Health and Social Care Committee

Now we move to item 2, and this is in regard to our piece of work on the impact of waiting times backlog on people who are waiting for diagnosis or treatment. We have our first panel, this morning, of witnesses that are with us in regard to our evidence session on primary care organisations. So, if I could ask the witnesses just to introduce themselves for the public record—the virtual witnesses first, please.

Bore da. Good morning, everyone. I'm Elen Jones, director for Wales for the Royal Pharmaceutical Society.

Good morning, everybody. I'm Judy Thomas. I'm the director of contractor services for Community Pharmacy Wales.

Bore da. Good morning. I'm Helen Whyley. I'm the director of the Royal College of Nursing in Wales.

Bore da, bawb. I'm Peter Saul. I'm joint chair of the Royal College of General Practitioners in Wales, and a GP in north Wales.

Thank you all for introducing yourselves and for being with us as well, and thank you for your responses to our consultation over the summer period, which helped to facilitate some of the questions that we've got with you today. But thank you for your time this morning.

My first question is to you, Mr Saul, in regard to—. Or Dr Saul, I should say, should I?

I don't care. [Laughter.]

You don't mind, you don't care. There we are. So, when a patient is placed on a hospital waiting list, either for their assessment or for their operation, they remain under the care, of course, of a GP, as I understand it. So, what are the consequences of that in regard to longer waiting times and longer treatment times?

So, the consequences, I think, from the patient's point of view, we need to look at it. The patient is being referred because we in primary care can't deal with the situation. We need further advice, whether it's advice about their treatment or it might be an operative procedure like a hip replacement or something like that. And the reason—. We've got to the end of what we can do with the patient or what we think is our limit of our expertise, so to speak. The problem with waiting times and waiting lists is that the patient is then left in almost a limbo, and we feel as GPs and other members of the team that we are restricted about what we can do with them because we need help. There's only so much we can do. So, we often get the person coming back to us more frequently with more problems—increased pain for example, symptoms—and, as I say, we feel to a degree helpless because we are asking for the advice from the secondary sector, but that's delayed because of the problems with waiting times.

One of the things that we do—. Let's take orthopaedic situations, a problem with a hip or a knee for example. We may be trying to engage with pain management teams, and that puts extra pressure on them. We are trying, say, to maximise the physiotherapy input that's given to that patient, again, to help them with their symptoms. That puts pressure on physiotherapy. The patient may have flare-ups, they may end up in hospital.

Let me use a different example, let me say a teacher. We've got a 40-year-old teacher who has got gallstones. We've done a scan, she's been diagnosed with gallstones, she's referred to the hospital and they say, 'Yes, you need to have your gallbladder out, and we'll put you on the waiting list'. On that waiting list, she keeps coming back to see the GP because she's having flare-ups of pain. She calls an ambulance because she has a bad flare-up one evening at the weekend, say, and gets taken to A&E. She calls 111 several times, she misses days, weeks from school, the school has to get a supply teacher in. It costs education money. And she's still going to need that operation at some point. The frustrating thing is, as soon as she's diagnosed, if she could have that surgery, it would release all that pressure down the line from the system, it would make it cheaper for her employers, the children would miss less school, and it is just so frustrating that we are putting patients in this situation, not deliberately, but because of the problems that we find ourselves in. I don't know if that answers the question, but it certainly paints a picture.

It does. It probably gives me another 10 questions, actually, based on what you've said, but I'm not going to ask those, because I'm probably going to be pinching questions that others want to ask. But you've set the scene, I think, quite well in terms of some of the other questions that we want to dive into.

I suppose the other issue here as well is we know that, back in March and April, elective treatment was put on hold, and I'm just wondering the extent that you think people perhaps haven't now presented themselves. Do you think that you've caught up on those who perhaps haven't come to see their GP during that period? Do you think that you've now seen everyone who perhaps delayed coming forward during that period? Or is that, perhaps, not the case?

I don't know that we have, actually, and I say that for two reasons. First of all, I still think there's a reticence among some people to come and see their doctor, partly because of a feeling that the system is under pressure and that they want to help the system by staying back. And our message to people is, 'Please don't. Please come forward'. But we're now reaching the other problem, because people have been coming forward in all areas of the health service, but in general practice, we're probably seeing about 125 per cent of the activity that we were seeing pre pandemic, because of people coming forward. But then, that makes it a bit more difficult for people to engage, because they also hear stories, which are true, that it's really hard to get to see a GP and appointments are at a premium. So, it's another disincentive, really, for people to engage. And again, our message is, 'Please tell us if you're worried about something'.

As I think this through as well, do GPs, do you think, perhaps take more time—? They've got a patient presenting themselves; whereas, perhaps in more normal times, pre-pandemic times, you would've referred them for treatment, now, as GPs, do you think GPs are holding back and saying, 'We know that there's a long waiting time so we're not going to refer at the moment, we're going to look for other alternatives'? Is that something that is recognised?

I think you're right, yes. You're thinking, 'Well, there's no point, because they're not going to be seen for a long time'. And another disturbing thing that I'm finding myself doing is trying to look somebody up and down, make a judgment about how financially affluent they are and saying, 'You know what? To be honest, you'd be better going to see somebody privately'.

Really?

And, you know, I feel uncomfortable doing that.

So, almost, rather than asking medical questions, to an extent, you're asking financial questions or trying to draw that out in your discussion.

Yes.

That's significant, isn't it? Okay. We'll go into some more specific questions now. Jack Sargeant.

Diolch, Chair. I've got some more general questions, not just to Dr Saul. They may be covered by Dr Saul, but our other witnesses could answer as well. Over the last 18 months, throughout the coronavirus pandemic, patients have been relatively accepting that their treatment may be moved on or rearranged to a different point, but as we are moving away from the pandemic and getting back to some sort of normality, albeit the pandemic is still here, to what extent are primary care practitioners having to manage expectations with their patients about the waiting lists and so on and when they will expect their treatment? I think crucially, the part of the question for me that is the most important is: is this causing front-line staff problems and conflict? I know certainly in the past, Judy, community pharmacists across Wales have had problems during coronavirus with conflict from members of the public. So, I'm interested—I'm quite content for anyone to pick that up, really—to hear all views.

Who would like to come in on that?

Shall I kick off? One of the things that troubles me is the patient who is not vociferous, who is not switched on, who maybe is less aware. Because what we do see is—and we've seen this forever, really, but it's become a little bit more pronounced with the pandemic—a group of people who know how the system works and can actually apply pressure into the system. I had somebody on Monday wanting a letter to expedite his physiotherapy, which is a perfectly reasonable request. This is the second time that he's asked for a letter, and, as I said, it's perfectly reasonable. But, it's the people who don't ask because they don't want to trouble, and it's almost like—. We see it in so many things in society; the ones who push to the front of the queue are not necessarily the most needy. And my worry as a doctor is identifying the people who are not pushy but who really do need treatment expedited, because they're just sitting at home quietly suffering. But, yes, this is happening all the time.

Elen Jones.

Thank you, Jack, for that question. I think, particularly in community pharmacy, we continue to have opportunities for that interaction with the local community, and I think your question does draw on some of our concerns around potential health inequalities. Being able to gain access to the heart of the community and understanding their needs is central to being able to address both the cause and the consequence of health inequalities. So, community pharmacy can help to mitigate these, and we do know that the network of over 700 community pharmacies does help to buck the trend of the inverse care law. It ensures that people have got access to healthcare services in even the most deprived communities.

I think there is an opportunity for us here to think about how can we ensure that community pharmacy teams can have better direct referral services to refer those patients that they see on a regular basis that they become concerned about. We have got pockets of really great practice across Wales where community pharmacies are working really closely with neighbouring GP practices and can escalate to that extent, but how do we actually unlock other services for our patients on a local level?

Thanks, both, for those answers. I think that's particularly useful, especially regarding the referral services and better access to referral services. I'm just interested in—. Dr Saul, you mentioned in your answer about the need for prioritisation, and you're looking—. GPs and all healthcare staff have a hard enough job, I would say. So, what does prioritisation look like? How can Governments and political leaders help with that? How do we make your life easier in the sense of prioritisation and getting people the treatment they need?

Prioritisation, I think, is, if somebody has a medical condition, looking at the impact of that medical condition on their life. And that might include things like lifespan as well. But looking at an individual patient. I think clinicians need to be able to prioritise, and we do. In the sense of helping us, I think it's having health systems that are not overtly bureaucratic, don't require bits of paper to be passed, or even e-mails to be passed from one to another, and for people to take responsibility. One of the things I think that we don't see is secondary services taking sufficient responsibility for their waiting lists. They say, 'Well, no, it's nothing to do with us, this is the waiting list, go and see your GP, pharmacist'—or whatever—'physio, nurse.' And I'd like further pressure to be put on other parts of the system to take responsibility for waiting lists.

With that in mind, then, do you think we should publish more data around waiting lists?

Yes.

Helen.

Thank you for that question. One of the things I was just thinking as Dr Saul was speaking there was about managing people on the waiting list. If you think about things like surgery, the patient will get to a point where they actually do go into a pre-assessment arrangement, predominantly led by nurses. That usually happens just before their surgery, but, actually, you could extend that type of service and do that at the point of referral, so you'd be looking not just at suitability for surgery, but actually, a more holistic approach to managing the condition. That often does happen alongside these referrals, so patients who particularly spiral downwards in terms of health will be referred into community nursing-type services et cetera. But I think the point for me here is about thinking about that seamless service and planning what the patient needs, and then the workforce who are able to pick up those needs through the patient's journey.

That's truly about putting people in the middle of the service, rather than running a service, which we've done for a number of years, that says, 'You'll see your GP, you'll have a referral, you'll sit on a waiting list.' There's some great initiatives in things like social prescribing. That could be woven into this system far better, to support social prescribers of services that community pharmacies and other community services do. But I think, if we really, truly want to deliver that community-based service, then we've got to invest significantly in the multiprofessional team working out in the community, because it feels like the second cousin, in terms of workforce planning, to the acute services.

That's very useful. Just one final question based on the points you made there. You mentioned a multiprofessional team and the community-based services, and I think it's similar to what Elen was suggesting before with the referral services from community pharmacists and so on. If you can try and give the committee just some indication of how much of a problem that is currently, with the difficulties patients face when they can't see a GP for a number of reasons. How big an impact is that having on the waiting times in general?

Obviously, there's data about how patients get to see their GPs. I think, actually, in the pandemic, the process of seeing GPs has been significantly improved, using new ways of working, et cetera. The point is getting the right help at the right time by the right person, isn't it, and managing that condition. Dr Saul painted a picture of a teacher. If that teacher had intervention earlier—so, for example, at the point of referral that they needed their gallbladder removed, they actually were seen and assessed, they got that clinical expertise about their prioritisation—that's now owned by secondary care because they're going to actually do the surgery, and therefore, that process gets slicker. That would have an impact on waiting times.

But if you take another model of people with things like back pain who might need a secondary care referral for exploration of the cause of it, there's a significant amount that could be done between that appointment with the GP and the actual being seen in secondary care for others to support how to manage that back pain. And that's a major role, and you see that now in some services, but they're not blanketed across Wales. So, some areas, you'll see GPs with physios in their practices; other areas, you'll see good community pain support systems; other areas, you'll see specialist nurses in particular fields. But it is a bit of a postcode as to what you will experience, depending on where you are and what resources your health board has put in place for you.

If I can, Chair, if you'll indulge me: how do we share best practice then, because it sounds like we don't share best practice well enough across Wales?

I think that's a really good question. Obviously, we've seen from the current—well, the last Government, actually, the transformation fund that's been led by regional partnership boards. But I think the review of that shows we've still got some way to go, as using those funds to actually scale up good and best practice. Obviously, you've got things like the National Institute for Health and Care Excellence guidance, et cetera—it doesn't have guidance in every area. But investment into those aspects are key and essential, and, for me, the evaluation of that transformational fund is urgently needed, and how regional partnership boards have been spending it, and have we seen the scale up from there. I suspect we have in some cases, but not in all of them.

