issues leading to suicide. They don't confide in anyone. So, that group is particularly difficult to do anything for, apart from making sure that people are aware that they can come and see us.

And that group of patients with chronic disease is absolutely key. So, we know that, with a diabetic patient, we should be asking about their mental health and screening them for depression when they come to see us, because, actually, if patients have got other health issues, getting out can be really difficult. They're not getting the opportunities to socialise if they're worried about: will they find a toilet when they go shopping? All those other things are really big risk factors for suicide, for depression and other things that really do increase their risks. We need to be absolutely clear that it's not just about educating one branch of the profession—actually this is a social issue as much as a medical one. If people aren't able to get out and if they haven't got a job and haven't got family around them, if they've been recently divorced or bereaved, particularly if it's a bereavement through suicide, these guys are high risk, and we need to make sure that the medical profession is skilled to pick them up and support them, but actually it's a societal issue too: how do we look at the things that go beyond medicine?

13:25

Just on the point about training, do you think that mandatory training would help for front-line staff, giving it the same status perhaps as first aid training or—?

I think that's an interesting idea. In terms of how much that would benefit, I think most GPs do go on regular update courses, because we have to demonstrate for our appraisal that we're staying up to date. So, I think people are often covering it that way, and when it comes to the wider practice team, I think it's important that people are aware of things, but whether a mandatory training route is the right way or encouraging health boards to include it in their CPD afternoons, I'm not sure. I think there are lots of different ways to achieve the same aim. What we need to get to is the point where every member of the primary care team is skilled and confident in recognising mental distress, speaking to patients sympathetically and compassionately about it, and then also knowing who they need to signpost on to other services and actually being able to get them into the other services, because I think from my experience as a GP, that's been a bigger barrier. Have you got time for some patient stories?

Okay, because one of the most sad cases I've ever dealt with was a patient who I felt was really high risk for suicide, who I referred on to the services, and a couple of weeks later, I was really surprised to find a letter back saying, 'We don't think he's at risk.' I thought, 'I thought he was at high risk', and then I thought, 'No, he's seen the specialist; stop worrying—they're the experts and maybe you were just overly worried', and then that patient killed himself. That post-bereavement visit was one of the hardest things I've ever done, because I knew that patient was at risk and I sent him to the right place and I still didn't get support for him, and I think all of us have got stories like that.

And I've got a similar one: I had a patient who came to my surgery and said that he was going to commit suicide. I contacted the mental health unit and they said, 'Oh, is he a drug user?', 'Yes, he does use drugs', 'Oh well, we can't see him, because he's a drug user.' I spent a long time talking to various people, I talked to the drug abuse service, and in the interim, he wanted to use the toilet, he said, so I let him out of my surgery, and he went into the gents' toilet and pulled the blade out of his rucksack—he was homeless as well, this chap—the rucksack he had with him and slit his wrists. We were alerted by the fact that there was blood coming out from under the toilet by another patient. I was being told he wasn't a suicide risk—we just needed to stop him taking his drugs. He did get care eventually, because he got admitted to A&E on a 999 call. Actually, that took a long time as well, but that's a different issue.

So, it is difficult because the mental health services are saying that unless they're actually in the process of committing suicide some time, they won't see them as an emergency patient and some of these patients have got nobody. If they're very vulnerable and they're homeless or they live alone, there's no-one else to help support them. Can you wait until you get somebody to come in whenever that is? When they do go to the crisis unit, sometimes they get discharged to wherever it is they came from with a question mark of a follow-up by the primary healthcare support services or the community mental health team and there isn't anybody there for them. They haven't actually put in a good package. I worked in a practice where a lot of my patients moved around, so they'd be referred to one community mental health team, but they were already under another community health team and so the first one wouldn't see them. So, the mental health services are not necessarily joined up in order to help these patients.

