Cynulliad Cenedlaethol Cymru

Good morning. Can you explain to us the inspection arrangements between you, Her Majesty's Inspectorate of Constabulary and Fire and Rescue Services, and Her Majesty's Inspectorate of Prisons in respect of police custody suites in Wales? And were HIW inspectors participating in the inspections of police forces in 2016 and 2017?

I can. The lead organisations for these inspections are HMICFRS and HMIP, so they set their programme and we are invited to attend as an observer to those inspections. So, we have the opportunity to be there to observe first hand what they're seeing, to potentially ask any questions that we have ourselves and, basically, just to get a feel for the type of issues that might be relevant to our responsibilities on the health side rather than specifically within police custody per se. We don't always attend those. We did attend, I think, in 2014 the one in north Wales and we did attend in Gwent in 2017. So, we were observing those particular inspections. But the ability does exist in the ones that we don't go to directly for the other inspectorates to escalate any matters to us that they might want us to take on board. Typically, the individual who we would send to those inspections would be our strategic lead for mental health services, who's a registered mental health nurse and can pick up on some of the more complicated issues that might arise in those particular settings.

Additionally, it's probably worth sharing with the committee that all three of those inspectorates are also members of the national preventative mechanism for the UK, and that's actually been meeting in Wales for the last two days. So, we have active co-ordination through that.

How do you make the decision about whether you participate actively in an inspection or not? What would make you do that or what would make you not do that?

If we had concerns, that would be a driver for us to attend. If we don't have concerns, we would not want to leave it a significant period of time in any case without having been out on inspection, because we think it's important that we keep up to date with the methodology they use, the type of things they're looking for, and it gives us an opportunity to engage first hand with their inspectors to hear about what they're finding elsewhere as well.

Is there any way in which you think those inspection arrangements could be improved, or are they working reasonably well from your perspective?

From our perspective, I don't think we have any particular issues with them. We're happy to place reliance upon the work that is done by the other inspectorates where we need to, and we're happy that the communication arrangements between us are such that, if they had significant concerns, they would raise them both with us and the other bodies that they needed to.

Okay, thank you. So, can you talk us through the data in your mental health hospital, learning disability and Mental Health Act inspections annual report for 2016-17 and tell us what it tells us about the use of section 136 in Wales?

I don't have the report actually in front of me.

Just headlines.

Headlines—in terms of section 136, there are two sources of information, really, on this. We've tended within the monitoring reports to look specifically at the Welsh Government statistical release, which looks at admissions to mental health facilities. So, I'm sure you will have seen reference to that, and we can certainly send a link to it if you haven't. There is another source of data, which is UK Government's statistics from the police, which we would also look at, certainly as part of our planning and as part of our examination of what's going on in the area, and that's the detentions under the Mental Health Act data, which is there. Just broadly, what it does show is that there does seem to be an increase in the use of section 136, but, in terms of the use of police custody as the place of safety, that does seem to have been very significantly reduced since there's been a focus upon it.

So, do we have—that's encouraging, obviously—sufficient health-based places of safety to meet demand across Wales, or are there gaps?

Before I address that, I think it is probably worth saying that, in this context, it's important to think not just about those suites, but about whether there are alternatives available to those suites, because it may be that pressure on those suites is in part due to a lack of alternatives rather than the need for more. So, the fact that there may be pressure on those services does not necessarily mean we need more of those.

There are suites in each health board. Obviously, accident and emergency is often used as an alternative where people need to be cared for by health professionals. But we have also highlighted within our inspections some issues with the use of section 136 suites. We've highlighted previously where the location of those suites may not be ideal in terms of geographical location, but also sometimes in terms of where they're located alongside mental health facilities or otherwise.

The other challenge that comes about in terms of the use of these suites is that, very often, because they're not in continuous use, their staffing may require the drawing of staff from the wards, and it may impact upon staffing levels on the wards. That, obviously, would be a concern to us. We've published our 2016-17 report. We're in the process of going through and finalising our 2017-18 report. In 17 out of the 24 inspections that we undertook in 2017-18 we did highlight difficulties with staffing levels in those mental health facilities. So, obviously, the pressure that an immediate or an emergency call may make on that staffing can be quite difficult.

Diolch, Cadeirydd. You just referred to the fact that you're invited to participate in the inspections that take place but that you don't always send representatives. Why don't you? Why don't you choose to participate in all of them, in order to inform better your work as the healthcare inspectorate here? I know that you're not responsible for those inspections, but there's useful information, I would assume, that you can glean about the provision of services here for people in Wales.

There is useful information, but, as I say, it's about prioritisation of the use of our capacity. The person that we would seek to send is our strategic lead for mental health. More often than not, that individual also has other responsibilities within the directorate and ultimately we don't direct the timing or the location, necessarily, of these inspections. So, we would seek to join in if and when we could, but we wouldn't always necessarily go, and that's because the nature of the relationships that we have with the other inspectorates mean that we're satisfied—we can draw assurance from the work that they're undertaking and the communication that we would have.

Okay. So, you would like to be able to make people available for each inspection, though, I assume.

I'd like to be able to do lots of things, Darren.

Yes, but essentially it's a resource issue. You'd like to send them, but you can't always have people available because of the other work priorities.

You can't always, and that's the nature of the business.

Okay. Can I ask you about the crisis mental health concordat between Welsh Government, NHS, police, the ambulance service, et cetera? There's been some talk of that perhaps being more effective in terms of the joint working here in Wales than has been the case over the border in England. Would you concur with that?

I think we have an advantage in Wales with our size. I think partnership working and thinking about things in the round is easier because we can get most of the bodies in the room to actually talk about this and think about where we want to go. I think it's positive, the health concordat there—it's obviously had an impact on the use of police custody. We look at issues relating to monitoring the concordat as part of our inspections. We don't monitor it specifically ourselves, but we do pick upon those issues and there are clearly a lot of interesting projects going on around the concordat. I'd probably say that I think that, Wales, we do have an advantage in terms of partnership working.

One of the other things that we heard from the evidence is that, in spite of that close working relationship, it's not always been perhaps achieving as much as has been the case over the border. Again, would you agree with that analysis, and, if so, why or why not?

I'll give a very personal opinion now rather than specifically a HIW evidence-based opinion, but I think one of the things we're very good at in Wales is innovative projects and pilots and trying new things. What I don't think we are as strong at is taking the learning from those pilots and projects and spreading them so that we have a consistent approach across Wales. I think that, in a way, is reflected in some of what we find within bodies as part of our inspections. We do get people that respond to our recommendations even within individual bodies, but we are not as good at sharing that learning, and I think it's a challenge for all parts of the system, actually, to think about when do we say, 'Yes, this is a good idea—this is working. We should be making sure that we scale it up and spread it everywhere' and exactly who is it that is going to hold the ring on that and make that happen. That, I think, is part of the space that the concordat certainly could be moving into in maybe a stronger way.

That's very useful. And are there any particular partners in that concordat who are less engaged than others, perhaps holding up progress?

I wouldn't have any evidence on which to draw to be able to speculate on that.

I can see the trends in terms of the reduction in those individuals who've been detained in police custody. I think one of things that alarms me in the documents and the briefings that we've received is that there is an increasing number of people who are detained in places that are not known or identified. Do we have some indication as to—I appreciate that it says 'not known' in the official statistics—what that might be?

I wouldn't be able to speculate on that personally, but I understand that the concordat is looking at the recording of data and monitoring data—

So, it has been discussed by the—

—and the collection of data. It's something that I think they are taking a better look at to see—. Because you need that information to be able to identify whether the system is working and 'not known' is never really a satisfactory response to help inform change.

So, it's on the radar with the concordat partners in terms of trying to find a solution.

That's my understanding.

Okay. Thank you.

Diolch, Cadeirydd. A recent report on the mental health community teams clearly highlighted concerns, throughout the report, very much inconsistencies—that was used an awful lot; the term 'variability' was used an awful lot. But you also highlighted concerns over the crisis care team 24/7 service. Obviously, you've made recommendations in relation to that. What discussions have you had with the Welsh Government on those recommendations?

So, you're right there. We recently published this MHT report, in February, and you're correct to refer to the fact that we reference some concerns regarding provision for crisis care. There are a number of issues raised in the report, but I think what we were definitely finding was that there's variability across Wales in terms of availability and access of individuals into services generally, but also in terms of crisis care and support, and there are some startling numbers, certainly in the report, in terms of the surveys that we undertook and that nearly half of people didn't know who to contact during crisis, and the fact that these MHT services tend to operate to a fixed time schedule and, clearly, crises can happen any time of the day. So, we clearly feel that that's an issue and, as a consequence, raised it significantly within the report. There's a whole host of recommendations in the report, but there are some recommendations around crisis care.

We're in the process of receiving responses from all health boards and Welsh Government in relation to the recommendations raised in the report. We haven't had them all in yet; we've had an initial response from the Welsh Government. So, I'm unable to comment fully in terms of what we've reflected in terms of what we've had back—rather, that's in progress at the moment.

When would you expect all the reports from the health boards to be in by? 

We're expecting the responses in by next week. By the end of next week is what we were—.

So, by, say, after Easter you should be in a position to actually have had an opportunity to look at the responses. 

Absolutely, yes. 

Okay. That'll be interesting—to see what they say—because they quite rightly point out that there are some deep concerns over the availability and, as you've also pointed out, information to families and carers, as well as individuals as to how they can access those services. Section 136 obviously is being used as a concept for an immediate need for care and control, yet a recent HMICFR report found that the majority of people who were actually being detained are being discharged quite quickly with no need for immediate hospital care. Have you had a chance to look at this, and have you had a chance to reflect upon perhaps why this is the case? 

Not specifically, but one of the plans that we've got in place for next year is our thematic review of crisis care. And I don't know if it would be worth—Rhys, if you'd like to explain the basis. 

Yes, certainly. Kate's right; we haven't looked at that issue. I think we are going to do a crisis care thematic this year, and I think that's, in part, born out of this MHT thematic. But I think there's been a bit of a trail that's led us to have the compelling case to do this piece of work, because we've undertaken in the last four years a review of homicide reviews that we've done in the past few years, and that highlighted some issues around crisis care. We also have a mental health stakeholder reference group and, significantly, one of the key issues that was raised by partners at that group was, again, concerns around provision in relation to crisis. And we also published a substance misuse thematic report last year which, again, tallied with some of the concerns raised in this MHT report, in that it highlighted the fact that services tended to operate to fixed time schedules, and out-of-hours provision for people experiencing crisis was poor, certainly in terms of substance misuse. But there's obviously often co-morbidity issues in terms of links into mental health with those individuals as well.

So, I think, when we put all that together, there's quite a compelling case that we need to look at crisis. It's something that we need to understand as to what are the arrangements and whether they're working, but I think also as much as anything—and I dare say section 136 suites will be part of the review—there's also something around, 'Well, actually, how are people getting into crisis in the first place? What's happening in terms of prevention issues? Can we stop people getting to the stage when they're having to call for help, in a way?'

On that basis then, clearly, and all the work that you already have done, are you confident that, in a situation where this may be happening, there's sufficient care and support in the community for those people who actually don't get that assessment, or leave assessment quite quickly? Because, as you highlighted, we are talking about vulnerable individuals who are going back into the community, and, in the reports you've done, do you have confidence that the support mechanisms are there for those individuals, who are basically on the edge of crisis? 

I think this MHT report certainly suggests that some areas are performing better than others. I think it's the variability issue that is the concern. I think certain areas have better arrangements and better provision, and I think that ultimately is why it's led us to want to do the crisis review work. I'll probably be in a better place to be able to answer that question definitively once we've done that piece of work, actually. I think this has actually stoked the interest and, really, as I said, set the chain of events that's led us to want to do this piece of work, because we want to understand why is this an issue, why is provision patchy across Wales, seemingly, why are people telling us that they don't know who to contact. So, there's something around us getting under the skin of that, and being able to understand nationally, then, what's the picture and what needs to be done.  