Thank you. Thank you, Chair.

Thank you. And just before I bring Joyce Watson in, just to pick up a point on Dr Saul: you were mentioning that, in some instances, patients present themselves and come back to their GPs, but other instances, they don't feel comfortable in doing so. And it just made me think about the role of district nurses or pharmacists in proactively reaching out to perhaps a certain group of people—perhaps those who are in more deprived areas, or are less likely to come back to their GP. Is there a role for those—for the district nurses and pharmacists—in doing that?

We've had a long tradition of working very closely with district and community nursing. And I think basing community nursing teams on practices rather than geography has tended to work better, and in some areas of Wales that's the case; in some areas, it isn't. But I believe in practice relationships with community nursing teams. I think there's been a lot of success with community pharmacy in the relationships that have been built up between them and primary care. And certainly as a college we've had lots of meetings with our pharmaceutical colleagues on areas of better working together. And as a GP, I frequently see patients who've been advised by their pharmacist to come and speak to us. So, I think that patients see pharmacy, certainly at the moment, as a more accessible way of getting some medical advice, and we're keen to engage with that as GPs.

Thank you. And I think, Judy, do you want to come in on this point? I'm particularly thinking the question is about reaching out to those persons who are marginalised or perhaps deprived, and in terms of being proactive in reaching those people who might not come forward.

So, as Dr Saul was saying, we do regularly flag patients that we have concerns with back to their GP practice. Often, the patient will be seeing the community pharmacist more often than they'll see any other healthcare professional. So that gives us a real opportunity to engage with those patients, even if it's just via some of our delivery drivers, if these patients are house-bound, which often they may be if they're waiting for an operation. There are opportunities in terms of sharing information, though, because, obviously, we wouldn't know that they're on a waiting list necessarily. Obviously, that has whole implications in terms of patient consent and where that sits. But there are, I suppose, more opportunities for community pharmacy to support that, in terms of checking in with patients. And there is a pilot happening in Hywel Dda at the moment, which uses delivery drivers to check in with patients, to see if they need additional support, and when they do, they're flagged to the Community Connectors in Pembrokeshire. So, that's the kind of thing that potentially we could do to provide more support to patients who may need it whilst they're waiting.

[Inaudible.]—there is, I think, you've just pointed out, is that you need to know who those people are. How do you overcome that barrier?

I suppose that's about access to a shared patient record, which is obviously a longer term commitment as to how we all work together. Because obviously at the moment there are silos of records and they don't always interlink with each other, and we wouldn't necessarily know. We do have access into the Welsh GP record for certain services, but we don't have access to that holistically. But there are potentials to develop that further.

Yes, absolutely. Joyce Watson.

Good morning, everybody. And it's great to hear that Hywel Dda are doing this pilot, especially since I live in Pembrokeshire. But we've been talking, as a Government and Members—both—for a very long time about using community pharmacies. I use them an awful lot. But, yet, we seem to have not managed in some places to get that message out to the public, who still want to see their GP at all costs. So, we've got quite a long way to go, and I really don't know how we're going to do that, but that's not my question. My question is related to that, and you've started a discussion about the holistic working together. You've given examples where some GPs have got additional resources within their centres, but, of course, access to those centres has been limited, because of COVID. We understand that. So, how do you think we can improve the holistic working together, so that people who are on waiting lists access not just physiotherapy, but psychotherapy if they want it, pain management if they want it? Because all these things will impact potentially on either the well-being or the deterioration of that individual.

Elen Jones.

Thank you. Thank you for that question, Joyce. I think we have seen a lot of improvement over the last five years in multidisciplinary ways of working. We have approximately 200 pharmacists now working in GP practices, and forging those really excellent relationships to help those local communities, and working closely with community pharmacy.

On your first point about ensuring that people access the right service at the right time, we have also seen an increase in the number of services that are being offered by community pharmacy, including the common ailments scheme, which is a really great way for the public to get support for a host of common and minor ailments through their community pharmacy. We also have some areas where there are independent prescribing pharmacists within the community, and those working in GP practice, as well as in secondary care. So, I think, there is something about using the skill set of all of the practitioners that we have. We've got more independent prescribing, not just within pharmacy, but with other health organisations as well and professions, and we do need to think about how we harness the skills of all professional groups, going forward.

Peter Saul.

One of the developments has been staff coming out into primary care. So, for example, in my practice, we have a diabetic nurse coming out to the practice, who's able to help us, advise us on patients where we're having difficulties, who's there for us to ask questions to, and who's able to upskill us. And, I think, that's a good model of encouraging practice-based specialist-type services. In that case, it's diabetes. Elen, I think, mentioned pain management and those sorts of things. The other point I would make is that, as—and I think this is something for us as leaders in our professional work to do, is to nurture and recognise everybody on the team. Because we've heard about delivery drivers and their role; receptionists, these are really, really crucial people because they're the ones who actually are seen as accessible by the patients, who have close contact with patients. We need to empower them to bring messages from the patients to the key individuals in their organisations, because I think a team that values everybody works well and that's one of the things we need to work on.

Thank you. Helen Whyley.

Thank you for the question. I think there's an aspect here around GP clusters and how they can work together to ensure that everybody knows about the sorts of services that are available, but also that they work together to bring the services that they know the patients need. Because, clearly, in a cluster, you've got a number of different professionals, as well as GPs, able to talk about the community need in that particular area.

For nursing, there's an opportunity happening now in that our new nurses, in two years' time, will come out of their courses prescriber-ready, which means that, if we want to embrace that opportunity in community services particularly, we need to start planning for that now. It doesn't mean that we want every nurse to be a prescriber, but there's definitely a support role alongside pharmacists, GPs et cetera, which we could utilise, particularly in the distract nursing workforce, who see so many patients, many of whom are house-bound, et cetera.

But, again, in order to do all of those things, we've got to think about workforce planning and workforce education and what we require Health Education and Improvement Wales to be doing on a Wales footprint right across the piece. And that's not just about individual professions; that's really thinking about the needs in the community—again, as I was saying earlier, about putting the patient in the middle of what's needed and then building the workforce, et cetera, around it. And I think, Joyce, that would be a good way of making sure that people get access to the same sorts of services by taking that very strategic Wales view, but translating it right down and into clusters and how the clusters work together.

Elen Jones.

Yes, I'd really like to support that point. I totally agree with Helen and I think ensuring that our workforce planning takes into account the capacity to train is really important. We're in a similar situation to nursing in pharmacy, where, in a few years' time, people will be coming out prescriber-ready from the pharmacy course and we need to make sure that they have the opportunities to learn and to embed their skills in their early careers.

We do know that pharmacists and doctors and nurses—the whole of the healthcare workforce—have, of course, been working at full capacity, with many redeployed to support things like intensive care, field hospitals, at the height of the pandemic, and, of course, the crucial vaccination roll-out. And the intensity, I think, of the work during the pandemic has highlighted more than ever the pressures on the workforce. So, I think, as we consider how we reduce waiting times and ensure that patients are both seeking and receiving the care they need, we must not forget that we can't simply keep asking an already stretched workforce to do more. We have to think differently about how we use the skillsets that we've got, and ensure that all professional groups are being utilised in the best way for patients. And I guess it takes us back to the ambitions outlined with the quadruple aim of the Welsh Government's vision in 'A Healthier Wales', and we have to ensure that we have a motivated and sustainable health and social care workforce, going forward, for patients.

Thank you, Elen. Joyce.

[Inaudible.]—at all is whether you think you have a role as primary care professionals to signpost patients to NHS waiting lists, but to give them some financial advice and support. It's just an open question because very often people carry on to the detriment of their health, because they simply can’t afford to do anything else.

Who would like to come in on that? I'm just conscious of time as well, so just try and be succinct in the answers. Helen Whyley.

Thank you. District nurses, for a long time, have given patients, certainly, signposting advice on how to find advice on things like benefits and other financial things. It’s one of the things that they do. It might not be the core thing of their job but, again, it’s about that referral system, isn’t it, and making sure people know where to go to find out that sort of information.

Peter Saul.

Social prescribing has really taken off, or is taking off, and is dealing with a lot of this. I just want to make one every brief point about that. We’ve heard about all these additional resources coming into primary care, and potential resources. We need something done about the estates. So, whether it’s actually hosting a social prescriber who can advise patients about debt and such like, or getting specialist nurses in, or training the new nurses, new pharmacists in primary care issues, we haven’t got the space to do it at the moment, and that urgently needs addressing.

Okay. That’s an interesting point as well. Thank you. Joyce.

One final area is peer support for unpaid carers—there’s an awful lot of carers out there who are not in paid employment—and whether you offer any support in that direction, or you can refer people on.

Who would like to come in on that? Judy Thomas, and Elen after.

We’ve done quite a lot of work over the last few years with Carers Trust Wales and others in terms of creating a suite of materials to support pharmacists and their teams in understanding the needs of carers, and also then supporting carers in terms of understanding the medication side for the person that they’re caring for. That is something that we are working on alongside those organisations, to try to support that messaging, and that’s alongside the RPS as well that we’ve done that work. So, it’s been very much partnership working to support carers across Wales.

I was just going to also say that point, so thank you.

That's fine. Thank you. Any more questions, Joyce, from you? No. Thank you, Joyce. Gareth Davies.

It's mostly just a footnote to some of the questions and answers that we've had today. I think it's been quite a candid session. You spoke about a lot of the realities that happen in our health boards and across GP services. So, I’m just wondering whether we can try and tailor this a little bit to really hone in on some of the everyday issues that people have, because in terms of what I hear from constituents about health boards, they talk about the COVID booster, vaccinations, and things like that, and some of the waiting list times. I think it’s about honing in about how can actually make a real difference to some of these long-standing issues, because it’s going to take a long time. Let’s be honest about how we recover from COVID-19 in terms of the long-term backlogs and how we deal with this. So, just to get an opinion really on how you feel that we can address this, going forward, because some of these issues have been long-standing and they’ve been exacerbated by COVID-19. So, what do you see, going forward, that we can really do to make an impact on people’s everyday lives and make things a little bit better?

Who would like to come in? Helen Whyley.

Thank you for that question, because I think that’s really important that we keep our eye on where we want to get to as well. Obviously, in terms of nursing, right now there are 1,719 nurse vacancies, just in the NHS in Wales. That doesn’t include social care and other places where nurses are employed. Because that is such a stark reality, I absolutely have to talk about the workforce and planning for that workforce, because you can put money into services, but without the staff to help to deliver those services—. Yes, you can put that money in, but you're not going to get what you want, because you just don't have the people to actually run and deliver that. So, for me, a long-term workforce planning strategy is absolutely key and fundamental.

In nursing, that's about thinking where nurses will go in their careers. Again, for nursing, shortages often in medical areas, A&E departments and things like that, are good examples: 'We'll go and make some nurse practitioners'—of course, because they're fantastic practitioners, but we do that on the back of having commissioned for those people to be staff nurses. So, really getting into the strategy of workforce planning for the nursing workforce is crucial and key. And if we look at why have we got those vacancies, when we have increased the number of pre-reg commissions, you have to ask yourself, 'Well, is that because they don't want to stay?' If they don't want to stay, why don't they want to stay? Are they getting the things that they talk to me about all the time, which is about proper reward for the job that they do? It's also about being valued and retained. The nursing workforce is predominantly female and it wants to have a flexible approach to work.

I often speak to members who are frustrated they can't work the way they want to—say, you know, Tuesdays and Wednesdays in the area that they work. They leave, and they go back to the area that they work in and work Tuesdays and Wednesdays for an agency. It's just not sensible. It's not good use of public money and it's not good continuity and quality of care for patients, and that's what nurses want to do. So, for me, alongside many other things we could do, we've really got to get our workforce absolutely right, and for nursing, that's an investment into pay, into retention and into proper continuing professional development and post-registration career pathways.