13:30

And particularly those with drug and alcohol problems, because often they're bounced out of the normal services into drug and alcohol services and then don't get that more specialised support for suicide prevention, but we know that taking drugs is an independent risk factor for suicide. And we went out and asked our members—there's been big discussion about this on the GP Facebook sites this week—and these experiences are typical of people up and down the country. We're really struggling as a profession, having identified that people are at risk, to get the help and support they need for them.

Do you think there's a risk also around students or people who are away at university and are registered at a particular university, come home, go and see their GP, but there's nothing really to say, perhaps because of problems with notes?

Yes. That's a massive problem.

There's nothing then to say that this person has been having some mental health problems or feeling suicidal or—.

There is a big problem and that was highlighted in the report last week from—I can't remember who it was, but I'm sure you would have seen it—about the gap between the NHS and the university services. You don't always get the notes very quickly. Sometimes, students, although they're advised by their universities to register with local GPs, refuse to for whatever reason and they end up seeing you as a temporary patient and you haven't got their past history. In fact, some of those students may have been absolutely fine in the home environment because they had a supportive network of friends, but they suddenly go to university and they've gone from a little pool into a big pool; they might have been the big boys and girls in the school that had all the prestige and suddenly they're in a pool of students who are all vying for attention with each other. We've talked about loneliness a little bit, but sometimes these students are very lonely and it is exacerbated by the fact that they're lonely in a crowd and not fitting in, and then there's alcohol, possibly, around freshers week and all these kinds of things. Some of the university support services were very good, but I believe that they had been cut back from lack of funding.

Lynne, you had a point—. Sorry. Lynne you've got a point on this.

Yes. Just to ask on this, really, there's been a significant increase in student suicides in the last year. Do you think that there's maybe a case for having a, sort of, dual registration system for students, so that they stay on the books of their home GP but also stay on the books of the university one, and that there's communication between the two?

Well, I was just about to pick up on that, because even when they do the right thing and register at their university address, actually, then they come back home in the holidays and you don't have access to their notes. So, I think, although there would be benefits to a dual registration, unless that information is being shared between the two, it wouldn't really give any additional benefits because we can always see them as temporary residents at the other site.

What we really need to get to is a situation where the notes move with the patient because we have so many challenges at the interfaces where the hospitals don't know what's happening in general practice; we don't know what's happening at the hospitals; we don't know what's happening one practice to another. And that's within Wales: if they choose to go to university elsewhere in the UK, it's even more challenging. So, I think we need to have more ambition for our view of medical records. So, we already see maternity patients successfully carrying their notes around with them so that their information is always there. In this day of apps and smart phones, I think we have got a need to give people more ownership of their health data. Now, that's probably beyond the remit of today's discussion, but it's not the dual registration, it's getting the information, and even if, perhaps, they were to get a printout of today's consultation to take with them, or something, that would be a vast step.

And foreign students have got a particular problem. So, sometimes that's compounded by some language problems or stigma about talking about mental health and they don't want to go back to their own country having failed. They've come from, some of them, more third-world-type countries as opposed to the richer countries.

Thank you. I wanted to ask you about the high-risk groups—we've already referred to some of them—and whether you think there should be help targeted towards particular groups.

13:35

Yes; what that looks like is a harder question. So, if we take groups, say, of people who have experienced bereavement through suicide, we know that they're at much higher risk of completed suicide themselves. What does that help look like? Should it be a medical form of help or, actually, I think often de-medicalising it and providing other sources of support—people to talk to who've experienced it, patient groups—that sort of thing can be very useful.

For patients using drugs, we need drug and alcohol services that are able to look beyond things like a methadone prescription and really deal with the mental health problems. And some of them can; some of them are excellent, but they do tend to be a group of patients that don't always seem to experience holistic care. We know that, for people who've recently been through a divorce or bereavement—they're at risk. So, for me, I think it's about society's wider services to pick up and support people. Joblessness as well—it's a massive, massive risk factor. Men of working age are the group who are singly most likely to have a completed suicide. Often, joblessness and relationship breakdown are part of that. So, yes, I think there should be, but I don't think the solutions just lie in medicine.