So, the current situation, effectively, led you to say, 'We need to do this—there's a need for this work to go on', because I will say—perhaps I would—you haven't got the confidence at this point in time that everything is in place to ensure people across Wales, no matter where they are, have that support in those circumstances. 

Absolutely. It's made us want to know more about the problem. 

Okay. And you've mentioned, obviously, homicides, and there's also the committee's recent suicide prevention report, which recommended a single point of access for specialist mental health services and that that should be implemented as quickly as possible. I'm assuming you support that recommendation.

I think this MHT report suggests that's a step in the right direction. Because of the variability of ways into services, I think single points of access allow individuals to be triaged and signposted to the appropriate services. I think what we're not necessarily also gleaning, however, is actually is that being checked to see is that working as it should and the effectiveness—is this that the way that it definitely should be happening on a national level. I think it tallies a little bit with what Kate mentioned earlier in terms of what is the way forward. We do lots of good things in pockets, but, actually, where's the endorsement, in a sense, of that national way to do things? I think whatever is deemed to be the right way to do things, what needs to happen, and again this links back to this MHT report, is that there needs to be enough awareness of that, then—people can't be falling through the gaps. I think that's part of the problem as well—both processes but awareness of the processes as well.

Okay. All these points we've been making—and we are looking very specifically at the police and police custody—clearly highlight there's an increase in pressures and demand upon the police forces in relation to mental health circumstances. So, I suppose the question is, and you've obviously looked at some of these, you've looked at some of the things in custody: are you confident that the police are using section 136 sufficiently and appropriately? Or are they being forced perhaps to use 136 more than they should be?

I'm not sure from the work that we've done we've got the evidence to form a specific view on that. I think what we are hopeful will come from the review that we're doing is to identify how we can make sure there is the right packet or package of multi-agency services to ensure that any individual gets the support that is appropriate for their needs, because it may be entirely appropriate for the police to be acting in a way to provide the immediate care and support that is needed for that individual. It may be that, having had that support, having been able to refer on then to health services for some sort of immediate care, there's not the need for ongoing care, because it's not always a mental health issue per se—it may be a mental health crisis for a whole variety of reasons, and everybody is different.

I think the real challenge for us—or the real challenge for the system—is to make sure that the different parts of the system are working in a sufficiently flexible and focused way that they can meet the needs of the individual. It's almost inevitable, I think, that the police—. The police are the first point of call, the first place in terms of patient safety. They will often be the first people on the scene where somebody is experiencing a crisis. But they need to be able to make sure that they've got both the advice that they're getting, at times, through the control room system, but also that they can refer on and access the right type of care and support for that individual. It may or may not be that, at times, they have to use section 136 to get that. I wouldn't be able to offer a view on whether that is being used for a particular purpose. 

But will that be part of your thematic review of crisis services?

The thematic review—. The way that we approach the work that we do is to look at it through the lens of the individual—so, what are the packages of services that are available, geared to the needs of the individual? Can they be accessed? Is it clear what they are? Are the different agencies working together in a way that actually matches what an individual needs rather than shoehorns an individual into the service that just happens to be available at that point in time?

A supplementary on this point, Helen.

Yes. It's slightly taking us back a little bit. As you've both referred—. Dr Chamberlain said that one of our advantages is that Wales is small so we can get people in the room, which I think—you know, in response to Darren. But then you've both touched on this sort of projectitis—that we're very good at doing good new initiatives but we're not very good at mainstreaming those. In a way, those two things, at one level, you might expect them to be contradictory, because we can get all the people in the room. Do you have any take on why it's so difficult for us to mainstream the good ideas? Because this is something that we hear in different contexts on this committee and in other parts of the Assembly's work as well, actually. What are the barriers to picking up those good ideas and running with them? You've got that look on your face that says, 'Do you want the five minutes or the full half hour?'

No, I've got the look on my face that says, 'If I had the answer to that, I think I'd already have written it up and posted it somewhere.' I don't actually know. Whether it's something about human psychology and a reluctance to pick up something and assume that it will fit; whether we sometimes, being so sensitive to our local circumstances, start from a position of, 'Yes, that's a really good idea, but here is different.'

It wouldn't work here. 

Or 'It wouldn't work here' or 'It would work here, but, actually, we just need to—.' And there's also something about the fact that change is difficult and takes effort. So, accepting something is a good idea is not the same as saying, 'And we have the capacity to overcome that change inertia and actually bring that here.' So, it's something about how you get over that instinctive, 'It's great and we'll do it next week.' I think there's something—. It's almost a psychological problem or an organisational psychological problem.   

Good answer. Back to David. 

But—[Inaudible.]—and that's based upon—dependent upon—them taking it up themselves. Is there a lack of strong leadership at a national level to actually push it forward? That's the next question. 

Is there a lack of strong leadership? I think we have a complicated organisational map in Wales.  

A very delicate answer. 

We do. We have 22 local authorities that are on particular boundaries. We have health boards that are on particular boundaries, we have police forces that are on particular boundaries—all of which are trying in their way to serve their communities. But their communities are different, and it is organisational psychology and inertia. It's bringing everybody to a position that they're happy. 

I won't push it. 

It's out there, David. You've put it out there. 

Right. Last couple of minutes, last couple of questions. Vikki. 

Diolch, Chair. Her Majesty's Inspectorate of Constabulary Fire and Rescue Services's thematic report on policing and mental health—obviously, one of the key conclusions there is that there needs to be a radical rethink and a longer term solution to what has become a national crisis with regard to policing and mental health and the amount of time it takes up. You've already touched on that in your answer to my colleague David Rees and suggested that you agree with that as a statement. But what do you think the longer term solution to that issue might be? And to what extent have you discussed this report with HMICFRS as well? 

Okay. I personally haven't discussed this report with HMICFRS. I think they're right: there does need to be—whether a fundamental rethink is right, but there certainly needs to be some focused thought about what is the appropriate range of services that need to be available to meet the needs of the population. I think there is probably a bit of work to be done, if you think about what we were saying about section 136 and whether the capacity is right. There's probably a piece of work to be done on demand—understanding the nature and location of demand and what type of demand is out there.

Having said about projectitis, there's probably a question to be asked about whether we are really looking at the possible and what's the possible in terms of whether there are other services that are being provided, maybe not just in parts of Wales, but outside of Wales. We have to be prepared to look wider. Where can individuals access support when they feel they have a crisis coming? Do they have the type of safe spaces that they can go to to get support from peers? How do we make sure those preventative services are in place? And that all plays into, therefore, conversations about, and in that context, what is the role of the police. And it can't be considered in isolation, and it's really important that it doesn't turn into a battle between one organisation saying, 'Well, it's nothing to do with us, you should be doing that', because, increasingly, the things that work best are the things that are done together and planned together. 

Okay, thank you. And, finally, you've talked about your own thematic review that you'll be launching in the new year as well, and you've discussed the reasons why you think that's necessary and some of the ideas behind that, but given the fact that this is already such a crowded field of research and the answers you've already given about projectitis, what else are you looking to bring to the table here? And how can you ensure that, whatever the recommendations that come out of your report, we can see those actually being put into practice? 

Okay. Can I just say one thing first, and then I'll handover to Rhys, which is that a number of the reports that I've seen refer to pace? And I'm keen that whatever we do, we can highlight what's going well, as well as what isn't going well. So, if we can help the various bodies that are involved in this address issues with pace in the right direction, then I think taking stock across the board would be useful, but Rhys—. 

Absolutely. I think there's a lot of interest in this area but seemingly the issues are still there. Again, one of the reasons why we felt duty-bound to do something from what we've heard, what we've listened to, what we've seen, what we've done—. I think as a consequence—as I said, there's a compelling case to look at it on a national level, to look at what's happening, what's working well, what isn't working well and to understand why as well, to get under the skin of it, as I mentioned, to understand the root cause of that issue. Is there something that needs to be done somewhere else that prevents us from getting to that stage? We're confident that it'll be an impactful piece of work. The CMHT report—people have taken note of that. In a sense, we'll be following through some of the issues from that to test whether those have had an impact as well. Likewise, with this piece of work, I think the ultimate aim is to actually understand what's the picture nationally, what needs to be done to improve things and to follow that through as well. Again, I think we clearly haven't started that yet and we'd welcome the opportunity, once we've completed that work, to come back to committee to talk to you about it as well.  

Thank you. 

Bore da.

Diolch, Chair. Good morning. So, Her Majesty's Inspectorate of Constabulary and Fire and Rescue Services question whether the police should be as frequently involved in responding to mental health problems as they currently are. So, I wonder if you could begin for us by outlining the role and responsibilities of police officers when dealing with people with mental health problems?

Yes, absolutely. So, there is a role for policing in dealing with people in mental health crisis, particularly where they present a significant risk to themselves or others. So, they're immediately going to cause harm to themselves or cause harm to the community, particularly when people are in a public place. So, there is certainly a role for policing within mental health. The challenge is that most of the cases we deal with—up to 98 per cent—don't actually result in section 136 detentions. They're much more around health and welfare concerns, but the police—we're an agency that are there 24/7, and often the first people to be phoned about issues or come across issues in the street. So, obviously, the police do have a role working with health partners. We're doing lots of work across Wales, through the mental health concordat group. But in summation, I'd say that the police, at present, are involved in too many issues that are purely health concerns, or may be linked to social care, as opposed to fitting that definition of an immediate risk to themselves or others.

I actually undertook a day out with a community policing team in my constituency in the summer, and this was an issue that was brought to my attention then, and I was quite surprised to see the amount of time that community police in particular, spend on this and particularly with the same individuals. To your mind, is there any way to break this cycle of police officers having to engage and, really, this drain on resources for the wider community, having to engage to such an extent with these sorts of people? But also, is there a way that that can be done that also safeguards the health of those people as well?

Yes, absolutely. One of the things that we do have in Wales at present, in various forms across Wales, is what we call 'mental health triage', which is community psychiatric nurses or approved mental health professionals who are based in the police control rooms or sometimes they're out on the street. And even if we receive the call, what they're able to do is help to navigate through the health system and they're able to access people's medical records as well. They're able to engage directly with that person on the phone and give them good advice, such as around medication or signposting to general practitioner or other services. So, that's a really, really important way to break the demand. My concern, if I'm honest, is that the service is really inconsistent at the moment. It's not funded consistently across Wales. So, for my own force, South Wales Police, we've got a pilot scheme that's running till September, but the police are funding that in its entirety. So, the sustainability is really questionable. I suppose, what I'd say is—I've been in Wales three years myself—many of the issues here are exactly the same as anywhere else, but I do think that we have an opportunity in Wales to be more consistent in the support that we provide, and, importantly, at that position of crisis that, actually, there's a far more consistent approach to issues such as triage.

On this point, before we move on, David.

You said there's a pilot scheme, which the police are funding. Is that pilot scheme across the whole of the south Wales area, which involves three health boards, or is it only across part of it, which would involve—?

No, it's based in our police control room and it does service the three health boards at the moment, so it took a while to set up. We're funding it ourselves. There is a proper, independent evaluation being done, which should be able to evidence the benefits. Most of the people who call us do have some form of mental health issue or complex welfare need, but the right answer to that isn't necessarily to send a couple of police officers in shiny yellow jackets.

Are you seeing differences? You've said there are inconsistencies across Wales. Are you seeing inconsistencies across the three health boards you deal with?