Elen Jones wanted to come in.

I think it's a really good point about actually what can we do now for patients. I think it goes back to Joyce Watson's point about how do we ensure that the public know what is already available to them, ensure that they are accessing the right service to begin with to ease pressures on other areas, such as A&E, and also ensuring that we are consistently commissioning these services across Wales, to make it easier to get those messages out to every member of the public in Wales—that they can have the same access to care wherever they are living. I think NHS 111 is a great example of a fantastic service that is available and is due to be rolled out in Cardiff and Vale—I think that will be the last local health board. I think when that service is available right across Wales, hopefully we can get some really strong messaging coming out about how that can be utilised, and also the referral pathways between NHS 111 and other services, such as community pharmacy, which are working well in areas where it has been rolled out for quite a while.

Gareth, do you mind if Jack comes in on—?

No, absolutely.

Cheers, both. Thank you, Chair. Just in terms of workforce planning, because we hear about it quite a lot, workforce planning, and we've heard it a few times today, I'm just interested in realising where are we. I fully agree that we need to focus on workforce planning, and one of the reasons is the well-being of staff, in my opinion. But I'm just interested in where we are on that journey of workforce planning, and how, as a committee, do we need to, perhaps, urge Government to move forward quicker on this—or are they doing everything they can? Can we help in any way of bringing that urgency forward? Because we hear a lot about it, but where are we with the action? That's what I'd like to know.

Health Education and Improvement Wales was formed three or four years ago on the back of a report that said we needed to do better in terms of workforce planning. I think that needs to be stepped up. We've got, obviously, the Government's delivery for health programmes and ideas underneath that about workforce strategies with action plans et cetera, et cetera. Okay, COVID has been difficult, but, actually, COVID has shone a light to say it's even more urgent than we thought it was. We've moved nurses into delivering track and trace and vaccine programmes and others. So, for me, that's got to be stepped up. So, where do we want to go next? We need to have a much broader, much more robust process of workforce planning—I'd like to see that scrutinised at Assembly level as well—to really pull through what it is that we want our NHS and our social care services to provide. Because you're not just workforce planning for one system, particularly nursing, and medics would be similar, as with other professions. The people that we're planning for are going to work everywhere in Wales, and sometimes outside of Wales.

So, on the journey of where we are now, I'd say we've made a good start, but we need to accelerate that significantly and quickly and to work in a more collaborative manner to put better skills into health boards, so they understand the population profile, potentially look at putting those skills into clusters for primary care-type areas and just get on with the things that we know and hear about all the time. When the agency spend comes out for 2020—I've not seen it yet—I will not be surprised to see it as being absolutely mind-blowing. It was very high for 2019. So, there's good public money being spent on things. If we could switch that round to invest in, actually, the expertise in workforce planning, I think we would see real dividends pay off for that, and tying that up then with initiatives like retention strategies. So, if you plan a workforce that then leaves, then your workforce planning isn't where you want it to be. So, workforce planning has got to be across a system and a continuum.

Thank you for that, it's very useful.

Thank you. Mike Hedges wanted to come in, then I'll come back to you, Gareth. Mike Hedges.

Very briefly, is it not true that if you want flexible working, the only way you can get it is by becoming an agency nurse, because the NHS and health boards are not very keen on flexible working? So, if you want to work three days a week or you don't want to work at certain times, you want to work three nights because you've got children, the only way you can do that is by going out and leaving the NHS and coming back in as an agency nurse.

I wouldn't blanketly say that that's true across every employer. I think the difficulty is that there are some areas where there's good practice and that is seen and valued and allowed to happen, because it's good for patients—that's the important bit here; it's good for patient care—but there are other parts of the service where that is very difficult and they haven't really embraced that idea of being able to work flexibly. I gave an example earlier; those are real examples. Again, that's about investing in an approach that's Wales wide, training our managers, making sure that they can see the value, because the value is patient care. I can't say that enough, really. If you've got a constant, stable workforce, you will get better quality patient care and you will also improve mortality rates, and that's the bottom line.

Thank you. Gareth.

I completely agree with what you said then, Helen. I think about how we manage this workforce and get people—you know, nurses—being able to specialise in certain interests that they want to do. I think we've got to value nursing and all professions and award them some autonomy to be able to specialise in some of these interests, and that goes in terms of providing a holistic experience for staff members. I worked in the NHS for 11 years, and I think people feel a little bit disillusioned sometimes, because they work their trade for three years, and then they have to fall in line with some sort of synchronised system. But getting people to realise that there's some autonomy can actually develop people further in some of those goals that you mentioned. I'm just wondering, really, what your opinion is on that and whether we can look at maybe getting those words into action, really. Because I think, over COVID-19 and a lot of the pressures, people do feel a bit disillusioned and a little bit low in morale. So, I think to boost that, we really need to present some of these things to some of the professionals to get them on board, really and—

Helen, just a small answer on that, unfortunately, because we're tight for time.

Okay. I think it's a very good question. So, 'career opportunities' would be my short answer on that. Look at paramedics, they are now moving from band 5 to band 6. Look at midwives, they're going from band 5 to band 6. What happens in nursing? You can be a band 5 for your whole career. So, career opportunities, not because they're just good for nursing, but because they're good for patient care. So, looking at areas where we know we want nurses to mature their autonomy, as you quite rightly said. 'Agenda for Change' lets us do that. There are opportunities; we need to seize them, and that's currently not happening. That would make a big difference to the nursing workforce.

Have you asked all your questions you want to cover?

In that sense, with 'Agenda for Change', there's also a glass ceiling as well, so the disillusionment comes in—you know, how the top of band 5 would possibly get more money than the bottom of band 6. So, in terms of tackling that incentive and looking at ways in which we can reward—and I don't think it's just about pay; I think it's just about job satisfaction, really, and looking at how people can feel rewarded in their career—it's not just monetary wise, but in terms of morale and expanding that profession into something that can be holistically provided, into something that's beneficial for patients and indeed themselves as well.

That's right. The issue with 5 to 6, we managed to sort that out in 2018; there's now a larger gap. But look what we're doing with pharmacies; my colleague was just saying about pharmacists coming out prescriber-ready. Now, there will be a programme there for pharmacists to go through a Master's level education in order to arrive at being prescribing. That opportunity is not being provided for nursing. So, that's the sort of investment that I'm talking about, so that—. Yes, there'll be some people that want to be a staff nurse—that's right and proper—but there'll be others that want to be a consultant breast-care nurse, or they want to be an advanced practitioner in primary care. At the moment, those people do it, if they're lucky, part-funded by their employer, but, predominantly, they fund it themselves. Those are careers that we need for the service, which are also good for the profession. I think that's what you're driving at, that sort of opportunity—it's not a given, but it is an opportunity there and presented. And we do it for other professions; we really do need to embrace that for nursing as well.

Thank you. Mike Hedges.

Both of us put me off mute at the same time then.

I'm glad Julian Tudor Hart and the inverse care law were mentioned earlier. It's something I feel very keen on promoting and trying to do something about. Is it any surprise that people who are hungry, who live in very poor housing that is cold and damp are more likely to become ill, and shouldn't we be doing more to deal with the causes of ill health, rather than just dealing with the symptoms?

Peter Saul.

Thank you very much. So, there is something happening here. In Scotland, there's a project called 'Deep End', which was started based on some of the work of Julian Tudor Hart, who was a GP who identified that the people most in need are least likely to get the care, whilst the opposite is true. And so this project—as a college, we're in discussions with Welsh Government about starting a project in Wales where we're trying to identify practices that are in the most deprived areas, with a view to networking them and to develop solutions from the ground up to help them deal better with patients who are most at need. And as I say, we're hoping to get something started in the next six months on this. So, it is an area that we recognise is very important and, in actual fact, the pandemic has highlighted this, I think, in the sense that, as I was hinting at before, it's the more vociferous middle-class patients who are the ones who are asking about delays, and not the ones most in need necessarily. So, as a college, we are working with Welsh Government to move on some aspects of this.

Can I thank you for that answer? Julian Tudor Hart, or the late Julian Tudor Hart, was a friend of mine, and, of course, he spent all of his career in the Afan valley, above Port Talbot.

The other question I've got, which really leads off what you've just said—we keep talking about digital GP appointments. I think they're wonderful for me, and I think that most people in this room would welcome them as well. There are a lot of people who don't have the access to the equipment, the digital skill, or the ability to be able to deal with things over a digital platform. They tend to be older, they tend to be poorer. How we are going to manage to not have a two-tier system, where the people in this room get an excellent service, we get a digital GP, and the people who can't get a digital GP are at a huge disadvantage?

Shall I take that one to start with? Yes, that's a really interesting question, thank you. It's been a big learning curve for me too to get to grips with this new environment, and I think some of it is going to stay; we're going to see—. Because, as you say, digital suits a lot of people. But I think that it comes down to training of health professionals, GPs, nurses, pharmacists, in how to use this properly and who to use it with. I think, increasingly, I'm seeing, as we get more experience, a recognition that, with individual people, it's not going to work, so we have to switch to face-to-face or home visits. Yes, we're still doing home visits. Probably about 50 or 60 per cent of consultations are now face to face, and it's definitely appropriate for many people. So, I get a list of patients; if I see somebody who I'm thinking, 'It's not going to work digitally with that one', I'll say to the receptionist, 'Just give them a ring and tell them to come up', and I think, increasingly, as we get more experience, that is the way it's going to be. And yes, our belief is that everybody who needs face to face should have one, and we're doing our best to achieve that.

Let me just finish on this—my GP practice does home visits, but I could take you to some GP practices in Swansea that don't.

Yes. It's difficult to know about individual circumstances, but as a college we think that it's difficult to understand a practice that would not be doing any home visits, because it's not just in terms of diagnosing the patient, but it's amazing what you can learn on a home visit and going and seeing somebody in their own house. It's like everything clicks, and you can understand, when you see how they're living, why they're coming to see you every week, and things like that.

Thank you.

Thank you. Joyce Watson.

I just want to add into the mix, if you like, the wider population who might not actually push for an appointment. We understand, of course, that those people who don't understand the system aren't able to push, but I'm just wondering whether there's an age profile here, because older people don't like to bother, don't like to be a nuisance. Some people might have mental health issues, so they become incapacitated in other ways in terms of testing the system. So, I'd just like to hear a little bit of detail, if there is detail—I suppose that's the question—about the wider aspects of people who don't actually push, beyond those people who might be middle class.

It's similar to an earlier question, I think. Elen Jones.

Yes, I think that's where the opportune moments, particularly within community pharmacy, are really important. As a community pharmacist—and I'm a community pharmacist by background, just to share that—you do build that rapport with patients and you get to know them very well, and you start to take note when there are changes in personality or in appearance, and in the obvious ways that they are presenting to you in the community pharmacy. So, I think it is really vital that we harness that as much as we can, and it goes back to ensuring that community pharmacy teams can make those referrals, can actually step in and have appropriate services to be able to support patients in their local communities. Also, community pharmacies do try and ensure that they've got appropriate leaflets and signposting in languages that are useful for their local populations, so we do need to really make sure that we're harnessing all the information that we're getting from those opportune moments and people trying to manage and self-care, which often is the right thing to do, but sometimes we have to step in and make sure that they're getting the additional services that they need.

Thank you. Thank you, Elen. Rhun ap Iorwerth.

Thank you very much. If I could look, in closing this session, at some quite general issues around the COVID-19 recovery programme that has been prepared by Government—I may be rehearsing some of these issues, but if I could put it in that context. First of all, on staffing, and I know, Elen, that you said, very clearly,

'we can't simply keep asking an already stretched workforce to do more',

but for the rest of you, perhaps, are the Government's recovery plans, as they currently stand, able to be delivered in a way that isn't going to put unsustainable pressure on staff? Who's going to start?