I would agree with that. I think we need more social support for patients across the board in Wales for all things, and I was just thinking about the recent review of perinatal mental health, because the other group that very often gets forgotten are the husbands or the partners of the people who are sometimes struggling with the change in their lives. There has been a recent improvement in the toolkits for GPs around perinatal health, but we need to ensure that we have support for those groups and particularly for the forgotten ones—the ones who had miscarriages or stillbirths who don't come home with a baby and who find it really difficult to talk to colleagues about what happened. If they do open up to colleagues, very often they find that those colleagues know of somebody else, so we need to make the stigma about some of these things less pressurised and enable people to talk about all of the well-being, really, or non-well-being.

Facebook has lots of wonderful pictures of people doing all sorts of exciting things, but you don't very often see the bad news on there that has affected people who are struggling with rising to the surface getting back to their normal lives.

And the other big group is refugees. I used to work in the refugee health centre in Cardiff and I saw decisions that really impacted on people's mental health, like adult families being split up by the Home Office. You'd have an 18 or 19-year-old child living in a different city to their parents. Well, the impact of being a refugee is disastrous for your mental health, let alone being split up from your family, and it just seemed utterly bizarre that a policy was actually creating something that was so bad for people's mental well-being. I tried—I wrote letters and things to try to get them all back together again, because this woman didn't need drugs, she didn't need anything else apart from that support from her family. I mean, it was just very frustrating.

What about doctors themselves, because obviously doctors are identified as a high-risk group?

Yes. And we know that most doctor suicides, I understand from Twitter—so, I'm not sure how robust this evidence is, but that's what's out there—. Most doctor suicides start with a complaint, and looking at how we handle complaints—

Against the doctor. How we handle complaint procedures with doctors is absolutely vital. The General Medical Council has recently changed its procedures for investigating complaints to try to reduce down the suicide risk of people under investigation. We also see other groups that are very likely to commit suicide: farmers and also vets as well. I think that uncertainties about funding for farmers in the post-Brexit world potentially create an extra risk factor on people that we need to be extremely sensitive to. Uncertainty is harder for people to deal with than actually knowing what's going to happen, and we need to be very alive to that.

I just wondered—. Obviously, it's also incredibly upsetting for doctors and other professionals who have patients who go on to complete a suicide. Is there any support available for doctors in that kind of scenario?

13:40

No, I don't think so. Doctors very often have problems when they've been managing families for a long time and there's a death that they feel is potentially one that might have been avoidable. There isn't support for those doctors, although recently GPs have been entitled to have occupational health services from local health boards, and there are some services for supporting doctors with mental health issues. There are a variety of different organisations run by different people. I think still a lot of doctors and medical students, surprisingly, do not access some of those services because they feel that there is a stigma—that if they go to some of those services, they have failed in their caring roles. Those services can be very useful to them—because I know people that have gone through them—particularly if they have mental health issues on top of it that are making them tip further into the brink, so burn-out, stress, anxiety—those kinds of mental health issues. They don't want to go and sit in the local psychiatric clinic with their psychiatric colleagues, and there need to be mechanisms for them to be treated by a different route. Sadly, one of the things that they use is alcohol. So, then, sometimes they get addicted to things like alcohol, which compounds the problem. So, we need to ensure that there are robust mechanisms for doctors to be able to get the support they need.

Farmers are very isolated—I'm just moving on to the very high-risk groups. Farmers are very isolated, and I don't know how we get to support those apart from the GPs being aware about that. I'm not sure if everybody knows about the high risk around vets. My daughter is a vet, so I—. She had quite a number of the students in her year with depression. They found it was quite difficult because, a bit like going into medicine, you think that it's all going to be care and loving and, for vets, you're going to be cuddling animals and things like that, and it's very different from that, being a vet. They have the ultimate solution in veterinary—not that I'm suggesting we have that in medicine—which is euthanasia. So, they've got the drugs handy as well.