There is, to some extent, but I think by putting triage in—. There's always differences in terms of the provision that's available in terms of places of safety and things like that, but by having the triage team in that does mean that the advice that we get is far more consistent. Importantly, because they're health professionals giving us that advice directly, with access to medical records, that's the best possible advice that we could inherit to deal with that patient.

Vikki, back to you.

Thank you, Chair. A couple of questions around the use of police custody as a place of safety. Firstly, you confirmed to us in your written evidence that police custody suites are only used as a place of safety in exceptional circumstances and for adults, and that would be such as significant violence, and never for a child or young person under the age of 18. Are there any actions that are needed to ensure that this practice is fully implemented and maintained?

In all honesty, one of the significant things that has progressed is the detention of people in police custody with mental health issues. Even for as large a force as ourselves, that's into single figures for the year—you know, under 1 per cent of people would end up in police custody, and normally it's because of extreme violence or it could be that they present with something slightly different than mental health to begin with. So, it's very, very rare. 

If I'm honest, I think there will always be a very incredibly small number of people who it may be appropriate to detain in police custody. What I would say is that when people are in custody now, we do have mental health nurses who are employed not just for people who are detained under section 136, but people will be in custody for other matters with mental health issues as well. So, being able to have healthcare professionals there is really important as well.

Thank you. That brings me straight on to my next question, actually, which is around the use of health professionals when a 136 is being used. So, could you confirm to us whether access to mental health professional advice at the point of crisis is available 24/7 to police officers across all four police forces in Wales when a 136 is going to be used?

So, in theory, there should be that help available. That looks a little different in every health board, so some would have 24/7 mobile phone contacts to crisis teams, but it's not consistent. Obviously, for ourselves, we have our own triage team, which can, in turn, link into local crisis teams et cetera, but it's certainly not a consistent position. If I'm honest, that becomes more challenging the more out of hours it is and the more busy it is for other agencies as well.

Could you tell us which health boards present a particular problem in that area?

I wouldn't like to single out individual health boards, to be honest. I think my main message would be that it's inconsistent.

Okay, I think we've covered the bit about triage. Sorry, Darren wants to say something.

Yes, I just want to follow up. I think it's important to highlight where there are problems. If there are particular health boards that there are problems with, we need to understand those in order that we can pay attention to them in our work.

What I'd say is that it's too much of a generalisation to say that one health board is better than not. By 'inconsistent', what I'd say is that some areas have a very different view on, for instance, sanctuary schemes. So, in one area of our force, we've struggled to get that off the ground, whereas in another area, working with some third sector partners as well, that's something that I think will go live as well. Because, all of this, in dealing with mental health, the last resort, really, is for police officers to go in the early hours of the morning. To me, it's all about prevention and putting those steps in along the line. Whether we can get hold of mental health professionals at three in the morning is less of an issue than actually, 'Can we stop us needing to go in the first place?' There are alternative ways that that patient could be dealt with. So, it's not that I'm averse to naming and shaming; it's genuinely the fact I can't single out one health board that's got everything cracked. It's such a patchwork quilt across Wales.

Obviously, we've got the mental health concordat meeting, and each one of those meetings, it's a very engaged group, very engaged meeting, and there's always good practice being presented there, but it's not everywhere. It's always one area that's developed one particular thing. Another example would be that we're tending to convey patients in police vehicles to hospital, and that shouldn't be the case. One area has made some investment in that, and others haven't. So, again, I'd like it really consistent that we're not detaining people and then taking them in police cars off to hospital.

Okay. Could I just check—from your evidence, as regards the triage business where they've got community psychiatric nurses located in police control rooms, and the funding for that, who should pay?

I know who shouldn't pay. I don't think it should be the police, if I'm honest. We've just done some analysis in our force, looking at how police officers, response officers, are spending their time. Over half of that time now is spent on issues that you'd call 'concern for safety'. So, that's mental health, missing people, welfare concerns in the street, and that's a real challenge for us, if I'm honest, when we're trying to tackle issues like knife crime et cetera. My view is that it should be consistently funded by Welsh Government across Wales, that triage should be seen as a core building block for a consistent approach to dealing with mental health crises.

We've had, obviously, some evidence from Cardiff and Vale that suggests that, actually, this model generally helps the police more than the health service. So, on that basis, wouldn't the funding be better coming from the Home Office?

Well, I don't know whether it helps health or police more; I just think it helps the patient more, to be honest. It's all public money, at the end of the day, and taxpayers' money. I'm not too fussed how it gets carved up. Certainly, I was very willing to put our money where our mouth was and fund the pilot to get it off the ground, but, as I say, long term, a real question on that.

Okay, thank you. Darren.

Yes. Just before I go onto my questions, can I just ask you—? There were some images, which were quite disturbing, on our tvs recently, about a Gypsy/Traveller lady who was arrested in her own home, taken into custody, who clearly had some mental health issues, was covered by a robe and nothing else, wasn't allowed to get any clothes. Is that the sort of way that you think the police ought to be treating people who have mental health problems in your force areas?

So, I'm not going into details around a specific case. What I'd say is that if people have any concerns about how they've been treated, there are processes that are followed to look at the police treatment. The Independent Office for Police Conduct look into any complaints against policing, and it's not for us to mark our own homework on whether we've done a good job or not with individual cases. We do have that independent oversight, which is really important. So, I'm not prepared to comment on individual cases.

Can I ask, is that typical of the way that people with mental health are treated in your force area?

Is what typical?

Is that typical?

I think I've just said I'm not going into individual cases—

I'm not asking you to comment on the case. I'm asking you is that the sort of way that people are generally treated?

So, what I'd say is, across our force area and across Wales, we treat everyone with the utmost respect. That there are a lot of cases we go to—people with mental health, complex needs—that we shouldn't have gone to in the first place is the bottom line. So, that's my view.

Okay, thank you.

Moving on, Darren.

Yes. I just wanted to ask you about this general trend of increasing numbers of 136 detentions and the disparity, if you like, or the ratio of detentions in some force areas versus their populations. It seems that, in south Wales, people are less likely to be detained than they are, perhaps, in Dyfed-Powys and, indeed, in the Gwent Police area, whereas north Wales appears to be a little bit closer to your sorts of ratios. Can you explain why that might be the case?

So, clearly, there are issues around density and sparsity of population, I think, around the services that are available in individual areas. What I couldn't say is—. We follow the same legislation, we follow the same law. So, I couldn't explain why one area would have a disproportionate rate of 136 detentions to anywhere else. What I'd say, though, is that, with 136, what we have to be really careful on is, because that's a very, very easy to measure issue—probably 2 per cent of the issues that we deal with that are connected to mental health—because it's so easy to measure and so visible, I find it quite frustrating we're always focusing on section 136, whereas, actually, it's the tip of the iceberg, really. That would be my view, but I know that's also the view of health professionals as well, in truth, and we view it as a success if 136s go down and an issue if they go up, but, in actual fact, it's the tip of the iceberg. It's about looking after people at the end of the day.

You've been talking about the need for consistency, though, and the situation is clearly not consistent if you're more than four times as likely in Dyfed-Powys to be detained than you are in south Wales.

One of the issues we've certainly found through our triage team is that there are cases that not only did we not need to go to in the first place, but, actually, if we had gone, we would have made the situation worse—that, for people who are on the edge of a crisis, the thing that would make it worse is two officers in shiny yellow jackets coming. And, actually, that's the importance of that really early advice and looking at other solutions. So, what I'd say is trying to get that consistency means that we also need that consistency of support, particularly out of hours.

Yes. I'm just looking at the figures, actually. I want to correct myself for the record, if that's okay. So, the rate in south Wales and Gwent is similar, but north Wales seems to be the worst outlier. Would that be consistent with the messages that you—? In terms of your discussions around the concordat, et cetera, would north Wales be the most challenging area, perhaps?

No, not in terms of a challenging area. As I say, what I can't say is that, in terms of 136 and the numbers, I don't think that that points to a differential in service. I think that that's just how it is across Wales, and we, last year, had an increase in the number of our 136 detentions in 2018 as well. What I'll be really interested to look at is, during the duration of the triage, whether that number changes because we are doing things differently as a result of having that service.

Right, I understand. Obviously, for section 136s to be used, there's got to be an immediate need for care and control. You've referred to this already earlier, and what we understand to be the case is that people are very often discharged from custody immediately after their assessment. Are you satisfied that they're going to safe environments once they're discharged and that appropriate care is in place for them?

Frankly, I don't know. What I would say, though, is that 50 per cent of the people that we deal with are actually already patients in some form. So, I'm concerned about a revolving door. What I can't describe is whether the services that are put in place for people once they're released are sufficient and, again, whether that's consistent. I'm not an expert, but the fact that over 50 per cent of people are known would tend to point to the fact that there is repeat demand and how much of that was actually preventable.

Okay. Can I ask, in terms of the section 136s, then, whether you are finding the same people popping up again and again needing to be detained?

Yes. So, 136s and in terms of the whole issue of mental health, it tends—. Yes, there's a lot of repeat demand.

There's a small number of repeats.

Yes. Well, it's a large number of repeats. I mean, 50 per cent of the people we deal with are people who are known already to mental health services. So, the bulk is repeat demand, yes, absolutely.

So, that would seem to suggest that they're not getting the appropriate levels of support and care in the community that they need to get in order to prevent them from getting into these sorts of situations where they're a danger to themselves or others.

Yes, absolutely, and how the most appropriate solution can still be for the police to go, as almost a sticking-plaster response.

If a person goes voluntarily into a custody situation without the use of your powers, then there's not always a requirement for police officers to continue to remain present in that situation, is there? Do you just want to explain what the implications of that are for the police?

Yes. There is a dilemma here. People can go voluntarily to places of safety, and they can be accompanied by us—again, voluntarily—and the police officer could walk away, then, when that person has been accepted by the place of safety. The real challenge for us in practical, operational terms is, if that person then chooses, again voluntarily, to leave and wander off, just how worried we are about their safety. Are they then a missing person that we need to invest a lot of time and effort in to find? So, just because someone is voluntary doesn't necessarily mean that we're happy to leave them. And again, we do need, in those cases, often, a 'phone a friend', which would be, for me, at the moment, our triage team to help give us guidance on whether it's safe to leave that person there. And, you know, I totally understand as well that there's a contradiction in terms when someone is actually in a place of safety voluntarily. We should be fine to leave them, but the bottom line is that the primary duty of the police is to protect life. We always have that as a concern, and we are worried about leaving people.

I suppose you've got competing interests. You need to release your resources for other response jobs, or whatever it might be, so there's that incentive to get away as quickly as you can, however you've also got this competing priority of keeping the public safe.

Absolutely, yes. So, it is difficult. There's no easy solution with it, and easy solutions to complex problems seldom work, but I do think there's some low-hanging fruit out there. I keep going on about triage, because I think that's one of them. I think mental health sanctuaries are another, where people who need some help and need some support—. Crisis cafes and things like that, which do exist in pockets, are really, really helpful. But, the real challenge, when we detain people—. We've looked at our average time of sitting with people we detain and it is three and a half hours. So, that's a long time. It's not just the number of incidents, it's the time. And, of course, it's unplanned as well, so if you've got a shift of a couple of people, that could take up a huge amount.

In terms of reporting, obviously, the focus tends to be on the section 136s. If you were looking at the number of individuals that those 136s related to, you're suggesting that it's a much smaller number.

It would be a smaller number, yes.

Are those figures routinely looked at or published?

Yes, absolutely. We have frequent user data. We have numbers of 136s, and we've done deep dives in relation to mental health. We did 24 hours in the life of mental health across Wales. So, we have done lots of data and analysis, but frankly, I think we're beyond that now; we should be into solutions, and consistent ones at that.