Helen.

Thank you for that question. I think the honest answer to that is 'no', particularly with the number of staff vacancies that we've got. It is the staff that will be required to deliver, and that's why they go to work, because that's what they want to do, but I don't believe that we are going to achieve as much as the Government has set out to do with our current staffing issues that we've currently got. Look at the new services that we've needed to implement—the vaccination programme's a great one, of which I think we should all be very proud, but we've had to move staff from elsewhere in order to do that.

I do think we're being creative. I work as a vaccinator; I've worked alongside pharmacy staff who are being trained to be able to deliver the vaccine in the pharmacies, but that all takes time. I said earlier: 1,719 registered nurse vacancies; that's a big impediment in order to deliver the plans that the Government have put out.

You succeeded in demonstrating that figure in a very public way across Wales in a campaign just this week, and we all took note of that. To the rest of you, then—Elen.

Yes, I think it can be difficult, as we've mentioned, to work in a flexible manner, but if we do start to think about how we can enable that, then perhaps it will increase the number who want to come back to work in health. So, although it is something that is difficult, I do think it's crucial to ensure that the figures across the board increase in terms of the numbers we have working on a daily basis. So, I do think that that flexibility is important, and being able to provide care for those caring for others is also very important to us.

Thank you. Judy Thomas.

Also, Rhun, Peter Saul wanted to come in as well. So, Judy then Peter. There we are.

I suppose, just picking up from what Elen was saying, and also Helen, we also have some significant workforce shortages across community pharmacy and across the wider pharmacy workforce, which have reduced the service that some pharmacies have been able to provide over the last few months, I suppose exacerbated by COVID and the need to self-isolate at different times, which has obviously impeded on our workforce. We're working with Health Education and Improvement Wales and others in terms of a new 'Train. Work. Live' campaign to try and encourage more pharmacists into Wales, and also working on our new contract as well, which we hope will interest people to stay within community pharmacy going forward.

So, I suppose those are longer-term steps of where we need to get to, which does have some impact on short term, but pharmacies have stepped up massively over the last few months. We've delivered twice as many flu vaccines this year as we did in 2019-20. So, we've doubled the flu vaccinations in just a two-year period, and we're only mid way through November, so we've still got quite a large amount to go. So, pharmacies are still delivering. So, despite the workforce shortages, we are still managing to deliver as much as we can.

I can promise you that that additional work you're doing is being appreciated. And if I could turn to Peter Saul.

Thank you. Diolch. I totally agree with Helen about the answer to your original question, which is also 'no' from me. I think we're looking at a recovery of several years—five years, maybe. We need to build up the teams that we've all heard about, multidisciplinary teams, upskilling colleagues in the health service, and that's going to take time. I've mentioned estates. We need better training in primary care situations to upskill these people. So, we need to support more education in primary care.

I'd just like to throw in another thing, and that is—. We're fortunate in GP land, because we've had an increase from about 136 GP training posts a year, five years ago, to 200. It probably still isn't enough. But we get people—and this doesn't just apply to GPs; it applies to other trained health professionals—leaving Wales, and I think one of the things that we need to do as a society is actually to encourage young people who are living in Wales to train in Wales for these jobs, to value them, because we know that if somebody from a community in Wales trains as a doctor, as a physiotherapist or as a nurse or whatever, they're much more likely to stay in that community than if we're training people from outside Wales who will return to their own areas.

Absolutely. Helen was able to give us, of course, a very detailed assessment—a number of nurse shortages she believes there is. What's your current assessment of the shortage of actual full-time equivalent GPs we have currently?

Yes. I haven't got a figure, but I'm judging it on the number of health board-run practices—health board-run practices because GPs have not been able to fill vacancies and they're having to give back the contract to the health board. I think we're probably—. Of 2,000 GPs in Wales, we're probably between 10 and 20 per cent down on that shortage at current times.

I think that shouts 'unsustainable' at us, doesn't it? And then, to the other question I wanted to ask, again looking at the COVID recovery plan in general, do you have confidence that the COVID recovery plan that we have in front of us now—it might change, but looking at what we have now—does that give you a confidence that it can deliver in terms of the focus of our inquiry here for those patients that are on the waiting lists?

I think it will deliver for some of them, but we've identified perhaps people in deprived areas who are less vociferous, who have less access, and I think there may be difficulties there. And I think the timescale is going to be longer than stated.

Is there enough of a focus on those people on waiting lists?

I don't think so. I know it because of the difficulties that it poses in primary care, and I also know it because of the number of people who every week talk to me and are worried about their waiting times.

Do you have that confidence, Helen?

I think it's very similar to what Dr Saul was saying. The nurses that I speak to tell me that patients are worried about how long they're having to wait. They also talk about the ones that deteriorate and actually never get to have those procedures, because their health is so badly affected it doesn't become appropriate for the procedure to happen.

I think the points made by my colleagues, Judy and Elen, as well, though, about how the staff are doing amazing things, because that's what they do, and that speaks right across all of the professions. So, it's not for a want of will on the basis of the staff. I think they are doing the absolute best that they can. But we also have to accept that that is causing burn-out in some of them, too.

So, I think it's going to be a real challenge to try and get back on track with the waiting lists in the time that is stated, and I do believe there is something to be done about the people who are on those lists to go back and reassess, reprioritise, to make sure that we get the prioritisation right, because what you also see, then, is people arriving at A&E departments, becoming really ill, and then the list all changes around because of those clinical priorities. We haven't really got a handle on how to manage those clinical priorities at the current time, in my view.

Yes. Elen.

Just to support Helen there, at the Royal Pharmaceutical Society, we undertake an annual survey of our members for mental health and well-being, and this year's figures show that around 89 per cent are at risk of burn-out. So, we are very concerned, going forward, about how we support the workforce, who are already so stretched.

That's very useful. And on that question that I asked in terms of your faith in the recovery plan that we have in front of us, that it does have the kind of focus that we want on supporting people on waiting times throughout the planned care, what do you think?

I think one of my main concerns is that we are not out of the woods when it comes to COVID, and we can see from the figures at the moment that the workforce is still having to manage people who are ill with COVID as well as trying to balance those who are on waiting lists, as well as the normal day-to-day activity. It is a lot to ask all professional groups to do.

Judy, do you have thoughts on that?

Yes. Really, just to support what Elen has said. Talking about recovery isn't necessarily always the focus, depending on what the current COVID levels are in any particular locality in Wales. It is, as I said, impacting on quite a large number of our contractors in terms of the number of staff that they have then self-isolating at any one point, either due to their own illness or other members of their families as well.

One last question, maybe to Dr Saul: given that we would like to keep as many people off the waiting lists as possible at this current time, is it time now, through the COVID recovery plan, to put a little bit more of a focus on the preventative as well?

Yes. I think that's been put on the back burner, for obvious reasons, but we need to get it more onto the front burner. Another thing is actually to make sure that primary care is supported to do everything that it can do. For example, in some areas, it's difficult to organise scans and investigations, which, in others, you can do from primary care and it can divert somebody from secondary care if you can get everything done in a primary care environment. So, we need to maximise that. And yes, I do agree, we need to get back onto the prevention.

Thank you, Chair.

Thank you. There are a few final questions to finish. I've got a couple myself as well, but Gareth and Jack want to come in, so just briefly, if you can. Gareth first.

Thank you very much, Chair. Just on that point, you were talking about different professions and things, in my experience of the NHS, there's a lot of cross-over work, you know, I worked in physiotherapy before being elected and what we tended to do, with time issues, we'd conduct things like personal care in order to enhance their physiotherapy experience, because it was a time-sensitive thing. So, in that sense of cross-working, talking about multidisciplinary teams in the NHS, do you think, going forward, in terms of how we tackle some of these issues, is it either—do we work in silos? Do we say, 'I'm a nurse', 'I'm a physio', 'I'm an occupational therapist', 'I do this, this and this'? Or, do we look at pooling those professions a little bit more to suit the needs of the demand? Because I think—

Okay. Jack, do you want to come in on your question, and then I'll ask the witnesses to come in on both questions?

Yes, thank you, Chair. It's very simple, really. Rhun asked a very good question on confidence in the COVID recovery plan and I think we can take from the answers that there's not particularly confidence there. So, what would give you confidence? What would turn your opinion to say, 'Right. I'm confident in the delivery of this plan'?

Okay. Who wants to address either point?

I don't mind.

Helen, do you want to come in on Gareth's point?

Yes, happy to do that. I think it's a long debate we could have about the specialist/generic-type practitioner. For me, I think there's something about both; there are certain things where generic practice across professions is very helpful, but then, you do need specialist professions to do what those professions do well. And we could spend a whole afternoon just discussing that, but, again, I think that's something HEIW should be thinking about in terms of the wider package of commissioning of education.

And in terms of having confidence in plans moving forward, I think we have to have a degree of confidence that our staff are doing the best that they can, and I absolutely do believe that they are because I see that every day. And I think what they're saying they need, it is about the staff and resource underneath. So, to have confidence in delivering that plan, we need to be able to understand how to (1) staff it, (2) manage the expectations of the people on the waiting lists, and (3) then, don't just go into an analogy where everybody goes on the waiting list and they have to wait until they get to the actual point that they can be seen in secondary care. I think that's part of the discussion we've had this afternoon. We have to keep going back to that waiting list and refreshing, 'Have we got the priorities right? Do we still need those people on it? Can they go into other areas?' That's the kind of label of prudent healthcare that I've seen and I've experienced, and I think that's most helpful to revisit that.

Okay. Anybody else want to come in on either point? Dr Saul.

I'll just briefly say that we need to engage with the public better, be open and plan—open and honest on what is achievable. And, also, the role that individual citizens can take to help matters and look after themselves and use the service most effectively.

And can I just pick up a couple of questions as well? In terms of—. I'm just concerned about the mental health backlog in terms of waiting lists in that regard. There's a concern, of course, about those that are on waiting lists then needing greater emergency support and people being bounced between service to service as well. And I wonder what the implications are, you think, of having to wait to access mental health services, and how that demand capacity can be better managed, and also whether there is sufficient capacity within local primary care mental health support services. Perhaps it's a big question for not much time we've got left in the meeting, but I wonder if anyone can address those points. Peter Saul.

It's resulted in probably more prescribing of drugs when other methods may have been maybe more appropriate because GPs and their teams probably feel—well, we do feel—a bit helpless. But there are answers: increased rolling out of online services for the right sorts of people, and increased basing of mental health workers in primary care teams, I think, are the ways to address this.

Thank you. Anybody else want to come in on that point? Judy. Judy Thomas.

Yes, again in Hywel Dda, we have a small pilot in one of the clusters, looking at how community pharmacy can help to support low-level mental health needs in terms of providing support on a regular basis, and also then giving them the opportunity to be escalated into GP practices if needed, to try to stop necessarily the kind of automatic medicalisation as well of patients. So, that's very early days in terms of that pilot, but that kind of gives opportunities for community pharmacy in the future to support in a different way by providing our teams with some mental health first aid training as well, so that they're quick to notice issues with patients and able to support them better in their local communities.

And, in terms of Peter Saul's answer there, is there any concern about those that might be dependent on medication, not just perhaps anti-depressants, but thinking of pain support as well? I would widen the question out really, but in terms of people being on longer waiting lists, that there's a concern about those that are on medication longer perhaps than they should be.

Absolutely, yes, because we know that it's not good to be on opiates, and that would include codeine medication. And it's a decision that—. I have this, again probably every week—somebody on a waiting list because of, typically, musculoskeletal pain, and they're saying, 'Look, these tablets aren't working', and then I'm thinking 'Do we move them up to opiates, to stronger medication?' I'm thinking what are the long-term implications of that, given that they may be on these for a year, two years, or even longer. And then, you've got the potential harms of using stronger medications. So, it's a question I haven't got an answer for, but I acknowledge it's a serious point.