And then if we look at junior doctors, often they have a lot of risk factors anyway. They're moving around, they're doing a tough job, they're stressed, and often away from family and friends. There's some recent research out that shows that working nights, or staying up late, even, is a risk factor for developing depression. So, they've got a lot of risk factors before they even develop a mental health problem. We certainly need to do more to support junior doctors and medical students, making sure that working hours are configured in a way that is as body-clock friendly as possible whilst still meeting the needs of the service, making sure that if they're moving to a new area,  there are things that they can plug into, like consultants inviting them around for dinner and things—the little things that are not about medicine but about being human. And, actually, sometimes it seems that we've lost that. Bangor—you've heard Linda Dykes give evidence to you before—have done a fantastic job with how they've made their emergency medicine jobs doctor-friendly and really offered good support and mentoring to the doctors, and that's really had a benefit in things like sickness rates, it's had a benefit in retention—all sorts. Actually, that shouldn't be a little pocket of brightness in Bangor; that's how we should do business. Every junior working in Wales should feel supported, but, sadly, not all of them do.

I think something that some of you might be concerned about—the rota. I think one of the problems with the junior doctors is they swap quite frequently from day to night in work. There are problems if you do night shifts constantly, and that's proved by reduced immunity status, but the worst is if you have to keep going from day to night without long breaks in-between. The other thing that happens quite often for some of these junior doctors is they turn out and find that, actually, there are shortages in the rota and they're covering a much bigger unit than they had anticipated, because the other half of the rota has not turned up—he's called in sick or what have you—and there isn't an easy mechanism for them to report that in Wales at the moment.

13:45

Okay. Let's move on to what you alluded to at the start—referrals to mental health services in general and that schism, as some of us feel, between primary and secondary care. Rhun's got some questions.

Yes, a couple of comments, if I may, first of all, on working strange hours. I remember when I was having to get up at 4 o'clock in the morning for five years to present a breakfast show—that took its toll on me in just being out of sync with the world. It's not good.

In terms of what we were talking about before, do you think, very briefly, that we have to tailor our suicide prevention messages to different groups? In farming, for example, there was a presentation in the Assembly recently by a widow from Pembrokeshire whose husband had taken his life. Is that tailoring important?

I feel a little bit anxious about anti-suicide campaigns, because we know that when, say, somebody kills themselves in a soap opera, vulnerable people are more likely to use that method. I think we need to look more widely into an increasing well-being campaign. So, for bereaved people I don't think the focus should be on stopping them killing themselves, I think it should be on what techniques they can use to get through the bereavement. So, yes, I would absolutely support tailored things to increase people's holistic well-being. If somebody doesn't have a job, then, actually, very often, that's the bit that needs addressing, and everything else will flow. So, does that answer the question?

Thank you. Yes, that's great. I apologise to the Chairman for taking us back there.

On referral, you both mentioned problems with referral with particular—

Yes. I'm going to get the examples out of my bag.

—patient stories, as you put them. So, maybe you'd like to address the issues of problems of—without a specific question from me—referrals from primary to specialist mental health practitioners.

If you start, I'll pull up the examples and then I can talk about them.

As I mentioned, if you've got somebody saying that they're suicidal, you've actually got to be—. You know, you can't say, 'I've got a patient who says they're going to jump off a bridge'—they've got to actually be on the bridge, on the parapet, trying to jump off. So, that was what I was told once by a mental health practitioner when I was trying to refer a patient, all right? And I practically went to the bridge with the patient and I actually threatened the mental health people that we would probably both jump off, because I'd had enough.

We did hear evidence this morning, actually, that suggested that when people are talking about threatening to take their own lives, that, actually, that doesn't necessarily mean that they're at more of a risk.

No, that is true, but I think there are some people who are very secretive about the suicidal thing. Some people will have rehearsed some of the suicidal things and some people will vocalise what they think that they would do if the last ditch comes. I think we have to be very serious when somebody is presenting something to us and saying that is what they're going to do because they haven't got any hope. I think we can't—. I personally, as a GP, feel that that is not something that you can dismiss, because I don't know which one is just wanting me to be more friendly and support them, and which one is actually going to do it. There is no viable way of doing that.