Okay. Moving on, Helen Mary Jones.

Thank you. The mental health Act code of practice for Wales—the guidance says that, in relation to the use of detention under sections 135 and 136, health and local authority partners must ensure that there's adequate provision of facilities and places of safety for young people and for adults. From the police service's perspective, are there enough health-based places of safety to meet demand across Wales?

I think it varies—that's the truth. And I hate to say this, but when I come here and I talk on behalf of Wales, the truth is that it's a big area and it does vary greatly. I think in my own force, we're quite well provisioned, if I'm honest, in south Wales. We're a more tight geographic area with a higher population and so I do think there's an availability of places of safety. One of the things we've done as well is masses of training for staff, in powers but also knowledge around where those places of safety are—you know, opening hours, and lots of relationship building. We employ mental health liaison officers as well so that they really know how to access places of safety and build up trust and relationships with the health staff who are there. But it is very variable, particularly in rural areas and out-of-hours as well. That's a real challenge for some of my colleagues across Wales. 

So, if it's more of an issue, for example, in rural areas, would that suggest that those patients are more likely to end up in your custody because there's no alternative? Well, I won't say 'custody'—looked after in a police station.

The figures aren't bearing that out. If I'm honest, at the moment, in terms of people ending up in custody, I think what it may result in is people sat in police cars for a lot longer or involved in longer transport. I think that's probably how it would manifest. 

That makes sense. You referred in one of your earlier answers to some of the work that's going on involving the third sector in terms of developing alternative places of safety, like sanctuary houses. Can you tell us a little bit about that? That sounds as if there are some potential good practice examples that we could draw attention to.

Certainly. So, in various areas, those already exist. Parts of Dyfed-Powys, for instance, already have that. We're looking to develop a sanctuary at Swansea at the moment, again, working with third sector partners in doing that. Sometimes, there's opportunities there such as buildings that aren't used—public buildings but they're not used out of hours. So, in an evening they could be used to convert into a sanctuary or crisis cafe. I guess one of the challenges with those arrangements is that you know how many people go there; it's quite difficult to say what would have happened if that hadn't been there. So, prevention is always quite difficult to—

You can't prove what you've prevented.

No, often not. But just from a common sense point of view, it seems right that if the choice at 8 p.m. at night is phoning the police or, actually, there's somewhere you know you can go with some medical expertise, with some advice around health, social needs, and really friendly people who are trained in caring for people with mental health concerns—that's surely got to be better. 

It's obvious from the patient and family point of view. Nobody really wants to have to call the police in that situation, do they?

Absolutely, no. Not at all.

Just to move off to a slightly different area, do we need greater clarity on where the assessment of intoxicated individuals can safely take place in health-based settings and make sure their needs are appropriately met? Do you find yourselves—? You know, is that a situation where your officers are ending up having to stay with somebody because, perhaps, the health professionals don't feel safe with that individual?

Yes. So, there is an issue about intoxication. It's never—. Quite often, it's not a precise science as to how someone's behaving—is it because of drink, drugs or mental health issues. So, it is quite a challenge, and I understand that. In effect, there are occasions when we do end up sitting with people for longer because they're intoxicated and so they can't have an assessment, depending on what state they're in, or maybe presenting more violently. So, that is a challenge, but I suppose it's a red herring that people can't go to a health-based place of safety if they're in some way intoxicated, because particularly, again, with access to medical records and knowledge about the individual, and some healthcare advice, even if someone has had drink or either taken or not taken medication, that's not a reason not to take them in the first place.

Thank you.

Okay. Moving on, David Rees. 

Diolch, Gadeirydd. In your written evidence, you didn't identify the number of young people who might be given section 136 or 135 orders. I appreciate the question wasn't asked, but could you, perhaps, provide the committee with details as to the numbers across Wales that fall under that category?

I can provide it. I haven't got those figures here, if I'm honest. It wasn't within my evidence that I prepared today, but I'm really happy to present it. It's very, very small numbers. Again, what I'd say is that I'm very optimistic about the work that's going on with the Early Action Together ACEs programme—adverse childhood experiences programme—because I do think that that's work, again, that is very preventative and would help prevent some of that crisis. So, obviously, in Wales as well we've put a strong investment in neighbourhood policing in police community support officers. We've got the safer schools programme as well. So, there's lots and lots of work going on with young people here, which is quite unique to Wales, I think, and certainly I'm really proud of that work that's going on.  

That would be very helpful. And if you could actually break it up into under-18s and under-16s as well, so we can see how people fit in to that. But, linked into that, obviously, there are many young people who are on the edge of that vulnerability who may not be considered in need of a section 135, but are on the cliff edge of one, we would say, and I want to have an understanding of what practices the police have for working with other services when it comes across in such individuals to ensure that those young people don't end up having to have an order placed upon them, but that we are are actually able to support them.

Yes. We do. What I would say—. I'm sorry, I haven't got the figures with me. But in terms of the volume of young people that we are responding to with mental health issues, that's a very, very small number compared—

But are you seeing that volume increase? Is the trend—

I'm sorry, I can't—. I wouldn't like to nail my colours to the mast on that in terms of numbers, but I know it's incredibly small. And I have given evidence to a specific inquiry about CAMHS as well here.

Okay. Hafal indicates that, despite improvements in the police management of vulnerable people in custody, there still are inconsistencies, which I think you've accepted. And it's not uncommon to find people in custody with obvious mental health problems—I think that's the important thing—who have not had appropriate adults requested by custody staff, nor engagement with mental health staff or other services. Now, this is definitely a policing issue, in one sense. What moves are you taking within the policing section to ensure that that sort of inconsistency is removed?

Yes. I dispute that there's inconsistency, if I'm honest. When people are presented in custody, there's a very, very detailed assessment of them that's undertaken by the custody sergeant, which very much looks at mental health issues, and as I've said already, within our force, we also have mental health professionals who work within custody suites as well, to assist—

Are they in each custody suite?

There is some mental health service. It looks a little bit different in each area. Each area commissions services slightly differently. But there is access to some mental health support, certainly. I think that when you look to all the research, there is a challenge, isn't there, around the representation of people with mental health issues within the criminal justice system, in truth, but in terms of them getting that support and considering that as an issue, asking for appropriate adults, I've not seen evidence that that isn't happening. If in any doubt at all, we would always ask for an appropriate adult.

Because in your own paper, you simply say,

'Of note, is that there appears to be a service gap in respect of the assessment of persons in police custody who have been arrested for a criminal offence.'

Which is slightly different, because they don't come in on the basis of mental health issues—it's criminal offences.

Yes. So, the challenge—. Again, this is an area where we're inconsistent. It's not a challenge with our health boards in south Wales. So, they will attend if someone's in custody for a criminal matter. They'd still attend and assess them, if appropriate, for mental health issues. Elsewhere, there is a challenge if people are in custody for a Police and Criminal Evidence Act matter—for a criminal matter—in actually securing attendance. So, there are issues in there where section 136 has been used after release for the criminal matter but it's been necessary to detain people for their mental health, which is obviously not right at all.

So, it's still an area to be looked at, in that aspect.

So, the consistency would be—. As I say, certainly in south Wales now, health boards will send staff on the incredibly rare occasions that we'd need to still consider detaining people post release for the criminal matter.

So, effectively, therefore, I can assume that you are confident that, in the south Wales area, which is clearly where there are more professionals in the custody suites, there is prompt identification of individuals with mental health crises once they're in custody, but you may not be confident that that's consistent across Wales at this point in time.

Yes, that would be a fair summary.

Okay. On section 136s, obviously, we know very well that measures are all about trying to ensure they're transferred to a safe place as soon as possible via safe means. I know that the concordat says to avoid police vehicles as much as possible, but the evidence we've received shows there's still a large majority of those still being transferred by police vehicles.

Yes.

How are you working with other organisations and other sectors to try and change things, so that you're not using your police vehicles in those circumstances? There are other services. Now, I appreciate there's pressure upon Welsh Ambulance Services NHS Trust, because if I had WAST in front of me now, they'd be saying, 'You know the pressures.' But how are you working with other services outside of WAST, in that sense, to look at how you can transfer people to those safe places, not necessarily in police vehicles?

So, the bottom line with it: in practical terms, the reason why we primarily take people in police cars, and it's unusual that people detained don't travel in police cars, in truth, is simply because of delays in waiting for WAST. It would be a significant delay, and there's a delay because of how busy they are, and, in truth, if you were to triage a call, if someone was suffering a medical emergency versus a case of transport, I can see why there's a real challenge there and a wait.

There have been trials of alternative patient transport by individual health boards, specifically for people with mental health concerns, and, likewise, also, street triage may include the ability to take people then to a health-based place of safety. I say it again, it's not consistent, it's not reliable, and certainly today, if you look across Wales, anyone detained is most likely to end up travelling in a police car. Frankly, I don't think it's for policing to invest in an alternative transport arrangement, and that's not something that we're looking to do at present, so we are where we are.

No, I appreciate that. But, therefore, the default at the moment is WAST, but there are pilots in some areas that might look at how health boards are accessing that.

Yes, absolutely so. I said about the concordat meeting, again, there are examples of good practice and initiatives that are piloted, and it's fantastic to hear about them, but they don't seem to then roll out everywhere. They seem to be in individual areas, and, to me, that's such a shame. We should be in a position now where we've got a really consistent operating model, and there'll always be challenges around geography and rurality, but that basic principle that, if you need detaining under section 136, there's a high chance that the police wouldn't have gone in the first place, because we'd have had the triage and that direct link to other mental health services, but if you did end up in that, that actually you'd get transported in a more dignified way than in the back of a police car.

You've just mentioned something that HIW mentioned earlier, which is that there are good practices being put in place, but they're not being shared out. Perhaps you might want to answer this one, then: do you think there needs to be stronger leadership, perhaps from Welsh Government, as to how we can take these good practices and, basically, roll them out across Wales?

'Yes,' is the bottom line.

I got the 'yes'.

Okay. Are you done? Yes.

Yes.

Funding next. Darren.

Can I just ask you—? You've sort of touched on this already, in terms of the fact that the concordat doesn't actually specify who pays for some of the work that is being done, and how the police take the view that, really, they're plugging holes in, essentially, the problems of the NHS, because of a lack of care and support around some of these individuals, particularly those that are presenting on multiple occasions. So, given that that is the position of the police, what discussions have there been with health partners about them, perhaps on a voluntary basis, helping to pool some of their budgets with the police in order to make things work better? And what direction or sense of leadership is there from the Welsh Government in terms of accepting some responsibility for some of these problems in the system, if we can call them that, so that we can actually knuckle down and crack them together?

So, it's fair to say that in each local area, there are significant efforts made with individual health boards and consequently that's why we end up with pockets of good practice in areas. What we haven't got is that consistent approach everywhere, so that's the part that we need to, I think, work towards, to be perfectly honest. So, at the moment we have to convince each individual health board something's a good idea, and then there has to be the funding there to actually fund it. Obviously, that's often in competition with other areas of funding. I do understand all that, and I also understand funding pressures as well, but I think, comparatively, a lot of these solutions are quite simple and low cost. You know, the sanctuary model that we're looking at is under £100,000 for the year.

That's across the whole of Wales. 

Well, no, that would be for one sanctuary to operate. But in the grand scale of things, that's quite small money, and even our own triage is actually quite low cost when you look at the number of issues that it could help resolve. I suppose I would say this because, obviously, I cover Wales for mental health, but it would be really good if there was just one consistent approach, based on the things that we know work. I think a lot of that identification is being done through the concordat group, but then beyond evaluation actually making things happen is what I'd really like to accelerate now.  