Okay. Lovely. Thank you, Peter Saul, for that. Are there any other comments from witnesses, before we wrap up the session today, on anything that's been said? No. Thank you. Is that a hand up, Helen, or not?

No.

No. Lovely. In that case, can I thank you ever so much for your time this morning? Thank you for your written evidence in terms of our inquiry over the summer, which was invaluable for this piece of work, but other work we're looking at as well. In the private meeting at the beginning, Peter Saul, you mentioned it was your last day today, in terms of your joint chairship, so I'd like to wish you well for the future in that regard as well. But we will send a transcript of the proceedings around to you as witnesses, and, if there's anything you want to add to what's been said today, please do contact the clerking team, and we'll make sure that's included as well. But, diolch yn fawr, thank you very much for your time this morning.

We'll take an eight-minute break, and be back just before 11 o'clock, if we can. Thank you.

Croeso, bawb; welcome back. We move to item 3, and this is in regard to our work on the impact of the waiting times backlog on people who are waiting for diagnosis or treatment. We've got an evidence session. This is the second panel today and this panel is in regard to mental health and psychological support organisations. We've got two witnesses with us this morning to give evidence. I'd be grateful if you could introduce yourselves for the public record.

Hi everyone, I'm Professor Euan Hails and I'm here from Adferiad Recovery. I'm their director of clinical and therapeutic governance. They thought it would be useful if I attended because I also work for one of the local health boards.

Bore da, bawb. I'm Simon Jones. I am head of policy and campaigns at Mind Cymru.

Thank you ever so much to you both for being with us. I appreciate that. The first set of questions is from Rhun ap Iorwerth.

Thank you very much and good morning. Thank you for joining us today. My first question is quite general: what are your views on the services that we have in place to support the mental health and well-being of people who are awaiting treatment who, perhaps, are in great pain and feeling depressed or anxious or have some other mental health problem?

Who would like to take that question?

I don't mind starting.

Simon Jones.

Thank you very much for the question, Rhun.

Contextually, people with long-term conditions or who are experiencing great pain are something like two times more likely to experience poor mental health, so it goes right to the heart of the question about parity between physical and mental health—how are we ensuring that when somebody’s treated for one, they’re treated for both as well. And it goes the other way, in terms of if you have a mental health problem, you’re more likely to experience some physical health conditions as well.

It’s certainly not an area of expertise in terms of Mind Cymru, but the discussions that we’ve had with a number of physical health charities such as Versus Arthritis and Diabetes UK Cymru is that it’s very patchy in terms of the support that’s given. There is some support, certainly for diabetes, that is given once the condition’s been established, but there’s not a huge amount that’s given whilst people are waiting. Obviously, people are waiting in great discomfort. Anything that can alter your self-perception or your self-esteem, if you can’t be doing the things that you used to be able to do, can have a significant impact on your mental health. It might not make you mentally ill, but, certainly for a period of time, it can create a huge amount of distress, and ensuring that support is there during that period is crucial.

I would have thought that the situation would be that if people do start to experience some kind of mental distress as well, the GP or whoever had referred them would be able to refer them to a mental health support-type service. Obviously, we’ll probably come on later to the pressure on those types of services as well, but I think the actual support that’s given to people whilst they wait for physical health conditions is probably very varied and quite limited as well, unless they come forward themselves and identify, 'I'm worried' or 'It’s impacting me in this particular way'.

Thank you for that. Can I just pick you up on one thing that you said? You said that we know that there’s a link between chronic pain causing anxiety and deepening mental health issues. Do we know enough about it? Is there room for more work on that to try to understand that more, because this is becoming more of an issue with extended waiting times?

I would say it's always worth speaking to people and finding out what their experiences are, because people’s experiences will be completely different as well, in terms of the resilience that they have, the community support they have, their own experience with mental health or with their own conditions. So, I would never suggest there’s enough research or enough knowledge out there, because I think it’s always worth speaking to people that are in those situations to find out what would help them the most. I think it was the Mental Health Foundation—I know Mind was involved—that did some work in England. The report was called 'Ask How I Am' and actually looked at the experiences of people with long-term conditions and mental health problems, and what would help them as well. So, there is work that’s been done out there. Obviously, that’s England focused, but we can probably draw some lessons and some principles in terms of how we can support people going forward.

Thank you very much, Simon. I think it's important that we get the views of both witnesses on this most fundamental question on services in general.

Again, I agree with what Simon’s saying, really, if you look at the length that people are waiting for any form of investigation, be it physical or be it psychological. To an extent, the support that is available, from a physical perspective but not from a psychological perspective and vice versa—I think that there is a need to actually focus on the correlation between what’s actually occurring and the length of time it’s going on for. There is a link between physical pain and, I suppose, anxiety and depression and other psychological problems, and there are therapies out there that can treat those. So, I think anything that can be done within the domain of that catchment would be a sensible and a useful thing to do. Lots of health boards now do employ psychologists within these sorts of situations, and the psychologists do offer psychological support.

If you think of care from tier 0 up to tier 4, there are things that people can access, but the only way they can access them is if they actually know that they're there, so you need an informed GP or someone who could point them in the direction of things like SilverCloud and the like, really. So, I think there is a fair bit of development that could be done there, and I think, if you introduced low-level psychological support to this population, you'd probably improve the physical condition, because the research shows that you will, but you'd also definitely improve their psychological condition.

And then I think, if you consider the social isolation, the loss that the family are dealing with and coping with, and then you've also got the worries for the future if you're working with someone with a terminal condition as well, really, there are lots of areas that we could be intervening in. And, again, as Simon says, often the population doesn't hit the threshold for mental health services, but there should be something there that they'd be hitting. And if you think about some of the work that's been done with child and adolescent services and if you look at the focus on the missing middle, I think that's probably what we're talking about here, really: developing services within those domains. I'm not sure if that answered your question, but—.

Yes, it's very, very useful. We've talked in an earlier session this morning about the need to make sure that prioritisation is as good as it can be within those waiting lists. Do you think, both of you, that there might be a case for considering something along the lines of psychological distress or something, when it comes to prioritisation of patients on waiting lists?

That's a very good point. I suppose a pertinent example now is that I'm relatively nervous being here, and I do theoretically know what I'm talking about because someone's called me a professor, and, if I'm nervous speaking to yourselves, imagine when you're going to a consultant or a medic to talk about a life-changing or life-threatening condition. One of the things that we don't often consider is the nerve of the person fronting up to speak to the medic, and, at the moment, they're not allowed to take their partner in with them, they've got to go in on their own and they probably forget what they want to ask and what they're talking about. So, I think any form of psychological support during that would be useful, certainly from the point of view of training for medics, training for junior doctors et cetera. It would be a win-win situation, really. So, yes, I think so.

And also, I think, if you consider mental health services working alongside physical health services, it does happen, to an extent, if someone's got a mental health problem and a physical health problem, but it doesn't sort of happen if someone's just got a physical health problem. As Simon says, someone needs to think, 'Oh, what about the psychological distress, maybe I should ask about that.' And unless they think about it and the person's brave enough to actually say, 'Well, I'm feeling a little depressed, this is miserable, what can I do?' you're probably correct in saying that not much will be done.

I think, just to build on Euan's point, we still know that, despite all the work that's been done around stigma, around mental health, people still are reluctant to come forward and talk openly about their mental health. And often, people will be presenting at a GP with a physical health problem, but the underlying problem may well be a mental health problem. So, that barrier is still there, even if—. And the physical health condition may well be easier to find a treatment for, in terms of, 'You need to go here for that', rather than, then, looking at, 'Well, how are you coping with that?', 'What support networks do you have within your family?', 'Do you need some extra support?' That comes, as I say, right to the core of that parity question: when we're asking somebody about their physical health, are we also asking them about their mental health and then what can be drawn in to help that person whilst they're either waiting for treatment or while they're just managing their condition full stop? Because that diagnosis can have a dual effect of relieving somebody, because they've got something to identify with and they know what's happening to them, or be quite a crushing moment—they realise that their life may well be changing and they don't know how to control it. So, it's a really important moment when that first diagnosis comes in.

Yes, absolutely. The question I'm asking here, though, is about whether we should go further than that and not just give them help with how to deal with the fact that they're on the waiting list, but is there a case for saying, well, because of the distress they're under, they should be given higher priority. You might have two people in pain waiting for the same kind of operation, one of them is dealing, if you like, significantly better than the other, and the distress caused to one of them is making them ill, physically and mentally, in other ways. Should they be prioritised? Is there an argument for that?

Yes, there probably is, but, again, you'd have to notice and someone would have to spot the distress to be able to ramp up the idea of care. And, again, something else that I was thinking about was, if you do have a life-altering condition, you would be visited by community nurses et cetera at home, you would have been visited by a community psychiatric nurse at home. A lot of that doesn't happen so much now, and a lot of the psychological support these people get would be from the nursing visit—changing a dressing, talking to them and asking how they're doing et cetera—and elements of that don't occur at the moment. I think allocating care by a level of distress pertinent to the person who is presenting in front of you would be a sensible way to go, and there are ways you can identify that, and there are scales that can identify that. I think we just need to consider using these things as part of 'normal' practice, to an extent, and if the consultant or the person who is doing the consultation had the ability to ask three or four relatively simple questions about the person's distress, about their mood, about their low mood, about their physical abilities, about their memory et cetera, then that would then give them the opinion or the idea that, 'Yes, maybe this person needs something slightly more than we're offering,' and then certainly to introduce the psychological support would be quite an easy thing to do. So, yes, I think what you're saying is correct.

Can I ask one question? I'm not looking for long answers on this, and I declare an interest as a co-chair of the long COVID cross-party group in the Senedd. Do you think—? I see some really distressed people who were previously healthy and who are suffering from some quite deep depression because of their long COVID. Has enough focus been given to the effect of long COVID on mental health? Are you aware of any work being done on that?

Ooh, now that's a very good question. And I would probably argue that that would be state-of-the-art research, because, basically, it's something that's occurring now. So, you can bet your bottom dollar that quite a few academics are sitting in institutions thinking, 'We should be doing something about this,' and consultants dealing with this sort of population are probably sitting there feeling, 'Yes, we should be doing something about this.' I think, as it's so new, probably not as much—. If it was something we expected, obviously, we could have had the forethought. Without the forethought, I think it's difficult to actually do what you're are saying, but it's certainly an area of need. If you look at some of the effects on people with long COVID, be they physical or psychological, they're a huge change to people's abilities and people's lives, so, yes, I think what you're saying, again, is sensible. Any form of research into those areas would be useful, and, again, there is correlation between delivery of certain psychological interventions and pain, delivery of certain psychological interventions and loss et cetera. If you can enable the person to get the physical care, but also the psychological care, the logical conclusion would be that both would improve. So, yes, I think you're correct again.

Simon, do you have any thoughts on that, quickly?

Yes. I'd agree with Euan on that. I think it's also important to consider the effect it has on family members and carers, which can often be forgotten, if suddenly they're caring for somebody who was healthy and is now struggling to a certain extent. Sometimes, we don't look beyond the person that has the mental health problem or that has the physical health problem to the wider community, and that has a huge impact on people's lives, if they suddenly become a carer, or the person, the member of their family, has changed significantly, not physically, but mentally as well, in terms of how they're emotionally coping with it. So, that's probably the only thing that I'd add is that, beyond long COVID or whatever physical health condition, there's probably a need to consider how family members can be supported, and that could be as easy as information about the condition, about their own mental health, where they can seek help—it doesn't have to be an expensive, intervention-type service; it can actually be just signposting to where—and that some of these emotions that they may well feel are perfectly normal and natural. And I think that's really important, that we don't end up medicalising people's distress and just trauma that people are experiencing; we recognise it, acknowledge it and seek to actually provide people with the support to either manage that or to move beyond it.