So, that referral has to happen quickly because you're not the expert. They need to go to mental health teams.

My colleague from Powys has shared his difficulty. He asked for an urgent assessment for a patient who was really quite severely depressed and spoke to the duty worker and was told, 'We only have two categories of assessment now: "urgent" means needs to be seen in four hours, or "routine", which can be four weeks. We've determined that he does not meet the criteria for urgent assessment.' That's somebody else's experience.

Another colleague, and he's from Cardiff, says that 'routine' takes a couple of months, 'urgent' 48 hours, and 'emergency' now. You have to discuss 'urgent' and 'emergency' with the duty worker. And, actually, sometimes it's incredibly difficult getting hold of the right person to have that discussion with. And bringing it back to the fact that we've still got 10-minute appointments, trying to really understand what's going on with a patient in 10 minutes and then have a conversation with somebody else who you can't get through to on the first number, and then you try the second number, and everybody else is waiting outside, is really, really difficult, and—

13:50

Do you want some more examples from across Wales?

No, answers like restoring the link between primary care and secondary care, GP to psychiatry paths.

Yes, that would be extremely helpful, because, actually, when we phone up, we want a number that works, we want to speak to somebody who listens to what we say and isn't just going tick, tick, tick on a list. But if we as experienced GPs say we're worried about somebody, actually, that, in and of itself, is an independent risk factor, but very often it just seems it's like 'tick, tick, tick, they don't meet enough', and that gut instinct isn't taken into account.

And, sometimes, you haven't filled in one of the boxes on the tick list that you sent, because, I think, in some areas, you have to send a fax and you have to have filled in the boxes. If you've left off one box or you haven't—they'll just reject it, and you might not know about the fact that they've rejected it for a while.

So, do we have to totally redevise the referral system, or sharpen it, or improve it?

Being able to talk to a psychiatrist is very, very helpful, and that's got harder and harder to do. If you're talking to somebody who's not a psychiatrist, but will arrange for the patient to be seen in the timescale that the assessing clinician, be it a GP or one of our team, thinks is appropriate, does it matter so much if they're not a psychiatrist? Well, if they're going to make sure your patient is seen by the right person, probably not. But the simplest thing is there needs to be somebody on-call who answers the phone and can move things forward, particularly overnight.

The other massive problem is that we are moving more and more towards telephone triage and telephone consultations, and you can spend half an hour on the phone with a patient with a mental health problem, really get to the bottom of it, and then the psychiatrist won't accept them until you've seen them face to face, and it just introduces so many delays. So, actually, having a conversation with a psychiatrist about removing that need for a face-to-face assessment by the GP if a thorough telephone consult has happened would be helpful.

What about the idea of ensuring that every practice, certainly every cluster, has a mental health specialist—it could be a nurse—so that there is access where you are to mental health specialism—a nurse or doctor?

I think it depends what you mean by that. So, a lot of places will have GPs with a special interest already, but there are still things that we need extra help and support for. If you're talking about parachuting a mental health worker into the practices, as long as they've got enough time to do the job effectively and they've got mechanisms to seek support when it gets beyond their competencies, that could be very welcome. But—

One at cluster level would be absolutely overwhelmed. I think, if it's at cluster level, you're replicating the primary mental healthcare teams we've got already, that we're already struggling with. So, yes, we absolutely need more capacity closer to the patients to deal with mental health problems—

But they also have—. If you're talking about suicide prevention, there has to be capacity in the work plan in order for them to see people very quickly, because, in some areas, there are already CPNs that are attached to practices, but the referral time is quite long, so they may not be seen. There are counsellors who can be very supportive to patients, as long as they are not actively—. But, if you're talking about prevention, early prevention, with depression and anxiety, the counsellors—. But, in some areas, the counsellors have got a six-month waiting list. So, when that patient presents with that problem and has got round to admitting that things are a bit dire, you need somebody there now, today, or a promise of them being seen in the next couple of days, rather than six months' time, by which time things—

Or even four weeks.