It sounds to me that you know what works, you've got some ideas of the costs if that were to be rolled out Wales wide. If those costs aren't prohibitive—. You've talked about £100,000 for one sanctuary model. Wales wide, you have some sort of idea, I assume. What sort of costs are we talking about? 

Well, it would be several million for all of Wales, but if you were to concentrate those in the urban areas, a couple of million would certainly make a difference, wouldn't it? 

So, if you focused it on where the demand is greatest, you'd make an immediate and significant impact for a couple of million pounds. 

Exactly, and in terms of mental health triage, again, under £2.5 million would put in a consistent service across Wales. So, when you look at that compared to other budgets, it's quite a small amount of money. The question is: who pays? How should it be collected? And then that causes delay, but the bottom thing is that it's the right thing to do. Now, I'm not saying from policing—I'm just saying for the patient that's the bottom line. 

Obviously, the NHS budget is many billions of pounds each year; I'm not quite sure what the total sum of it is in the current financial year, but it's many, many billions of pounds. So, for the sake of £5 million, you could plug the major urban areas and deal with this issue of triage on a national basis with a joined-up approach across the country. 

Absolutely. 

Okay, thank you. 

Helen Mary has a supplementary. 

Yes, I'm just thinking about those costs and the balance of costs. I suppose this is an impossible question to answer, but you must be—the police service across the whole of Wales—must be spending huge amounts of money in terms of officers' time. And I suppose it would be wonderful to be able to quantify that, but I guess you could quantify that for the 136s, couldn't you, because you know how many there are and so you could average out the amount of time each one would take. But I suppose with all the informal interventions, it wouldn't be possible to have a clue. I'm just thinking about when we're making the case to Ministers that they need to spend more money, it can be handy if we can show where there might be savings in other parts of the public purse, because as you said earlier, it's all taxpayers' money in the end, even though it comes to us through different sources.

We do have some approximation of costs. Again, primarily, that's based on our day in the life study of mental health demand. So, we do have some ideas of costs. But, again, prevention is a difficult one. That's why the triage we have got is going to be subject to evaluation. We funded it because we thought, actually—

It would save resources. 

We do a back-to-the-floor approach with our staff, and we go out, spend a lot of time on patrol, understanding the challenges facing operational policing, and for two years running they were saying, 'We've still got the same issue with dealing with mental health.' There are lots of other things that have moved on. There are things like how we share intelligence with partners, respond to drugs warrants, stop and search—loads of clarity on the things that we have control on, but the mental health issue is still exactly the same issue as it was a couple of years ago. That's why we've put the triage in in south Wales to make a difference as soon as possible. So, that's why we've done it. 

David.

Obviously, who funds it is a big question, because policing is currently funded by the Home Office and the health service is currently funded by the Welsh Government. So, who funds it is a big question and I don't want to get you into that situation, but have you got examples—? Take England for example, have you seen any examples in England where something similar works and there are funding streams that are identified?

Absolutely. So, we were quite unusual not to have a form of triage in south Wales for so long. Again, it's inconsistent across England as well, who funds, whether it's health boards, whether it's a combination of funding—

So there's no consistency in England either.

No, and for a while, there was money through the police transformation fund, when it was a fairly new initiative as well. So, again, it's quite different. Approach this with a sense of optimism. I've worked 30 years in the police, 27 of them in England. I think we're in a position to lead the way in Wales, as we're doing so many things. So, I don't approach this glass half empty; this is a chance to nail it really, really well for the benefit of our public in Wales. 

Last couple of questions, Helen Mary.

Yes, just building on that really and looking forward. In their written evidence to us the Police Federation has called for the mental health crisis care concordat to be put on a statutory basis. I was wondering what your view would be of that. And more broadly, are there areas of legislation that need to be amended that would help you in dealing with mental health crisis situations? Or is it about—[Inaudible.]—or is it not the law and is it more about practice and—?

Generally, I think the mental health crisis care concordat is really helpful. I think it has brought all of the partners around the table. Honestly, I don't think the answer is more legislation, and I'd be quite concerned as well if we put anything on hold, waiting for more legislation and that that was the gap. I think there's plenty there now to get on with to be perfectly honest. So, I wouldn't object to the legislation, there's no reason not to do it, but let's be honest, that's not what the block is now.

That's not the problem.

No.

Okay, thank you, that's helpful. So, if legislation doesn't need to be changed or it's not going to make a difference—I have to be careful not to put words in your mouth there. But are there any changes that could be made to existing operating structures that might prevent the risk of criminalising people who present with mental health problems? Is there anything structurally that needs to be done or is it again this consistent approach, and—?

Yes, it's a consistent approach. I describe it as moving from concordat to operating model. That would be what I'd say. So, based on the things that we know that work, there's one consistent operating model in Wales. Yes, it's slightly different in each area, but that's because of geographic difference, but you can recognise absolutely from the way that dealing with mental health occurs that that's part of one joined-up system, and it doesn't matter where you go. I think that's the step change that we now need to make.

That's helpful. Thank you.

Could I—?

Just when I'm wrapping up.

Just one point to finish on. Clearly, we've been talking about the role of the police and custody in policing, but I suppose I want to ask the question of: when they leave police custody, and because you've got people on site and everything, how do they work with the other services to ensure that vulnerable people are supported as best as they can be to ensure they are supported in the community? So, what's the process from the point when they leave your care to going back into the community, where they can also make sure there's access to them? Because one of the concerns we have is that when people leave, what are they going to?

Yes, well, as I describe there, within our own custody, we have mental health professionals who are able to give some of that signposting, so that's one of the things. But, in truth, when people are released, they're released, so the police role with those individuals will cease. So, we may information share—.

One of the other things that I should have mentioned earlier, I'm sorry, is in terms of the way that we share information and help to protect people longer term. One of the key ways we do that is through a multi-agency safeguarding hub or MASH, or an equivalent model—they might be called something else. But, again, that's something that varies very much across Wales. I think having that structure, where people whose job it is to safeguard are working together, sharing information, and have information systems that enable them to do that is very, very important indeed, as well, I think, in terms of that ongoing support and care, but importantly knowledge as well and knowledge sharing. I think MASH is very, very important and, again, that would be as part of the building blocks to preventing harm in all its forms—mental health is just one element, but preventing harm in all its forms. MASH is another area I think I'd be really, really keen to see as a consistent approach across Wales. We have a working group ongoing at the moment in relation to that.

From that, I assume it's not consistent across Wales at this point in time.

No.

Diolch, Chair. Health boards have identified a need for a common understanding of mental health issues. How important do you think it is that there's a shared language and understanding of mental health crisis or mental ill health among partners? 

It's okay. The mics work automatically, so just go for it. 

I think, from my perspective, it's actually really important, because I think, in terms of being able to support people who have a mental health difficulty who experience a crisis, it actually needs a partnership approach. So, actually, all partners having a common understanding about defining mental health and what mental health distress is I think is really important, because if we don't have that common language, we could be talking about different people. And I think, for me, there's a range of interventions that we need to be able to offer people. So, we need to have a good understanding about the needs of an individual, before we can think about what sorts of services we need to be commissioning for individuals and who should be the appropriate agency to support people. 

If I could add to that as well, I totally agree with what Chris is saying. But I think also we have to be very careful that the language that the police will use is that, often, 40 per cent, 50 per cent of their work is to do with 'mental health'. I think we have to be careful what that means in reality. This is often people in mental health distress, mental health crises, emotional crises, rather than core mental health business. And I'm not saying it should either be one or the other, but we just need to be careful that we understand that the reference by the police is much broader than some of the services that we have. 

Carry on. 

Thank you. So, moving on to crisis prevention, then, and a question for you, Philip Lewis, in the written evidence, Cwm Taf Morgannwg University Health Board made the case for further work to reduce the number of people whose mental health deteriorates to the point at which they need a crisis assessment. So, what action do you think is required to reduce the number of people whose mental health problems escalate to that point? 

I guess it's a whole-system change that ultimately needs to happen. This pervades every aspect of life. Whether this is child and adolescent services, education services, primary mental health care services, which are often dealing with people's resilience and emotional stability, to try and create an environment where we don't see people going into distress in the way that we see under police contact, because the idea is that we should be able to get our interventions in much earlier than that. Very often, what we end up doing is putting people through distressing pathways to end up in the right service. If we could get those services at the front much better—. I'm not sure I've got any particular solutions at the moment, but I think that's clearly the message. There are lots of people who are heading to a distressing situation, and you feel there could have been other mechanisms ahead of an event that results in a police contact. 

Anybody else with anything they want to add to that?

I think this is a key area for a partnership approach. As people have been saying, we've come through a system, as the mental health services have grown over the years, of very much a specialist mental illness support provision. I think, as the definition of mental health and mental distress broadens, I think there's an onus then on a range of partners to provide services to support people with those almost degrees of mental distress and mental ill health. I think it's fair to say that all the health boards are trying in some way to take that responsibility seriously and try to reach further into things like general practice, with primary care services, and to organise our commissioning of third sector organisations as well, which are usually really flexible and competent in looking after people and have good, open access support for people who are in mental distress or social and well-being distress who present often in crisis situations. So, although probably there needs to be a more co-ordinated partnership approach, I think all the agencies at the moment are trying to do that. I think the concordat is probably a good example of one of the inter-agency initiatives that's helping. When we talk across Wales about developing services, we are talking about reaching in and offering our partnership perspective and our partnership support to people with a range of mental health problems now. 

You've led straight into what was my second question there because I was going to ask about what kind of engagement you'd all like to see from GPs and local primary care mental health support services. I don't know if anyone else wants to comment on that. 

It's a huge task at hand for us. So, at Hywel Dda we've just gone through three plus years of engagement and public consultation in redesigning our mental health services. A key part of that is reducing the level of mental distress, increasing accessibility to services 24/7, even in rural areas like ours. That does rely on excellent working relationships with the third sector and a range of key partners as well. We are implementing that in a fully co-produced approach with all our key stakeholders, service users, carers and the third sector. But we clearly need to invest more heavily in the third sector. Our plan is to have easily accessible, 24/7 drop in centres in each of our counties. We would like them fronted by the third sector, to put in services that prevent crises from happening in the first place. That's where the real investment needs to go. I don't think we should be investing necessarily in traditional, secondary mental health services, police and social workers et cetera. That's dealing with the symptoms rather than the cause. We need more investment to deal with the cause of the problems and prevent these crises happening, which very often are socially related.  

I would agree with that. I think that most health boards are starting to see a shift of resources away from the secondary care, traditional model more into the primary care, early intervention, short-term intervention. I understand the problem—wading, ourselves, through a myriad of assessments, but actually getting to work with people as quickly as possible—. You've done that in Cardiff with some GP work.

Yes, we've been quite lucky in Cardiff. We've had investment from the health board around GP sustainability more than anything else, because of the high numbers of people with complex mental health problems that GPs are dealing with as part of their day-to-day caseloads. We've had support to invest in mental health practitioners, who are supported by the third sector, to be working in practices and working to the GP model where you'll see people as part of appointment slots through the day, and these are people who are referred into the practitioners service from the GPs.

Some of the results have been fairly astounding really, in seeing people earlier and then people not then having to be referred through the myriad of more complex, specialist services that often people are, because the GPs haven't got any other choice. And again, we've been really lucky that the health board now is going to roll that out right across Cardiff and the Vale with an expanded third sector contract to support that as well. So, we're keen, along with other models being tested around Wales—

We're all watching.

And other areas have got really good practice as well that they can show the rest of Wales. But we're keen to share the results of that as well with the rest of Wales, just to support—

I've got a supplementary from Helen Mary.