Diolch yn fawr iawn.

I think—. Just quickly adding to what Simon was saying, I think the problem also is the societal perception of what long COVID actually is or isn't, because there are a number of people out there who (a) don't believe that COVID exists, and (b) certainly don't believe that long COVID exists, and you've got someone who's fronting up to a GP because they're in discomfort because they've had COVID and then someone else is saying, 'Well, COVID doesn't exist.' There's going to be a huge psychological impact there as well, really. So, I think it's a condition that will only—probably more people will get it. But I think if you can intervene into it and you can offer some form of psychoeducation for the public—which is being done—it won't feel as stigmatising and as difficult and people won't be questioning, 'Well, do I actually really have anything, or am I just maligning?' or whatever. So, again, it's so new that people just don't believe it's there.

Thank you. Gareth Davies.

Thank you very much, Chair, and thank you for the evidence that you've given so far. In terms of how mental health support is proactively given to patients, what's the content of that? Because I used to work in community mental health teams, and I had a very sad case in 2015, when one of my patients unfortunately committed suicide and it went to a coroner's inquest and things, and one of the coroner's recommendations was that the health boards assess patients between services, so, essentially, if they come from home treatment teams to CMHTs, or whenever they're transferred, there's a reassessment of their mental condition on transfer. I'm just wondering if there's any progress on that, really, and whether psychiatrists and professionals are acting upon that. So, if a patient comes from an acute setting to a community setting, are they reassessed on presenting themselves to community?

I've worked in community mental health centres from both an adult perspective and a child perspective for many, many years, really, and in assertive outreach teams and in crisis teams et cetera. You would argue that, if you've got an internal transfer of care from an acute ward to an out-patient facility or CMHT, that, yes, the person should be reassessed when they actually go into the community, but you would also argue that the community should be involved when they're actually on the acute unit. And if you think about care and treatment planning, it's designed that way. You would have a pre-discharge meeting, where all the relevant people are invited; you would have your care co-ordinator there who would be working on assessing the person, and, once they go out to the new service, they would see the consultant, they would see their care co-ordinator, an assessment would be conducted and a new care plan, to an extent, would be developed and planned, really. I think that is—. It's difficult to say if that's becoming normal practice, because, again, I don't work in a community mental health centre any more; that was a number of years ago. But again, certainly looking into delivery of care to young people who come through CAMHS, one of the complaints we have is that, 'You're assessing me again and again', and, often, unnecessary assessments are annoying, but if you've got someone who is coming into your service for the first time from a different service, then, yes, you should assess them and then you should develop a care plan that is pertinent and fitted to them. I suppose the idea, in a way, is that you co-produce it with them, and then all their future care basically hangs on that, really.

So, yes, it should be. And you can understand one—. Many, many years ago, when they introduced the care programme approach in England, you had the Christopher Clunis incident in which, basically, he went into a service, he wasn't assessed, there wasn't a history given, they didn't know what was going on. And the results were somewhat catastrophic, really. So, yes, you should be reassessed when you actually enter into a service. If you're in a service and you're referred for psychological interventions, you should have an assessment for psychological interventions, but you shouldn't have a reassessment for your core needs and things. So, it would be pertinent to what you're getting. But coming into a service, yes, I think you should. Simon.

Yes, I think there is a wider issue here around care and treatment planning. If somebody is being discharged from an in-patient setting, they should have some form of care and treatment plan. We know that most people do. I think there was a report 18 months, a couple of years ago, maybe, that the quality of those maybe wasn't where we wanted them to be, in terms of—. I think Euan makes a really important point around people being involved in their care planning as well, so that they know what to do, maybe, if their mental health starts to deteriorate—who to contact, what their triggers are, the fact that, if you are subject to in-patient or secondary care, under the Mental Health (Wales) Measure 2010, you can re-refer back into secondary care; you don't have to go back to your GP. There are some really important things that people need to be aware of, so that they can identify early on where they can go and seek support.

So, I think it's acknowledged there's a way to go on care and treatment planning; it's a good concept, and people have them, but actually—and obviously the care and treatment plan goes beyond the health setting as well; it looks at your education, your work and all those other bits, as you well know, that can actually be protective factors for your mental health. So, I think there's certainly something there. I think the point about reassessment is one that Euan makes well. I think there is that need to ensure that we're not just assessing people, and people are telling their story time and time again to multiple different professionals, but that assessment is shaped towards what information is needed rather than dragging it all back through, because I think that creates distress and upset for people, because they feel they're having to tell their story multiple times—'Why haven't you heard this already? Why don't you know what my needs are?' So, I think there are things we need to look at, certainly.

And I think it's interesting as well, if you look at the development of the statutory care plan and the development of the measure itself, I think both Hafal and Mind were quite actively involved in that, and again, it's an example of third sector organisations working with the Government, working with health boards, to develop something that's really rather useful. And as Simon says, if it's used as it should be, it covers virtually all aspects of the person's life, and you develop a pretty tight care plan in every area that the person will be presenting with, and the needs that they have, really. I think not to do an assessment would be erroneous, and I don't think you could defend that, really.

That's a really helpful answer, thanks for that. Just to move on from that, really, in terms of looking at psychological therapies, it's long been believed amongst patients and some wings of the mental health professions that, often, medication isn't seen as the best answer, and it's talking therapies and psychological therapies, cognitive behavioural therapy, that sort of thing. I'm just wondering what sort of progress is being made on that in terms of funding it and getting the staff to facilitate some of those needs, because we're often plunged into taking medication, that's seen as the answer, but I think sometimes those talking services—obviously, Simon will know—are sometimes the best therapy, and whether the health boards are facilitating those needs at the moment.

Shall I answer that? I am an accredited cognitive behavioural psychotherapist, and I do deliver psychotherapy and eye movement desensitisation and one or two other therapies, really. Yes, the therapies are being delivered. I think one of the problems we've got in Wales, which is an historical problem—and I don't want to go over old issues—is that we didn't have the Adult Improving Access to Psychological Therapies programme that they did have in England. Maybe we shouldn't be talking about that here, but England did pump a lot of money into the development of psychological interventions, and we can certainly say whether or not that was successful or that wasn't successful.

I think what we did in Wales, which was probably more developed than what they did in England, we developed our policy implementation guide. We've now developed the Welsh matrix and we're basically saying what should be delivered, at what level, and to what condition of people that are coming in. Health boards historically struggle in Wales to appoint people with a level of psychological therapies training, and that's an historical thing. We do have many psychologists, we do have a number of nurse therapists, et cetera, et cetera, but I do think that, from a psychological therapies perspective, because one of the deliveries is psychological therapies, we should probably have more people on the ground.

An aside to that is most of the health boards and certainly Hafal and now Adferiad have developed their own psychological therapy programmes. I developed a training programme for CAMHS nurses to teach them how to do psychological interventions. I used to run courses at the Institute of Psychiatry, Psychology and Neuroscience training nurses how to do psychosocial interventions or CBT, and we trained a lot of people. So, what we're trying to focus on now is developing levels of psychological skill. So, we have the 45 levels in the matrix, so the idea is we'll have community nurses, community occupational therapists, et cetera, who can deliver a psychological intervention all the way up to a psychologist or psychotherapist who can deliver level 5, level 4 psychological therapies.

So, I think more is being done, and I think health boards and, certainly, Adferiad—Mind I can't talk for—have focused on this quite a lot. We developed a programme called 'Let's Talk!' that was funded by the National Lottery, and the idea of that was that we developed and introduced people to psychological therapies training, we clued up GPs about what was available out there, and we enabled people to access things. We've also developed a really quite innovative waiting list focus with Betsi, whereby we offer up to six sessions of counselling while people are waiting for psychological therapies. We've developed a similar programme with Cardiff whereby people waiting in CAMHS for psychological therapy or for CAMHS intervention are offered a resilience programme that we provide, and we've trained up community psychiatric nurses and others to provide this.

I do apologise. We want detailed answers, but we've got more questions to get through than we've got time, unfortunately. I'm ever so sorry.

I could go on forever about psychological therapies, sorry.

Not at all. I'll just ask the witnesses—

I do apologise.

No, not at all. Can I just ask the witnesses to lean forward if you're speaking a bit, just so that we can pick up on the mike as well? Some on the Zoom were saying that it was a bit difficult to pick up, listening to the witnesses. Are there any further questions, Gareth, ever so briefly if you can?

Yes, I've just got one last one on time and real sense. You know, for a real-life example, if I become ill today, I present to a mental health service, what sort of pathway would I experience and what time would I get to see a psychiatrist, get a support worker, get a care co-ordinator? What would those time frames be in terms of where we are today, if you like?

Who would like to touch on that, briefly?

Yes. The target, if you presented to a GP and you were looking to access local primary mental health support services and you had a mild to moderate mental health condition, it would be 28 days from referral to assessment, and then 28 days from assessment to treatment if you're looking at accessing a specialist. If you needed more intensive help, so specialist psychological therapy, the target would be 26 weeks, which is six months, which, from our perspective, is an unambitious target, and people aren't being seen within that period, either. There are considerable numbers of people waiting beyond the 26-week target for support, and we can provide the committee with a report we did earlier this year called 'Too long to wait', which looked at some freedom of information data around that.

Staggering, really, yes.

Thank you.

Just a quickie, then, very, very quick, certainly, the waiting list initiatives and the therapy initiatives that Adferiad and others have developed with health boards have been designed to actually work with them on the waiting lists, really, because we are aware that they are quite long, and we want to help, really. So, yes.

Thank you. Jack Sargeant.

Thank you, Chair. I've got some questions but we'll be going over some of the stuff we've been over, so I'll try and cut them down. Just before we do that, I just want to pick back up on a point Simon made about the care plans when you're perhaps an in-patient who's been discharged, and the creation of a care plan and the involvement of the individual, which is absolutely correct. But when you're going out into that community, is it the case that—and this may happen, I'm not sure—but shouldn't the wider community, that support network for that individual, should they be considered in the care plan as well, for example, the family or a friend who would be the next of kin, perhaps?

Yes, absolutely, and it's something we've heard from people as well that not only they weren't involved maybe as much as they would have like to be in the development of their care plan, whether it's parents, whether it's a partner, whether it's other family members who weren't aware of what was in that care plan as well, or involved. So, absolutely. It's one of the crucial things that I think needs to be addressed, and we think needs to be addressed, around care and treatment planning, and there being multiple recommendations around the need to improve this particular aspect, but involving the person and those that are supporting them should be central and should happen a lot more than probably it does at the moment.

Okay, thanks for that. I'll take from that, because the outcome of that is there's quite a large weight on the support network around them, so they need to be—. Okay, thanks for that. Just moving back, then, to access to psychological therapies, we mentioned the target of 28 days. It's ambitious. Is it achievable?

I would say, for local primary mental health support services, the 28-day target is achievable, because it is low—. These are mild to moderate conditions. I think the interesting thing, when you look into the data, is the disparity between how quickly adults are seen and how quickly children and young people are seen at LPMHSS level. Children and young people are less likely to actually be seen within that 28-day target from referral to assessment, certainly. The 26-week target—. And I know—. I caught some of the session before, and I don't want to go into discussions, necessarily, about workforce, but there are workforce issues in terms of creating the capacity to meet the need, both within adult services and within children and young people's services. But again, if you look at specialist CAMHS services, I think it should be four weeks between referral and first appointment, and I think there are over 500 children waiting more than that four-week target.