And the other issue as well is social prescribing, because we've already talked about—for a lot of people, it's the environment they're in. So, there are the acutely depressed, suicidal people we just need help with now, but, actually, there are those people that you know are at risk, and being able to link them to somebody that maybe doesn't have mental health expertise, but knows what's around in the community and can link them to a barn dancing club or the rambling club or whatever it is they need, tell them about the RADAR scheme for disabled toilet access—that sort of thing.

No, no, but that's—

Absolutely right, and we're glad you mentioned that. It was on my list of things that I wanted to ask about. I'm sorry to hurry you, because I'm aware of time pressures. When it comes to referring children and young people is the situation worse, or equally bad, or how would you rate it?

13:55

I think it's probably worse, because getting referrals into CAMHS is difficult. One of the problems is, as I mentioned to the education committee, actually young people very often don't come to the GP. So, there need to be improved facilities within schools for the school nurse to be able to refer young people to CAMHS, and to have rapid access to support services for these young people.

Also, CAMHS don't deal with mental distress very often. They will pick up psychotic patients, patients with eating disorders, but, actually, miserable people, depressed teenagers, people that are just struggling—it is a nightmare getting any help. The school counsellor will say, 'Oh, they're too bad. You need to refer them to CAMHS'. CAMHS say, 'Refer them to school counsellors'. The school counsellors have already told you that they can't cope with them, and you're there in the middle thinking, 'I just don't know how best to help'. In the past, we were able to start younger people on anti-depressants. Now, the evidence shows that's not a good idea, either, and you're just left thinking, 'I know if we intervene now, we can help you develop skills that will help you for the rest of your life'. Trying to get that help is incredibly difficult.

The primary care support services and the in-house GP counselling services don't deal with children and young people, usually. Or the primary care support service is supposed to, but there are not very many child-trained workers there.

Obviously I recognise the very significant challenges that there are with CAMHS, but one of the things that's happened in Gwent is that GPs can now phone through to a dedicated person for telephone advice, like a psychiatrist, if they're presented with someone who is suicidal or self-harming—this is children, now. That seems to be working quite well. How widespread is that? Is that a model you think that we could look at for adults? Because it seems to me there's a lot of onus on you, isn't there, in a 10-minute consultation, to make what are effectively life-and-death decisions, aren't they?

So, in terms of that, I've worked in the Gwent area and that isn't something I have experienced myself. We've got—. Only 30 per cent of the time is actually covered by the in-hours services, and, out-of-hours, it's even harder to get any support. I think for the group of people that are actively suicidal or self-harming it's very useful to get help and advice, but, actually, it would be lovely to be able to intervene before that point and that's when it's probably the hardest point to get help—with those people that you really feel are very high-risk, but, like Jane's patient, haven't done it yet, and then suddenly they do something and an ambulance comes and they get a bit more help. So, it sounds useful—it's not going to solve the problem, because we need those services further downstream.

Okay. What further data do you think we need in order to get a more complete picture of self-harm and how this is presenting to services, including in primary care?

Are you talking about people who self-harm or suicide?

Self-harm, really, I suppose. Because that's obviously a risk factor for suicide.

It is a risk factor, but then not all people that self-harm are at risk of suicide, that's the problem. I think they're a very, very difficult group to manage because some of them are just attention-seeking people, and they do need support—I'm not doing that down, they do need support—but it is different from the suicide prevention support.

I would maybe have a slightly different way of phrasing it, in saying it's a cry for help. People have developed maladaptive ways of coping with stress, and, for them, that's how they can sometimes get help. For others, they get a physical release from doing it. Rather than needing more data, actually what I'd like to see the money spent on is more services and more support for people. Because, often, if you can help people develop other ways of coping with stress, those behaviours will stop, rather than escalating to the extent of a completed suicide. So, given money doesn't grow on trees, how do we want to spend it? I'd like to see it spent on services for people rather than more research that will tell us that they're at higher risk of completed suicide, because that is already well evidenced.