Yes. What we're hearing about prevention is very encouraging, but one of the ways that you could divert people out of these situations would—. Just to roll back a bit, we've had evidence from the police service, we've had evidence from academics, showing that between 50 and 60 per cent of people who end up with a section 136—so these are people who are very ill indeed—are already known to mental health services, and in one particular academic study, only one of those people actually had a care and treatment plan. Now, surely, one of the ways that you could be preventing people getting into these situations is ensuring that those people who are already known to you are not in what the senior police officer described to us as a sort of revolving door, because they're not getting the mental health treatment they need. We're not talking here about people who are distressed or intoxicated who, quite rightly, you could argue shouldn't be the responsibility of mental health services; we're talking about people here who are really poorly, and they are repeatedly presenting with crises. What more could be done to ensure that those people with identified needs are actually getting those needs met? Because that's part of prevention as well, in terms of preventing them getting into crisis situations.

I think, we're potentially talking about a range of people, and without having seen that exact study, I couldn't comment precisely on that. Anyone in receipt of care from statutory mental health services will have a care and treatment plan, and that will include a crisis and contingency plan that will identify, in collaboration with that individual and their carer, exactly what steps would help them alleviate a crisis and what they could do about it rather than finding themselves in positions where they do end up with the police. There are a certain range of conditions, particularly those people who have more difficulty managing their emotions, that do end up in repeat crises, and those—

Surely, people with mental health problems can be expected to have a bit of difficulty managing their emotions. I'm not very comfortable with the responsibility being put back on the patient there.

I'm not suggesting that at all in any way, but there are a particular group of patients where they do have a particular sets of issues, where they're more likely to come in contact with the police, for example, and that's where we do try to have frequent, multi-agency planning meetings so we can have a co-ordinated response and an appropriate plan of care for them under the circumstances. It's not always possible to eliminate that entirely, and I'm sure there's more work that can be done in and around that, but, certainly, increased multi-agency, co-operative working and planning around that is very important to us.

I'd just ask, if it's important, why it is not happening.

I think, as we said earlier—. Let's take Cardiff, for example, we've got about 5,000 people that we support on our combined caseload just in secondary mental health care, and if we rolled out this primary care model, we could be coming into contact with over 100,000 people a year. So, the likelihood of somebody going into crisis that we wouldn't have been prepared for, that is a likely scenario.

But what we're talking about is building up an infrastructure within the community—not just from mental health services, but with the third sector, the local authority—where you have social and well-being hubs. You can have well-being advisers, social prescribing, et cetera, which often then divert people away towards more meaningful activities, which then prevent people from going into crisis. I think if we just rely on the resource that's only in the mental health service, I think we're going to be struggling to deal with what are often very complex problems around accommodation, having a meaningful day, et cetera. So, I think we're trying to play our part in expanding that infrastructure in the community to support people out of hours when people do feel as if they're going into crisis. For example, we have third sector contracts with organisations like Mind and the 4Winds in Cardiff, which do offer support out of hours, where people can be contacted to have a befriending service just to talk people through a crisis, rather than needing, specifically, a mental health service or a police officer to support them. So, we are trying to do that and trying to build up that infrastructure of support, but we've got a little way to go as well.

Okay, back to Vikki for her last question.

One final question from me, talking about building a broader support network. We've taken evidence from the Welsh Local Government Association, and that highlighted the importance for families of being able to know who to contact if they want to support a loved one when they're on that brink of possibly going into a mental health crisis. So, what can be done by mental health services to ensure that those kinds of contacts are out there for families and carers of people with mental health problems, who may be best placed to actually put in place that support if they're able to, before the individual is, perhaps, at that point?

I fully agree with you: I think it's really important, whether it's the individual who's trying to access support or the people around them, it's absolutely vital that people are able to access that support. We've been doing a lot of work within Gwent recently, talking and listening to people who are trying to access support and their families. One of the key things that comes up is that perspective around families, who know the individual best, often finding it very difficult to access support when required.

So, we're just starting to do a piece of work at the moment in Gwent that we're describing as developing a single point of contact for individuals that would be accessible for individuals themselves, family members or professionals to be able to access support 24 hours a day, seven days a week, to be able to have a meaningful conversation with somebody who can help think about the best way to support that person at that point in time. So, I think there's more we need to do. That would be my sense.

I'd echo that as well from a Hywel Dda perspective. That's one of the things we heard clearly through our public consultation: people wanted a single point of contact. It's a challenge to develop, because we have three local authorities, all of whom are developing a single point of contact, and we have NHS 111, so, potentially, you can see that we've got more than half a dozen single points of contact sprouting up. So, as we're in the implementation phase now, we're working very closely with the local authority to try to align everything that we have, because what the public told us was that they want one single easy-to-remember number, a bit like 333, that they can ring up from anywhere, whoever they are, and be directed through to somebody with local knowledge and understanding of mental health problems.

Okay. David.

Thank you, Chair. I'm listening to your points, and I'm just rewinding my mind back to the Healthcare Inspectorate Wales report on community mental health teams and the inconsistency that was highlighted. Perhaps I'm not talking to the right people, in one sense, here, because I should perhaps be talking to the chief executives and chairs to ask them the question. There's inconsistency, but there's also some good practice—you mentioned some good practice this afternoon. I just don't understand why you're not sharing that good practice across all boards.

What I was trying to work out was why, if one—you say you're looking at what goes on there, but there are other examples being given to us of good practice that doesn't seem to be shared. The point you've made about the single point of contact—well, that was, again, highlighted in the report from HIW. These things seem to be happening bit by bit, rather than as a collective. Why aren't we getting a collective approach, a leadership approach, to say, 'This is the best way forward, let's all do it'?

It's interesting, because although we've all taken our own unique approaches towards developing mental health services, if you put us all together in a room and talked about the types of service we're developing, we're all in absolute agreement on what our priorities are and where we need to make the investment. So, the interesting thing that's come through our discussions together is that we all agree that there's an increasing demand on well-being, maintaining well-being and reducing mental distress, and that we need to invest more in our primary care services and third sector services. I'm sure you see the nodding heads next to me—we're all agreeing with that.

So, despite that apparent lack of a co-ordinated approach, when we go to the national crisis care concordat assurance group, we find that we're all speaking the same language and trying to develop the same sorts of service, albeit in slightly different ways, which is really helpful to us, because we can get feedback from each other on how well each branch of a service is developing. So, for example, I'm currently replicating that primary care pilot that Ian instigated in Cardiff and Vale. We've all got—

We've been doing the same things ourselves, and I guess the reason I know about that is because we have mental health leaders' collaborative meetings, where I heard Ian present on the project that was done in Cardiff, and I guess that's where we share ideas and information and evaluations, and then we have to think about the context of our own relationship with our local authorities, our own geographical challenges and the various other things, then. So, I guess there are variations on the model, but I agree with Richard: in principle, I think we're all trying to do the same thing. I think the direction of travel is fairly unified.

It's good to hear that, but the evidence we've had to date, and obviously the evidence that we've received today, and the HIW report didn't say the same thing. So, that's something for you to think about. They also highlighted the concerns over the 24/7 crisis pathways. They do also vary. I'm just asking: where are we now in ensuring that your health boards—you can't answer for other health boards, I appreciate that—are actually delivering a 24/7 crisis pathway in these circumstances?

Cwm Taf has been fortunate. We've had a 24-hour crisis service for a number of years. In fact, it's probably six or seven plus years where we've had 24-hour access for people in crisis.

Yes, it's the same in Cardiff. We've got two 24-hour crisis teams.

Same in Hywel Dda. However, again, that's dealing with the symptoms of the issues rather than the causes, which is why we're so keen to develop these 24/7 drop-in services again, to help prevent people from reaching that.

I appreciate that, but we have a situation where we have to look after the people today as well.

Yes, absolutely.

Within Gwent, our crisis resolution home treatment teams, at the moment they finish at 10 p.m. at night, but in terms of an out-of-hours assessment, we have an admissions ward on the Talygarn site, where individuals would be assessed.

We're perhaps slowly identifying some of the boards that haven't got it, as well, as a consequence. You also talked about, in your paper, the triage model. We've had reference to that by the police this morning. That seems to be very effective. Do you think that is something that should be rolled out across Wales, and do you believe there's strong enough leadership for delivering this across Wales? I know Cardiff and Vale and Cwm Taf have probably been involved in this with South Wales Police.

I think the work in South Wales Police has had good leadership from the three health boards and from the police, and that has, I think, underpinned a strong model, which, in its infancy at the moment, is working really well. We'll await formal evaluation and we're going out to tender for evaluation of the project, but the early indications are that it has been very successful. As part of that, we looked at what was happening in Aneurin Bevan and the work they were doing in police call centres, and also there's been some success in Devon and Cornwall with their police triage system, and some of our teams went down to look at that. So, I think we spent a good bit of time analysing the data, trying to understand what the demand was, so that we had a real strong sense of what this model was about and what it could do. As I said, it's very early days at the moment, and it would be interesting to see how that evaluation plays out, because we only went live in the middle of January or at the end of January. But the early indications are that there's plenty of work, plenty of contact.

So, when is the evaluation? Are you going to do a 12-month evaluation?

It's a nine-month project, with the evaluation starting, I think it's on month four, looking retrospectively, then, at all the data.

And if that evaluation identifies that this is a good scheme, would you expect strong leadership from the Welsh Government to ensure that there is a consistent approach across Wales?

I think if the scheme works and it's making a difference to people's lives and how we manage the service, then we have to do what we can to make that happen.

Because, we've got two boards here that are not in that scheme.

There are different approaches across Wales. So, Dyfed-Powys and Hywel Dda did set up a triage scheme well over three years ago—I think it's approaching four years ago now—and that was a slightly different model, where we have a mental health practitioner and a police officer on duty, and they're able to go out and travel to anywhere they need to, as well as being based in a force control centre. The anecdotal evidence back from officers in the force is that it's excellent—they love it. They're absolutely relieved to know that the triage team is on, and it now runs seven evenings a week. In terms of outcomes, that's very difficult to predict. The use of section 136 went up year on year after triage was established. If you look nationally at evaluations of triage services, there are all sorts of different models. They've not been evaluated terribly well. It's very difficult for us to say which is the best triage model to adopt and whether it has any impact on mental health services as a whole. The evidence that we have is that it's appreciated, well received, people like it. But has it made a distinct impact on people's lives? That's one thing we haven't unpicked with the evidence yet. So, the evidence is still in its infancy with triage models, I'm afraid, other than it provides a lot of reassurance to a lot of people.

So, you've got a triage model—but with somebody who may go out with officers?

They have their own van. It's unmarked, and they can go out to wherever they're needed, yes. 

You cover quite a wide area, in that case.

That's Dyfed. We run it in Dyfed. 

Okay. Only in Dyfed?

Yes. Hywel Dda only covers Dyfed, unfortunately.

It's still a big area. 

It's a huge area, yes. 

In Gwent, our mental health practitioners are based in the police control room, and that service is operational seven days a week. I think, as colleagues have said, actually, police colleagues particularly think it's a very valued service, and I think that opportunity for police officers to get advice and support on the spot immediately in terms of thinking about the best way to support an individual—they find it incredibly helpful. Interestingly in terms of some of the data, there's been no impact on the number of section 136 assessments in Gwent since that service has been in place, but Gwent Police colleagues would describe a reduction in the number of times that they need to deploy police officers out to the scene. So, I think that's interesting. In relation to the Gwent model, that's currently being evaluated independently by Swansea University, and I think police colleagues are expecting that evaluation in the next couple of months, so it would be really useful to look at that. 

So, we could end up with three different evaluations by the end of the year, basically. Maybe a fourth if north Wales is doing one. Okay.