What I would say is, COVID has had an impact, but some of these issues are historic. CAMHS has been under pressure probably for as long as—. I've worked in the voluntary sector for over 10 years, and it's probably always been thus, and we've really got to start grasping what these issues are. Some of them are workforce. Some of them, with children and young people's services, are absolutely investment. It's about investing in support. And some of it is around how do we utilise, as Euan has talked about, as our local Mind network delivers, how do we utilise the voluntary sector to provide extra support and to have a real choice of options, particularly when people are experiencing mild to moderate mental health problems, so it prevents that escalation to a point where they are seeking specialist CAMHS. That was one of the challenges that was put down around the missing middle, is young people being referred to a service that they don't meet the threshold for, rightly, because that's not the service they're looking for.

You've briefly answered—. Well, you have answered my next question. It is an historical issue. The pandemic clearly has made—. And I can see Professor Hails nodding with that, but there was clearly an issue before COVID, and it may have made it worse, but there is still that issue and it needs to be addressed. But having said that, there is evidence that some people are paying for private therapy, which, for obvious reasons doesn't sit too easy with me. But are there the assurances there that the private therapy workforce is regulated in Wales?

Can I just ask witnesses, or all of us, just to raise our voices slightly? The Zoom people are telling us that it's a bit quietly spoken this morning, so just raise your voice slightly, if that's all right. Thank you.

I think that's a very good question. It probably falls slightly outside my expertise, to an extent, but certainly, if you're looking at the private psychological therapies workforce that is accredited to offer things like CBT, eye movement desensitization and reprocessing, psychoanalytic psychotherapy, most of the people delivering that will be accredited and they will be responsible to a professional body. Lots of them are nurses and/or psychologists, so they've got that level of accreditation as well. Counselling, maybe not so much, no.

Okay. That certainly gives an area for the committee to look into. Just a final question from me, Chair, with regard to A&E. You've seen some of the sessions, you've seen the news, and there's a reason why we're doing this inquiry on waiting times, but have you seen there's been an increase for mental health problems in attendance in A&E, because people are struggling to access the support? Is it a case of an increase in demand for that crisis care support that we see, or is it across the board—a number of different issues?

Do you want to go first?

Yes, I don't mind starting. I think what we saw in March and April 2020, for local primary mental health support services but also for psychological therapies, was a cliff edge in terms of referrals. If you look at the data, it was down, in terms of referrals, by about 70 per cent in terms of people seeking help. And we know that people were reluctant to seek help during that period. So, that, potentially, builds up a lot of issues for people. Obviously, at the start of the pandemic, people weren't really sure whether this was going to be a month, three weeks, and it's turned into 18 months on and off, so, what we're hearing and what we're seeing is people coming now, seeking help with much more complex mental health problems. Certainly, a group that we've been particularly worried about are those who have a long history of mental health problems and maybe their treatment and support had been disrupted in some way during the pandemic, which means that now, they are presenting with multiple issues that could be substance misuse and mental health, or their mental health might have just got worse during that period.

In terms of crisis care, obviously, the data that most people look at is on sections 135 and 136 of the Mental Health Act 1983, which is around people being picked up, essentially, by the police under section and brought for assessment. There's no surprise that, during the pandemic, those numbers really fell, because people weren't outside, they were in their homes. We're now seeing those climb, we're seeing them climb for young people as well, which is a real worry. There's a lot going on around crisis care and a lot of positive things happening around crisis care in terms of sanctuary models, in terms of crisis houses, to provide alternatives to A&E. But I think what I'm hearing from colleagues across the voluntary sector is that there's increased pressure at those points now. We're going into a period as well, in terms of the winter, where, historically, mental health referrals tend to rise a bit; I know that certainly our local Mind network services see them rise in January and February and around the Christmas period. So, there's a winter pressure element, as well as people coming back into the service, which creates a concern.

What we're seeing in Adferiad Recovery services is that the population who are seeking help are growing and they're also worsening, to an extent, as well. And certainly, I think, as Simon said, there was a marked increase of 50 per cent in referral rates into certain services as COVID lifted and people started to return to a level of normality. And, you can consider that the acuity of the presentations was also markedly raised, and from a young person's perspective, the number of people coming in with eating disorders has increased, the number of people with acute difficulties and psychotic incidents, and the level of acuity of these presentations is high. And then also, I suppose from a CAMHS perspective, if you want to consider beds and things, there's not a huge bed establishment either, really, so it's difficult to know where to place people. And as Simon says, quite a few of the third sector organisations have developed sanctuary models, they've developed crisis beds, et cetera, to try and deal with this population, working quite closely with health boards and things. So, yes, things have increased.

Just very, very briefly, Chair—and a brief answer. Quite honestly, I'm on antidepressants—I've got no problem with saying that—but do you think, given the things we've discussed this morning with regard to waiting times and so on, that people are being prescribed medication rather than being put on the waiting list?

It's a really difficult question, because some people will want medication and need medication, actually, and that's what some of our service users will say: 'I needed this in order to be able to access the psychological therapy. I needed that for a period'. It comes down to talking to a patient and patient choice. They should be aware of the options available to them in terms of medication or peer support, or a voluntary sector service, or going and getting talking therapies as well. So, I think that's the key, and it comes down to how well a GP, often, knows what is available and can feel confident in talking to somebody about their mental health and what the options may well be for that person. That will differ from person to person. So, I think it comes down to choice in terms of that. Obviously, we do see high prescription rates in poorer communities as well, which I think is something that needs a lot more thought and a lot more looking into about what lies at the bottom of that particular issue.

Again, just to add to that, if you think about cognitive behavioural therapy, it is as effective as medication in mild to moderate depression for 60 per cent of the population. So, theoretically, if there were more psychological interventions available, then maybe there wouldn't be such a fall-back on medicine.

Thank you. The next set of questions is from Joyce Watson. Joyce is one of the Members on Zoom, and Zoom Members are having more difficulty in picking up the sound. So, apologies for that. Just try and raise your voice level a little, and lean forward if you can. Joyce Watson.

Thanks, Chair, but it's not about raising your voice; the sound is distorted. But, anyway, thank you. What I want to ask about is the alternative, and whether you feel there is enough signposting in the first place, and provision in the second place, about social support, and catching people early before it escalates to a greater need.

Simon, shall I answer that? That's again a very good question, and Simon and myself did discuss early intervention, and very early intervention, when we were in the waiting area. I think, as you say, there could be more signposting, and there could be more understanding of what's available for people to actually go to, and there could be more provision of very early intervention services. If you think about the Together for Children and Young People programme, one of the biggest work streams that they looked at and developed was early interventions. One of the reasons that the missing middle was focused on was because of that. But, also, if you look at the developments when you're working with people with a first episode of psychosis, there's been huge developments across Wales in developing first-episode psychosis services, and the research and the evidence shows that the earlier you intervene, the much better the prognosis is for the person that you're working with. So, yes, there should be more signposting, and there should, as you say, probably be more early services.

There's a huge range of services within the voluntary sector as well that delivers on that. We, along with 17 of our local Minds, deliver a programme called Active Monitoring that's been funded by Welsh Government since June 2020. It's seen about 6,000 people. The interesting part around that is it's a self-referral service. You don't have to go to your GP in order to access it; you can refer directly via the website and get an assessment, and then be supported, whatever your particular pathway would be—anxiety or panic attacks, depression, loneliness, grief; there are a number of pathways within that. That's seen quite an effective response in terms of how people feel before and after that. So, I think, it's not just looking at what the NHS deliver, but actually, how are we commissioning voluntary sector services to provide that patient-centred care that, we know, across the sector, delivers really well. And I think self-referral is a really interesting area to look at as well, so that people can feel they can seek out their own help and be supported.

Certainly from an Adferiad perspective, we do offer first-episode psychosis services now across Wales. We offer peer mentoring services for people with serious mental health problems and substance use problems. We've developed psychological services working with our health board partners in north and south Wales. We've got the Hafal promise, which again was funded by the Assembly, that no-one is left alone. So, they can phone up Hafal if they need help. Obviously, that will be taken into Adferiad now. And, again, it's an area, I think, as Simon says, that, as the third sector, we are well positioned to actually work within. Sometimes from a secondary service, CAMHS is, as Simon said, focused on probably the poorliest population, and sometimes, when people actually come into that service, that's not what they need; they need something that's either in the missing middle or at a lower tier, really. But, I think, if you took your argument to its logical conclusion, and if you intervened as early as you possibly could, they may not be coming into CAMHS in the first place. So, yes, I think, you're correct there.

And just finally from me, we've seen a lot of innovation on remote-based support. Groups have grown probably from the ground up. So, in terms of moving forward, in terms of that innovation—and it's been driven, of course, by the isolation of COVID-19—how can we take that forward, not lose really what there is? And any views that you might have about what is available through that medium, because young people are quite comfortable, very often, with that remote support. I'm not saying it's the only support, but it might be their first point of contact.

I think that's, again, a very sensible question, and you have seen the burgeoning and development of digitalised interventions due to COVID. This would have happened anyway, but it's happened a lot more quickly. One of the concerns that we have in Adferiad is the fact that that doesn't then become the new norm. I think we have to find a happy medium between face-to-face work and digitalised work, because some young people like it, some young people don't. And with the population growth and an ageing population, some people don't actually have access to digital systems; some people don't have Wi-Fi et cetera, et cetera. So, I think that we have to be nuanced in the development of the digital delivery, but I think it's a great opportunity, and it's something that we should grab fully, and develop fully, and enable people to access services from a remote perspective.

Again, Simon and I were talking in the waiting room. I offer young people cognitive behavioural psychotherapy, and one of my thoughts is that, sometimes, when they come and see me, they're not in the best of spaces, because they're brought there by the parents. They may not want to see me; I'm somewhat older than them. And I've found that, when I've delivered therapy over Attend Anywhere platforms, the relationship is more even, to an extent, really. And, then, there's not the concern or the stigma of coming into CAMHS to see someone. So, I think it's a good development, but I think we need to focus on it carefully, and, I think, as a Government, you need to actually take hold of it and actually plan how it's going to be delivered, going forward, so that it's doesn't become, 'I go into a mental health service; I get something digital'. You need more than that; you need a face-to-face, you need to be able to see someone as well, really.

I think I'd just add to that. Obviously a number of Members here represent rural constituencies, and what we've seen is actually the digital offer reach parts of constituencies or parts of the country that maybe the face-to-face offer wasn't, because people weren't able to travel or were reluctant, due to stigma or other reasons, to travel to the local town or wherever the base was. So, we have seen positives that it is reaching different people, and particularly maybe some professionals as well, who can't have time off work, but actually they could do something in the evening. But it comes back to, as Euan said—it's your final point there, I think, Joyce: it's around choice, what suits the person. It shouldn't be the system suiting. It shouldn't be the other way around—'This is what we offer. Can you fit with this?'; it's 'This is what I think I need, and what are my options? Actually, I'll do a bit of this'. A blended approach comes through, hands down, as what most people want. A bit of face-to-face, with a bit of online maybe in between, to help support them.

But also, if you think about systems like SilverCloud, it's designed for a person to do without any form of human contact; it's a digital therapy. And systems like that do have a growing evidence base, and they are also useful for people to use. So, if you're looking at tier 0 and tier 1, digitalised stuff is really rather useful. As you go up the tiers, digitalised, and, as Simon said and I said, face-to-face contact is important. But with the digitalised delivery you can reach certain parts that you may not have been able to reach before, and some people, who may not want to come into the service, will be happy to see you over the internet.

Can I ask one final question? It's probably too early for an answer. Is there any work going on, in terms of the digitalised delivery of services, on reducing, perhaps, in some cases, the stigma? Because people go online, rather than turning up, where people feel disempowered from physically turning up, in case people understand that they have a particular need that they don't want others to know about.

Anecdotally, Joyce, yes. I've noticed it with some people I've seen. Coming into CAMHS, some people find it difficult; seeing me over the internet, they don't find it difficult. So, yes, I think, you're quite correct in that, really. Simon, any—?