And are there any toolkits or good practice guidelines that GPs use when they've got someone in front of them who's either been self-harming or they're worried might be at risk of suicide? Is there any guidance?

14:00

In terms of how they should be assessed, anybody coming in with anxiety, depression or another mental health disorder should be asked about suicide risk. There's no evidence that asking somebody about suicide increases their risk of doing it. Interestingly, relatives often find it odd that doctors ask about it, and I've had more upset relatives asking, 'Why are you suggesting it to them?' than actually patients, who very often welcome the opportunity to talk about it. 

The royal college of GPs does have toolkits that people can use as well, and there are—. The training course I went on has materials that they leave with you that have a list of protective factors, risk factors and things like that. Scoring systems have been trialled in the past but they're not shown to have a strong predictive value, so they're not recommended. Still, many of us would use something called PHQ-9 questionnaire when assessing people with depression, and I find that extremely useful when talking to men, who may not find it easy to talk about how they feel and often giving them a questionnaire gives me a lot more information about things. But always that question must be asked. Different people ask it differently. I would often say, 'Have things ever got so bad you thought of ending it all?', and then from there it's really important to explore, 'Do you just have a fleeting though of suicide? Have you actually made plans? Have you written goodbye letters and got your affairs in order?', because all those things indicate somebody that's at a higher and higher risk.      

And do you think that a lot—? Is that uniform, then? Is that something that most GPs do? 

Yes, most GPs would do that. I think all GPs would do it and also be very careful to document it because, actually, if, sadly, a patient does go on to commit suicide, you want to be completely clear that you have done everything that was appropriate under the circumstances. So, yes, we'd do it and we'd document it. 

The evidence is that a lot of the patients don't come and talk about their depression when they go on to commit suicide, even if they have been to see the GP for whatever reason in the previous few months. 

Thank you. Yes, internet and social media: we did have an evidence session recently where it was suggested that there was a potential for harm through social media, particularly for younger people. Do you think there's any value in GPs routinely asking young people that come in and present with mental health issues about their social media and internet usage as an indicator as to what might be happening? 

So, we'd often explore bullying and things like that, and it would often come in as part of the conversation. In terms of whether it becomes a standard part of the question taking, I think we're back to the whole 10-minute thing, and we would very much target the consultation on what was most appropriate for that child. So, if bullying had come up, then I would ask a little bit more about how the bullying was taking place—was it an issue online? 

I think there is evidence out there that, as Jane alluded to earlier, people only put the nice parts of their life on Facebook. I had a conversation with a GP colleague recently, 'How come you go to so many lovely places? It's like, 'Oh, it's just Facebook—it's not real', but often people, especially when they're vulnerable and down anyway, are not looking at Facebook with that kind of 'it's not real— it's just showing off' mentality, and I think it's been really great seeing tweets from the Senedd of people sharing their struggles with mental health issues just this week, wasn't it, and, actually, people who are role models sharing that they have struggles too, and all of us not just presenting the sanitised versions of our lives, but the warts-and-all version. 

I don't think that social media is exclusive to young people. I think it affects everybody. Bullying in the NHS is very high. One in four people say that they have experienced bullying in the NHS, so we need to be aware that it is a big problem. 

But there's also huge opportunity as well, because there's research out there that shows even talking to a robot is good for your well-being, and things like Alexa and the other apps—actually, people having a conversation with them, it makes them feel better. Similarly, there are lots of cognitive and behavioral therapies courses that can be delivered online, and increasing the availability of those through the NHS would be helpful to patients when it's not possible to access help in other ways. So, it's not all bad. It certainly should be enquired about where it appears relevant, but I'd be a little bit reluctant to see a blanket rule that everybody needs to be asked about it.   

And you've just answered my second question, so that's absolutely fine. 