Section 136—obviously the definition is that it should be used for people in immediate need of care and control. That's fair. Her Majesty's Inspectorate of Constabulary and Fire & Rescue Services actually did a report on mental health and policing and found that the majority of people detained are actually discharged following assessment with no need for immediate hospital care. Now, I accept there's possibly a definition of 'immediate' and that could span a short space of time, but why do you think the case is that a lot of these assessments under section 136 are actually identifying that, actually, once they've done the assessment, they don't need to be admitted, they don't need to have hospital care—they are actually being discharged back to the community? And I suppose the question will be: have you got any views as to what type of support must be in place and how that works to ensure that when they go back to the community they don't end up back in the same situation, maybe even possibly the following day?

We looked at this a couple of years ago when we spotted that trend in the Hywel Dda figures in Dyfed. So, we took a sample, and we looked back through those, and although people weren't being directly admitted to hospital care, many of those people had needs. So, you couldn't identify that there was an inappropriate use of section 136 by officers in Dyfed Powys. There were genuine reasons why they had used section 136, and many of those people went on to receive other forms of support that they needed. Again, that leads me back to an awful lot of what we need to be doing today, which is to prevent people getting into crisis in the first place. Future investment, I feel, really needs to focus on how we prevent crises from happening, rather than, again, trying to deal with the symptoms.

Just building on Richard's point, in terms of the Gwent data, if we look at the last two years, 44 per cent of individuals who were assessed were admitted following discharge. Thirty-nine per cent of individuals aren't admitted, but they have some sort of follow-up plan. That might be support from community mental health team or third sector, et cetera. And only 17 per cent of individuals who were assessed were discharged with no follow-up plan. Richard, on your point in relation to other options to support people, I think one of the areas that we're thinking quite carefully around is the provision of sanctuary support. Actually, there are a number of models within the UK where they've established really strong sanctuary provision, and some of the evaluations of those services show a real impact on the demand and individuals presenting to emergency services such as A&E and the police. So, that's something where we're really keen to try and work with the third sector locally about how we can deliver that service. 

So that there's a coherence across the health boards in Wales and we're all planning the same sorts of services.

And can I just finally—? Obviously, going back into the community is important; the support provided and advice given is crucial. Earlier on, you all said that people are told about what advice they can get and where they can find that support, and yet the HIW report published two months ago now—less than two months ago—stated quite clearly that a large proportion weren't aware of the support they could get and the access and who to contact out of hours. Are we now making strides towards ensuring that everybody is informed, that the out-of-hours contact details, everybody—that the family are informed? Because, again, a large proportion of family members were not involved in those discussions. So, are we now in the process of making sure that that is happening?

I believe that was part of the outcome of the community mental health team HIW review, where they reviewed the quality of care and treatment plans, because the number of care and treatment plans is very highly complete. But the quality issues are something that has concerned all health boards, I think, over the past three or four years since the implementation of the Measure. I think we're all taking steps to implement greater service user and carer involvement in helping us to improve the quality of our care and treatment planning—routine audits, taking feedback from those routine audits back into clinical practice and having very clear assurance plans about how that's influencing the quality of care and treatment plans we're producing. It's an onerous task when you're dealing with a directorate, even just in Hywel Dda, of 1,000 staff, but it's something that we're very, very keen to prioritise. We need to make those care and treatment plans—the quality of those care and treatment plans—far better, more meaningful for our service users and carers.

I appreciate the quality, because it is about the involvement of the carers and the individuals themselves to ensure that everyone's aware of what that care plan is. So, I appreciate the quality, but it is crucial, on your preventative agenda, to get that right.

Yes. Absolutely.

Diolch, Dai. Obviously, you're all very well aware that, to adhere to the Mental Health Act 1983 code of practice for Wales guidance in relation to the use of powers of detention under sections 135 and 136, health and local authority partners have a duty to ensure that there's an adequate provision of places of safety, both for adults and for young people. Are there enough health-based places of safety across Wales?

In Hywel Dda, we have three places of safety designated for adults. Each of those is attached to one of our in-patient units. We have a dedicated children and young persons place of safety as well, in a separate in-patient unit, or attached to it. We're very, very conscious we don't currently have an identified place of safety in Aberystwyth, and we're working very hard to put one back in. We intend to do so this year when we increase the hours of one of our community mental health teams to 24 hours. Under the changes to the mental health Act, implemented by the Policing and Crime Act 2017, anywhere can be a place of safety, and I think there's a lot more scope to work within that. Our future plans are, and will be, to have non-health-based places of safety available in each locality as well. So, if you had a lower level of need, we would like people to travel less far and be seen more locally, and be looked after not necessarily in austere, perhaps, clinical places, but in more welcoming, friendly environments, leading back to a hospitality notion, as well, and places of sanctuary.

If I can make a comment from Cwm Taf's point of view, we certainly have a place of safety. I think the picture is changing somewhat since we built ours about 10 years ago, and what we are seeing more and more is a complex mixture of people who are in emotional mental health distress, unfortunately often with alcohol involvement, drug involvement. So, the complexity of their care prior to undertaking an assessment has changed somewhat in the sense that we might have facilities, but we haven't necessarily staffed those areas to deal with a complex mixture of intoxication, potential violence and aggression. And that has a huge impact on our interface with our police colleagues, because they're often better equipped to deal with that level of violence and aggression. Sometimes, that's very short lived and things will settle down, and that often leads to a different outcome at the end of assessment to the point of arrest under 136, for example.

So, I think there's a challenge for us, not just in terms of the facilities and the buildings, which are reasonable and improving, but in how we staff those. And is that a health board, a regional—? How could that look in terms of demand and capacity? There are issues like that. I know there was some work done in the concordat to think about how we could better provide facilities where the police are not spending inordinate amounts of time waiting for someone to be sober, to be at a level where it's safe for a mental health nurse to manage that situation, which is often difficult, given there will be other crisis work going on that's involving the staff. We hear that quite a lot across our health board colleagues; that's a similar pattern, I think that's fair to say.

We don't have the geographical challenges that somewhere like Hywel Dda has, so we have one place of safety that we're lucky enough to have—a new unit at Hafan y Coed. We built it to the spec that we felt was safe and appropriate. But similar to Richard, we've got concerns about the clinical environment there and having a very clinical environment for people who may not have been expecting to be conveyed to somewhere like that for an assessment. So, we're considering alternative places of safety as well. But yes, the same sort of thing.

In Gwent, we've got one place of safety and we feel that that's able to meet demand, but very similar issues to colleagues—picking up in terms of how it could be a more friendly environment, but also picking up on Phil's point; since the introduction of the policing and crime Act, we have seen a change in the presentation of individuals to our place of safety. So, significantly more individuals are engaging in significant aggressive behaviour and intoxication, so we're doing a piece of work now thinking about what we need to do in terms of changing the skill mix of staff. We've already put in temporary additional staff to be able to ensure that we can safely support people in that provision.

Okay. That's helpful. Thank you. So, for each of your health boards, when demand for access to the health-based place of safety exceeds capacity—and that must happen sometimes, because this is unpredictable, the demand—are you satisfied that there are adequate escalation arrangements in place so that we don't end up with police custody as a default option?

The evidence we have is that we had one detention to police custody in 2018, and that was deemed appropriate. So, with the three, plus the children and young persons places of safety, it would be very rare that all three were in use. It can happen. We have very clear escalation procedures identified between us and the police and we have very clear ways of notifying each other where there may be an issue with the assessment facility—for example, 'There's somebody in that one'. So, we'll alert people, the duty advanced mental health practitioner and police officers to let them know and they can divert people to the next one along. So, to date, we've been rather fortunate; we've managed to consume our own smoke with the three places of safety that we currently have.

In Cardiff, we have less than one a day, so the demand hasn't reached—

[Inaudible.]

That's right. And looking back at the 136s that were assessed in the police station over the last year, there's been one or fewer per quarter and they've all been appropriate as well, because of the level of challenging behaviour that people have presented with.

I'm not concerned about the demand. Certainly, in terms of custody, we've had none in 2017-18 where we've assessed in custody. I have to say that that is because there is a very strong agreement between South Wales Police and Cwm Taf—and I'm not sure exactly what the agreements with the other health boards are—in the sense that there's a clear escalation process in terms of managing people who are violent, for example, and good working relationships, in the main, where they will remain—which affords us then being able to keep the people in a health board place of safety rather than traditionally what we would've done a few years ago, which is use the custody. So, there's a lot of strong inter-organisational work to make that happen.

In Gwent, approximately 12 months ago, when the police and crime Act was being introduced, we thought that there was a hypothesis that there could be more people who were requiring the health-based place of safety. So, at that point in time, we created an additional waiting area, because I guess we were very keen to get a sense of what would be the demand coming through. And what we found in the 15 months is that there have been less than 20 occasions when we've required use of the health-based place of safety when there's already been somebody in there, but it's been possible to support people within the waiting area. But I think, for us, it's something that we continue to monitor. If we do need to think about developing further places of safety, we will need to do that.

Thank you. You've partly, I think, answered this, but in each of your health boards, are accident and emergency departments classed as, or used as, places of safety? No? That's good. I'm just quickly looking ahead—you've touched, I think, on the issue about when you've got people who are very heavily intoxicated and also that can sometimes contribute to very aggressive behaviours and things that are quite difficult for health staff to manage. Can you say a bit more across the health boards about what you're doing to ensure that those patients can be safely managed in those health settings, and, where possible—although it may not always be possible—have we got the appropriate levels of staffing so that you don't necessarily need a police officer to be sitting there until the person's behaviour has de-escalated for whatever reason? I think you, Mr Lewis, touched on that—that you were reviewing your staffing to see whether you had got people in place and to look at what those higher levels of need might be.

Yes. I think it's fair to say, from Cwm Taf's perspective, that as it stands at the moment, if we had someone who was presenting with challenging behaviour, we would struggle to manage that. Fortunately, one of our places of safety, and the one that we all defer to by night, is based alongside wards, so there are numerous links to further staff to support that. But we have to recognise as well that those staff have got patients on wards, of course.

The difficulty is that the demand coming through the door—and these aren't huge numbers, to be frank, and the numbers that need high levels of interventions in terms of intoxication or even violence and aggression—these aren't massive numbers. So, we aren't staffed to manage that, and, typically, you would need at least four staff on duty, because any restraint in mental health would require three people to partake, and you would always want one spare person in case things escalated further. So, we're not in a position to staff a crisis suite there, and I guess there's an interesting argument around that sort of demand and capacity: on a more regional basis, does that make that fit that model, whilst introducing the logistics of travel, of course, to all this? It's a difficult balance, and I know those were some of the conversations that were had as part of the concordat work around what could or would a regional kind of approach be for this, where police could drop people off, knowing that, in terms of violence and aggression, it could be managed; in terms of safe detoxification, that could also be managed.

I think I can answer that in the case of what's happening now and what's happening in the next two to three years. So, for now, of course, we have three separate places of safety. They are staffed by regular ward staff. We do have an additional staff member on each ward to manage the 136 facility, but, as Phil correctly identifies, if somebody comes in with serious needs, we wouldn't want them going to police custody, we'd want them in a health-based place of safety, and we work co-operatively with our police partners there, so they will stay with us until we can have sufficient staffing in place for them to be released, and we prioritise that as soon as we can.

In terms of the future model, when we have our community mental health centres fully developed—and our new central assessment unit will be the first part of the new development built—that will have a special dedicated section 136 facility. That will be staffed adequately to manage people with more acute needs, and then the plan is for the three community mental health centres that have a non-health-based place of safety—they will be available more locally to manage the lesser needs. So, we thought of that in terms of our future planning.