I absolutely agree. I think we need to be careful with that discussion, that it doesn't end up that it's still seen as something people can't talk about, and it isn't normalised. Seeking help is normal. Feeling alone, feeling upset and distressed in the last 18 months is absolutely normal. We've gone through an incredible experience. We need to normalise those conversations and being able to talk about it. So, yes, if it helps somebody get help, where they previously wouldn't, that's absolutely right. But we don't want it to become a situation where it's still hidden, in a sense, and we're not having that discussion around it being good and positive to seek help and it is normal from the earlier stage to the older stage, and I think that's where we just need to nuance that discussion a bit probably.

Mike Hedges.

Thanks, Russ. I'd like, first of all, to say that I'm very pleased to hear you talking about early intervention—that is something that I've talked about for a long time. The other thing I talk about is fairness. You talk about people accessing digitally. There are poor people, there are poor people without access to digital equipment, there are people with low educational standards. They need access as well, and there's a danger, isn't there, that, if everything is digital, those who are digitally excluded become even more excluded? Is that a concern of yours, because it's a serious concern of mine?

It's interesting, Mike, when I was giving my evidence before, which you may not have heard because I wasn't speaking into—. I said the same thing, so, yes, there certainly is a digital divide, and, again, you could look at that from age perspective as well really. Some young people might be more easy and happy to work on a digital device because they use them quite often. Some people don't have access to a digital device, can't afford a computer, can't afford Wi-Fi et cetera, et cetera, so, yes, you're correct.

And I think if we go to a digital-by-default approach, which we wouldn't be supportive of, it's not just the skills or the access to the equipment, it's actually that some people don't want their support to be delivered in that way, and that creates a digital divide. It's not just about access to hardware or training—it's about what a person wants. And I think that's why we're really cautious around saying, 'Yes, these really help people and support people in a different way', and it's certainly sped up in the last 18 months and we've seen some really great outcomes, but it comes back to choice—it comes back to what would help the person feel supported, and that's the starting point.

And one other point is privacy—if you've got IT equipment, you've got your own room and the doors are locked et cetera. When you're in a place where there are lots of other people, you lose your privacy when you're engaging via ICT.

I agree. I think the big message to take from this, from what everyone is saying, is choice—it's my choice to be seen digitally or it's my choice to be seen face to face and, therefore, the services should provide that.

And the privacy issue, I think, is really important when we start talking about inequalities: people who live in houses of multiple occupation; or young people, maybe if they're parents are around, some of them might feel more comfortable in that setting; others might not want their parents to hear and so actually feel intimidated about doing that in that setting. So, again, you can't have a blanket 'this will suit everybody', and I think there is a challenge inherent in that, but it's about the options.

Again, I think—just a quick one—as you mentioned first-episode psychosis services, sometimes people don't want to use these sorts of systems because they've got beliefs and ideas about the systems that you're talking to them on. So, sometimes, it just doesn't fit with the person who you're working with.

Thank you. Any other questions, Mike? No. Thank you. Can I just ask you both, really, can transparency and the quality of data that is published on mental health waiting times be improved at all? And I suppose what sits behind that question is understanding demand across the different levels or tiers for services and among different population groups.

Yes, always—it can always be improved. We've been waiting now for a number of years for a core data set. It'll be familiar to those who were on previous committees. We've raised the issues around data often. If you take things like crisis care, where we look at sections 135 and 136, that data is published. There's also data about crisis resolution and home treatment teams in terms of throughput for those teams—you know, what level of demand is there? That data isn't published. I think there's a lot more that can be done.

It was only, I think, earlier this year that, for the local primary mental health support services data—so, the primary care data—the Welsh Government started to separate adults from children and young people data. And that's where we get the picture—the children's rights picture—that children are being seen a lot slower and are less likely to be seen within target than adults. So, there's absolutely a need to look at what data is available. And that's not just an academic argument; that's about actually understanding the throughput of the system. Then, that needs to be met with outcome data and things like patient surveys and all those things—how are people experiencing the system? And you get a picture of what the system’s doing and how it’s coping alongside how people are experiencing it. It feels like there’s work under way, but there’s a long way to go until we get to the point where we’ve got a really clear picture.

Just to take, I guess, your second point around inequalities, the collection of ethnicity data is not good. We know that things like the Mental Health Act, from data in England, disproportionately affects young black men. We can’t pick up the same picture in Wales because there are issues with how consistently that data is collected as well. So, looking at those inequalities, it’s difficult to even build a picture around some of those. So, that’s a long way to say 'yes'.

Thank you. I appreciate it, and Professor Hails was nodding, so I don’t need to ask him that question, but how can be it be improved? Is there any advice that you’ve got in that regard?

I think Public Health Wales have done a lot of work over the last few years of developing a minimum data set for people going through services, and I mean a minimum data set from a psychological and condition perspective. We can properly talk about the data for how long does it take, when are you seen, where are you seen, and how long does it take before you get your therapy once you’ve been seen, but we don’t often talk about the condition-specific data that Simon mentions. So, if we can actually start to say that, 'Betsi saw 55 people. This is the baseline. This is what they ended up with afterwards' , that sort of data would be really, really useful. So, I think using standardised measures with all people that come through the door would really help our services. We could benchmark, we could develop services and, certainly, from a third sector perspective, anything that—. We do do quite a lot of data trawling, to an extent, from the people who use our services, because all people who come into Adferiad are members, and we do ask them a lot of questions, but I think, from a health board-specific perspective, it would be useful to get clinical data out there as well.

I'd just add, in terms of Mike and Jack’s question around poverty, if you have a really good mental health data set, you can overlay that data set on deprivation—the index of multiple deprivation—and see are there differences in terms of areas and what’s happening and things like that. You can really manipulate that to get a good picture of what’s going on. So, there is a long way to go in terms of inequalities.

And then, I think, also you can correlate that to things like substance use, drug and alcohol usage, obesity, et cetera, et cetera. So, there are lots of things you can do with data, and data is quite useful.

Perhaps a view as well on unmet need as well. So, those who have not presented themselves, or those with existing conditions that haven't, perhaps, come forward and so conditions have got worse during the period.

Also, I think if you take your argument to the logical conclusion, we should be recording unmet needs. So, if go and see my GP and my GP can't provide what I need or the health board can't provide what the GP thinks I need, then that's an unmet need. So, yes. And the more we're enabled to develop and get unmet need figures, the more it enables us to actually develop services, and it would be interesting to see if the unmet need is in a certain deprived area, or a non-deprived area, really, as one of your questions was alluding to.

And I think as well, with unmet need, some of that is challenges of accessing support. What can meet the need might well be there. Speaking to colleagues from organisations that represent black and other ethnic minority organisations, access to mental health support is the single biggest issue, seemingly, for those organisations and those communities. I think it would be interesting for the committee to hear from them directly as well, because I think that could be seen as an unmet need, but, actually, the meeting of that need is available—the challenge is how it's accessed, how people are supported, how people are signposted, and how appropriate that is in order to meet the need of that particular person.

There are two aspects, aren't there? There's the unmet need, in terms of those not presenting themselves at all, and those that have presented themselves but not been referred, I suppose.

And we've seen an increase. Definitely, work that Time To Change Wales have done has seen an increase in self-stigma during the pandemic, of people saying, 'I'm not going to seek help because I'm just feeling a bit down and, actually, there are people out there dying. Hospitals and GPs are overwhelmed.' People have been holding back as well in terms of seeking help. So, that's the concern now—that we start to see those people coming back in to seek support at a point where support is under pressure.

What I would say as well is that I think it's important to note that the front line is doing everything it possibly can to support people. It needs to be supported, whether that's through a medium to long-term plan in terms of the workforce, which I know you heard about before, but also investment in certain areas and really thinking about how the voluntary sector can actually support the workforce as well. Because a lot of those people that have been working on the front line have been taken off to do COVID duties and have experienced the trauma involved with that as well—they're tired, and they've been trying to keep mental health services going as well. So, there's a huge pressure on the front line, and at no point would either of us want our evidence to finish without recognising that they have done everything they possibly can to support people during a very difficult time as well.

I mean, Adferiad mirror that as well. We've come here to support services not to damn services, really, because I don't think COVID is the time to do that because services are struggling and people are doing their best, basically, in a very hard time. So, I agree with what Simon said.

Thank you, Professor Hails. To you, Simon, I've got some words here that you previously stated, and I think you probably reiterated these in your contribution today, as well, but you previously said that,

'people in Wales continue to struggle to access mental health support, still face a lack of choice and still wait too long.'

So, I wonder, in that context, what confidence you have in the Welsh Government's recovery plan, and how realistic and achievable it is.

I think I have confidence in terms of mental health being recognised within it. I think, previously, we would have seen mental health maybe not being, particularly with such a massive physical health pandemic, taken on board. I think there's a very clear desire within that recovery plan, and we've certainly heard it from the Deputy Minister as well, for mental health to be up there alongside the physical health recovery. I think it's recognising that some of these issues are deep rooted and long-standing. As I said, things like access to CAMHS is not—. The last 18 months have only highlighted those issues, they haven't created them, so I think it is a long haul.

I would hope that, with significant investment, with a Deputy Minister that wants to drive this agenda forward, with health boards becoming more aware of what they need to do and more aware, through the data and through what they're seeing from the front line, we can get there. I think you've got to believe that none of this is inevitable for people. If we get the support in early, as a number of you have said, and get it at the right level, people do improve. And I think that's one of the areas of feedback that we have received: when people are able to access a service, they're really grateful and it really helps them. The struggle is about the access, and that access is long-standing in some parts of the service.

Thank you. And just a final word to Professor Hails in terms of the same question, and anything additional you want to add in terms of your confidence in the Welsh Government's recovery plan.

I am confident that the recovery plan will enable us to do what we need to do. I'm also cognisant that we have talked a lot about early intervention and very, very early intervention. I think we also need to remember the population that are out there who have serious enduring mental health problems and who may be receiving a reduced service due to COVID or due to the areas that Simon's been talking about to an extent, really. So, I think we need to focus on prevention, but we also need to focus on working with people who have the condition and who have it for a long time. Because I'd be concerned that that population was slightly disenfranchised by focusing more of the money on the prevention when we can't prevent it with this population because they've sort of got it, to an extent, really. But I don't think that's been missed. I think that there is a broad focus on delivery, but I do think we need to streamline the delivery to the need of the population in the context of what they're actually presenting with, which is basically what we're talking about. So, if you've got someone with a psychosis, schizophrenia or bipolar, they need certain sorts of interventions, which may not be as available as those for someone who has a mild to moderate disorder. So, I'm thinking that we need not to forget the people with serious conditions as well.

Absolutely. Absolutely.

And I don't think you are, but it's just something I thought would be worth saying.

Well, thank you very much. Diolch yn fawr. We appreciate your time this morning. We'll send you a copy of the transcript, so, by all means, have a look at that and, if you think of anything you want to add to what you said this morning to help our work, then we'd be very grateful for that as well. But, thank you very much for your time this morning. We really appreciate it. We're just about to finish—you can stay in your seats by all means, or leave, but we've got about another minute of business to go. But, by all means, just hang fire for a moment.

I move to item 4. We have a number of papers to note. They are set out on the agenda and also in the meeting papers. Are Members content to note those papers? Thank you very much—

Happy and content. Can I raise one item when we go into private?

Yes, Mike. Yes, you can. Do you want to do that now?

Well, it was my question on standard spending assessments and expenditure by local authorities, comparing how much they're spending against what they're calculated to need for social services. I did ask that, if you may remember, several times. Mr Heaney looked at me and he did say they would write, and I haven't seen the answer yet.

Okay. Well, I'll explore that in the private session, Mike, and get back to you on that. Thank you. Diolch yn fawr.

Okay. We move to item 5, and I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public from the remainder of the meeting, if Members are content. Yes. Thank you very much. That brings our public meeting to an end.