Right, okay. I did have one other question as well. What are the college's views on the importance of information sharing between health professionals and families and friends of patients with an identified suicide risk? We have taken evidence from Papyrus that, actually, it would be really helpful if GPs would be more willing to share that information, but, equally, we understand that you've got duties of confidentiality. Do you think there's room for changing procedures on that, to make that easier?

14:05

So, I think the first thing is that we need to have the conversation with people. Me as a doctor saying, 'I'm really worried about you; can I have a conversation with your family?' And a lot of the time, people say 'yes'. So, first, that needs to happen. Then, when they've said 'yes', actually, that conversation needs to happen, because, if you can imagine, 25 patients, morning surgery, if they're number one, by the time it gets to number 25, that can—. We need to make sure that it's then scheduled and that conversation happens. So, that's the first side of things. 

The second side of things is where patients don't consent, and then it's really difficult because it is so hard to tell who is going to be at risk of committing suicide and who's not. You then get into some very tricky issues about whether it is okay to breach confidentiality. I could go into that in more detail, but I think that is a whole can of worms. If somebody is clearly about to do something, it's a bit easier in a way. You can call the police, you can call the ambulance service, you can do stuff knowing you're doing it in the patient's best interest. But somebody who's come to see you and they've got a few risk factors—maybe a male, working away from home, who's recently divorced—is it appropriate then to start phoning around the family without consent? Well, I think most of us would say probably not. 


I think, under circumstances where the patient is clearly refusing but you're more worried about them, people probably at that stage should have a discussion with their medical defence unions because they can give some very sensible advice on when it is and isn't appropriate to break consent, but possibly, also, with a psychiatrist. But if we could crack good information sharing between different parts of the system, that would be a great start. 

You need to assess whether they have mental capacity in order to deny that consent because their mental health may prevent them to have that capacity. The other thing that you can do with patients is ask them if they have somebody that they feel that they—. If you've got somebody who has no family locally, is there somebody that they feel that they could share their feelings with and maybe ask them to support them—and I've quite often done this—and rehearse with the patient how they're going to discuss that with that particular person, to ensure that that person will be there for them, because the GP can't be there and phoning them up every few minutes. So, that's quite helpful, but that takes more than 10 minutes.

And on a similar line, actually helping a patient make a safety plan. So, if they say that they're getting these fleeting or not fleeting thoughts of suicide, when you feel like that, what can you do, who can you phone, what can you do that makes you feel good? And I think, actually, they're conversations that need to happen more widely than just between the doctor and the patient. All of us need strategies for when we feel down, and I think that's the sort of thing that schools can have a key role in influencing and also society as a whole. We have to take this out of the realm of medicine because there's only so much we can achieve there. Actually, what can we get out into society, getting churches, ramblers, other voluntary groups, to pick up?

Okay. Can I just ask one other question? It's on suicide bereavement. As you've highlighted, people who are bereaved by suicide are at a much higher risk themselves of taking their own lives. I did hear the other day about some good practice where a GP surgery had a procedure in place so that where there had been a suicide within the practice, they almost immediately did a home visit and then they flagged on that family's notes that if any of them rang about anything that they were always to be put through to a doctor. Is that kind of thing happening a lot, or is that something that we ought to be looking at?

It always used to. So, after any death, most practices I've worked at, you'd go and visit the family. Now, with the pressures on practice, I think it's happening less often that people are doing bereavement visits. I think it's good practice, but it's like the 10-minute consultation; we all know we need longer. Actually trying to do it—do you go an see Mrs Jones in the nursing home who needs somebody today, or do you go and see this family? It's symptomatic of the pressures on the workforce that they don't always happen. 

I think, yes, that is absolutely ideal. In smaller practices, they'll know anyway. So, you'll often have a list of people who have recently passed away and the receptionist will be aware. In bigger practices, those things like flagging it on the notes are best practice and are certainly a very sensible thing to do. We have a weekly blog where I write out to members, and I'd be very happy to include that as a suggestion as to something surgeries would like to consider.

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