In Cardiff, we're lucky enough to have all our acute services on one site, and the 136 suite is co-located with our crisis ward and our crisis services, so we can draw on 19 wards that we've got there for staffing. So, we don't need to put extra staff on, and it's quite rare, as well, so—.

So, that's not an issue for you, because of where it is.

It's not an issue for us, yes.

What about in Gwent?

So, our place of safety is next door to one of our acute wards, but I think, as I mentioned, in terms of the changing nature of presentation of individuals, we have temporarily increased staffing levels within the 136 suite whilst we do a more comprehensive review, because I think it's absolutely essential, isn't it, that individuals who are being assessed and staff are safe. We do have a very good relationship, actually, with Gwent Police, and, actually, those sorts of occasions, you absolutely see people working together across agencies to make sure the situation is safe for everybody.

Thanks for that. If we could look, then, at transporting issues, and, of course, that's more of a challenge for Dyfed and Powys than it might be for Cardiff, without wanting to make any assumptions, but the concordat states that NHS transport or other vehicles should be being used to transport people in this situation, but the evidence is suggesting that that's not happening and that most people are still being transported in police vehicles. So, I can see you're all acknowledging that that's the case. What plans have you got in place to begin to address this? It is a huge challenge, and it's obviously more of a challenge for the more rural health boards, but it's also not appropriate, is it?

We recognise that it's a huge—it's an enormous challenge for us. What we find is that, being such a large geographical area, we have issues with advanced mental health practitioners making their assessments and needing to find transport to transport someone to hospital, and great difficulty in accessing WAST in a timely fashion for that. Police officers, similarly. They could be in St David's, and, even if we had a transport service that was based in Carmarthen, it's going to prove most likely better for the person at the centre of it all to be transported by police, rather than wait for a transport service to arrive from wherever it arrives from. So, there's a bit of quid pro quo within all of this, but we recognise we need to have a far, far better transport solution.  It was clearly called out by the public in our transforming mental health consultation as well, and we have a work stream dedicated to enhancing our transport provision. This year we're setting up a pilot service that will be based out of Llanelli initially, working alongside a commissioned drop-in service in Llanelli town centre, because part of the problem we have is we haven't accurately mapped our transport need. We simply don't know what the real demand is out of hours, and that's been very difficult to gather. So, the first task of the transport service will be mapping what the demand really is in out-of-hours transport service. I suspect it's not that frequent, but when it happens it's really urgent and necessary. So, with the mapping we can do from that, that'll help us plan what we need to provide over the coming two to three years. So, we should be in a position to evaluate that pilot towards the end of the year, as we get six months of data coming in.

Thank you.

Yes, we've got similar problems as described in Cardiff as well—WAST are having real difficulty in responding to the prompt nature of our conveyancing needs when people are detained in the community and then need to come into hospital. So, we're going through the data collection phase at the moment, and it seems like a daily occurrence that this is happening, although it's very difficult to predict at what time of the day or night that could happen. So, at the moment, if there are time lapses that cause us great concern, then we privately book the transport then to bring individuals in, to avoid police transportation, but we would like to get to a position where we've got a contract now with a provider and we're working with our transport department to try and choose the best way to do that—whether it's not for profit or a private provider, et cetera—and what's going to be the safest and the most cost-effective way of doing that from an accredited transport provider as well. So, we're looking at that at the moment, but it's currently a risk for us.

Okay. That's helpful.

We're very similar to that position Ian describes in Cardiff. We're over-heavily reliant on the police because the response time of WAST doesn't meet the need. We are exploring St John's Ambulance, who we have a contract with, to do other conveyancing, not linked necessarily to 136. So, if someone is assessed as needing admission in the north team of our patch, where the beds are at the south end of the patch, they will do that conveyance, unless there are particular risks, in which case we'd ask the police. So, we're trying to think about imposing that model across 136. It's in its consideration stage at the moment, but we well recognise it and it's covered across all our agendas of Mental Health Act work—the conveyancing remains a massive challenge for us.

I think in Gwent we absolutely recognise the challenges other people describe in terms of conveyancing. So, in April 2017 we took a decision to invest in a conveyancing service, so we explored the various options. Ian's described some of them, and the decision that we made at that time was to invest in our own service, so, actually, we've employed just over five workers who are based in one of our in-patient services, and we have a vehicle that is there and it is available.

Interestingly, in terms of the data, we have about 100 requests per month to be able to access that conveyancing service. We use it in many more ways than just in relation to conveyancing people around—crisis assessment—feedback from stakeholders is really, really positive and it's making a significant reduction in the number of times that police are needing to convey people.

Is that a 24-hour service?

Yes.

We mentioned the ambulance trust. The ambulance trust, in their written evidence to us, have called for a single—you know, one national crisis care model, with some local flexibility, to address the challenges around transporting people with mental health crisis. Ian, would you have a view on that? Would that be helpful?

I'm not quite sure what that—

I'm not quite sure what they mean either, but that's what they've told us. So, just to explore a bit whether there would be one agreement with the ambulance trust around what their responsibilities are around this.

Any system that deploys skilled staff to situations that they're going to be more familiar with, I suppose, and conveys people safely and in a timely way would be helpful, and, if that suggestion meets those criteria, then we'd be really supportive of that. I think there are various schemes happening around Wales. I know in Cardiff we've got a diversion scheme with the ambulance service where they can divert people from A&E into the mental health service if it's safe and they're known to us. So, we try and do our best to divert people in that way, but, from a purely conveyancing point of view, if it meets those criteria, that would be really welcome.

Okay, that's helpful. Thank you.

Diolch, Chair. And, as the Chair has just introduced you, you are the chair of the concordat assurance group that reports directly to the Minister for Health and Social Services, but also the chair of the Wales Alliance of Mental Health too. How difficult is it for you to balance those two roles and responsibilities? 

Well, the alliance is a coming together of the national mental health charities in Wales. We come together voluntarily and share what we know our beneficiaries feel is most important and most urgent for them in terms of changing the environment, improving the environment. And one of our priorities was very much crisis care, because people were telling us that the actual experience during crisis could be almost as damaging and distressing as the illness itself, and, in particular, being detained within a police cell and receiving focus there, as opposed to having the right kind of treatment early, was extremely distressing in a number of cases. 

Mind, and a number of other organisations, held a series of inquiries with people who were experiencing this kind of thing and, over time, we developed the idea of a concordat. It was a really positive thing that so many people came together in Wales and felt that sense of having to do something about the experience that people were having. 

So, the idea then of chairing that concordat assurance group was very much based on the fact that we were there on behalf of beneficiaries. We were there on behalf of the individuals who were experiencing a mental health crisis and we weren't one of the agencies—if you like—who were involved in the delivery. And, therefore, I was in a position to be able to step back from that and bring everybody together in a constructive way to think about what we could do to improve the situation for people in Wales. 

That's really useful, thank you. How effective do you feel the current governance arrangements are around implementation and assurance work in regard to the crisis care concordat and the delivery plan? 

The governance arrangements—. You may be aware that there have been two lots of the assurance group meetings. So, what happened was that the concordat was signed right at the end of 2015, and we had an 18-month task and finish group, which was essentially to make sure that the concordat was bedded in and that we made real progress against the priorities. And we were deliberately really focused in what we were doing so that we could reduce the number of people who were going. So, there are over I think about 550 people who were in mental health crisis and detained in police stations when we started, and there's been a 90 per cent reduction in those numbers. There were 16 children, including a 12-year-old, and now there are none. 

So, we were able to make significant progress on that part of the concordat. And we were able to create, I think, an atmosphere where people were able to learn and talk about things that were quite tricky and difficult without finger pointing, and I think that's why the concordat membership wanted to restart, because they felt that, without that focus, it was pretty tricky to keep going on that path. And the assurance mechanisms are really using what's there already.  So, we didn't try and invent a whole new beast. We used the regional mental health and criminal justice partnership board, because they were there already, and we used the national board to feed into that and to learn, and then provide assurance in a written format on a six-monthly basis to the Minister. 

So I think the mechanisms for assurance are really clear and, in fact, we weren't able to provide assurance in one case recently around south Wales. We reported that to the Minister, and I think that action was taken off the back of that to bring people together. So I think the potential is there for assurance. I think it would be really helpful if those six-monthly reports were published so that the reports are available for everybody and we shine the light of day on what is actually going on. 

You said that you thought that action was taken as a result of you highlighting that. How sure can you be? There seems, perhaps, a little lack of clarity there. We'd all like to think that there is direct dialogue.

Well, I think we have to wait and see, because I think one of the issues that we've got in relation to assurance and to seeing progress is the outcome information for the individuals themselves. So, do we know, for instance, how crisis is averted in the first place? Do we know what the experience of crisis care has been for the individual, and do we know what happens to the individual after they've been through crisis? So, within the implementation plan as we have it here, we've added, this time around, improving the data and the intelligence around what happens to the individual. So, until we have that information, obviously we can't be completely assured of what's going on. And that information is really important on a regional basis, between partners, and then it's important to bring that together so it gives us a picture across Wales.

Thank you for clarifying that. You talked about a regional basis there. Could you confirm for us whether regional action plans have been published and are being reported on for each area?

The national framework for setting up the regional action plans this time around is relatively new. They have been reported on to the assurance group. I don't think that they have been published individually. 

Okay. Thank you.

You mentioned in one of your replies to Vikki Howells that we've seen this really significant reduction in the use of police custody as a place of safety, which is obviously really good—it's a really good thing. Is that attributable, do you think, to the concordat? Do you think that we can make that direct link?

Well, it's co-occurrent, so, insofar as we can make a direct link, it looks that way. It was certainly the case that there was focused attention on that right from the start. And I think it's one of the areas in the concordat where you can measure progress. There are other areas in the concordat where it's more difficult to see exactly what's happening, but with those sets of figures, because they're gathered sequentially over time and published, you can see what's happening a bit clearer. 

Thank you. You'll know that Her Majesty's Inspectorate for Constabulary and Fire and Rescue Services described the concordat as an excellent first step, but also went on to state that, while partnership working is better, it's not necessarily delivering better outcomes. Do you think that's an accurate assessment, or is it, again, that we need more—[Inaudible.]? 

Well, I think it comes back to this issue of visibility and transparency of outcomes for the individual, because, for me, outcomes means what happens to people. So, I couldn't say whether that statement is right or wrong because we are not sure, and I think it's very important that we hear the voices of individuals and those around them in terms of what happens, and there are a number of opportunities to do that through things like care and treatment plans, and advocacy services, and so on. So, there's the potential to do that, but we don't have that at the moment. 

So, you'd say there's the potential to do that, which is helpful, but is there a plan to get it done, and if there isn't, how could one be put in place and whose responsibility ought it to be to make sure that it happens? 

The plan is for a national core mental health data set, which is another one of the Wales Alliance for Mental Health's real priorities. If we had two main priorities, they would be it. There are two aspects to that data set. One is demographic and service level data, but the other is outcome data for the individuals, and looking quite holistically at whether people are better, are they in work, do they have a community around them. So, looking at life outcomes. And I think that it's really important that there's pace behind the development and delivery of that data set, and that it is then regularly published so we know what's happening. And also I think, within the plan, the regional groups, working together across agencies, themselves should take ownership of understanding what their beneficiaries' experience is, as an absolute way of improving and knowing what they're doing.

You mentioned pace in your answer about the data set, and I think, if I'm right, that we're not expected now to have that complete until 2022. Not wishing to put words in your mouth, but obviously we will be making recommendations as a result of this inquiry, would it be your assessment that that ought to be done faster, if at all possible? 

I think there are parts of the data that are available, and I don't see any reason why some of that couldn't be published in a digestible and accessible format earlier than that.

That's helpful, thank you. To turn back to the concordat itself, do you think it's ambitious enough?