Health and Social Care Committee

Hi, everyone. I'm Professor Euan Hails. I'm a member of the Royal College of Nursing board Wales and a mental health nurse by background.

I'm Lisa Turnbull, I'm the policy, parliamentary and public affairs manager for the Royal College of Nursing in Wales.

I'm Julie Keely, I'm a GP in Brecon in mid Wales, and I'm chair of the south-west Wales faculty of the Royal College of General Practitioners.

Thank you for being with us this morning, I appreciate it. We're just making sure that we've got the microphones all working in order. There we are. Thank you. Diolch yn fawr.

Can I perhaps just ask Dr Keely first of all? Can you perhaps tell us some of the ways in which GPs have contributed to tackling mental health inequalities?

GPs have been willing and able, and flexible, in working with our partners in secondary care. We are very aware already of certain groups who are at higher risk of mental health issues, and also groups who are less likely to be provided with good care. There are certain groups that we have been mindful of for many years, for example people with learning disabilities, those with severe mental health issues. As I'm sure you know, many patients in that group die 15 to 20 years earlier than they should do based on physical symptoms, not only their mental health issues. That's for many reasons. Mental health issues may affect their ability to engage with health screening programmes. Many of them smoke. They're on drugs that can make their physical health a lot worse, for example antipsychotics. Often, they don't attend for monitoring, and it's constantly trying to chase people and keep on top of the job.

Likewise, with learning disability groups, there is a lot of hidden physical morbidity, and for both of those groups in particular, we focus additional energy on undertaking physical examinations to detect other morbidities in addition to the mental health problems that are already known to us at an earlier stage, where, hopefully, we can make some impact.

There's also massive inequalities when it comes to people at extremes of age. Scarily, there's a 20 per cent prevalence of mental health problems in young people. Pre-pandemic, they were the stats. I suspect, probably, during the pandemic, and post pandemic, certainly for my patch, we're probably looking at 30 or 40 per cent. That's for many reasons—social isolation, lack of contact with school peers, lack of provision of additional social activities to maintain good mental health. They've all been taken away during the pandemic and are gradually being reintroduced again. But there's a huge need that is currently being unmet.

Likewise, with other extremes of age, for patients in the over-65 groups, there is a relatively high prevalence of dementia and depression, and the pandemic has really exacerbated that. A lot of people rely on their social network, having contact with other people, just a friendly face, someone to say 'Hello', to know that someone cares about you, and have become quite lonely and depressed consequently. Sadly, that's been the case, and continues, to a greater extent, in that vein. And with the pandemic as it is at the moment, I don't think we're entirely sure where it will all lead.

There's also, sadly, due to a crisis with mental health staffing, not enough resources to deal with them in secondary care, which we fully appreciate. The services have been under-resourced, understaffed pre-pandemic, and that's just been exacerbated. A lot of people have left due to ill health personally, and particularly well-being issues and mental health problems in those service providers. And that's not just for secondary care; I think that's also happening in primary care. We're seeing lots of people, for example, retiring earlier than they should do, or would liked to have done or planned to do, because they have been adversely affected by the pressures of COVID and how that has impacted on them personally and professionally, and have actually left the health profession, just adding to the current crisis.

But we try very hard to maintain contact with people and be that first port of call in primary care, and that has remained the case during the pandemic.

Thank you for setting the scene there. That's helpful. I think Members will want to dive into some of what you said in their questioning. And to colleagues at RCN, you can probably guess my question, but the same to you in terms of how nurses have helped to contribute to tackling mental health inequalities.

Thank you very much. I think the first thing to say really is to explain that we have mental health nursing—. So, when you graduate and qualify as a nurse, the four fields of practice that you would graduate in are adult, child, mental health, learning disability. So, we do have a section of the workforce that is specifically skilled and educated to respond to mental health issues. We then also have a variety—and my colleague will go on to say a little bit more—of leadership positions after that, people who would specialise in, say, eating disorders or particular types of trauma. We also have particular interventions. We also have consultant nurses—those kinds of levels of practice. Of course, the general nursing population as well—so, if we're talking about different specialities—will intervene in different ways; so, children's nursing, school nursing, health visitors, a nurse working in A&E. So, there are a variety of nurses in different positions and specialities that will have different opportunities to engage with mental health, whether that's around prevention, resilience work, whether it's around mild issues—so, dealing with mild anxiety and mild depression—or whether we're actually talking about the more specialist interventions.

I think one of the areas that we've tried to focus on in our written evidence, and we'd like to highlight today, for inequalities, is the services and workforce for people with severe and enduring mental health issues—that we do feel that that has had a lack of strategic national focus from the Welsh Government in recent years, and that the workforce is not sufficiently planned or developed. So, what you have there is you have a situation where the people in the greatest need are those that are actually unable to access any kind of service, or have to wait a long time. The capital estate itself, if you look at the in-patient estate, is very poor. And that creates a number of vulnerabilities then on particular groups in that. Then, if you look in that small population, so you're looking at particular groups, whether that's people with learning disabilities, whether that's very young people, or whatever you're looking at in that group, then those inequalities are further worsened because those services are just not there or not appropriate for those groups.

So, those are the areas that we do specifically want to draw attention to. We do think that nursing has a huge, huge contribution for that particular group—whether it's efficient nursing to take care of people who need, for whatever reason, short or longer care, in terms of residential facilities, or whether we're talking about nursing in the prison population, or whether we're talking about nursing teams in the community who would do interventions. So, nursing has the solutions to those issues, but there are simply not enough people out there with the right level of skills to provide that care and level up that field. So, I think, as a general introduction, that would be the key point that we would want to be making. I'll just turn to my colleague to see if there's anything they'd like to add.

Just briefly, if you can.

I think the evidence from both people has covered the area we're looking at. I've been a mental health nurse since 1984, and I'm also a cognitive behavioural psychotherapist and an EMDR psychotherapist. Nurses deliver nursing interventions, but they also deliver psychological therapy-type interventions. I'm also a consultant nurse, so I consult and manage, lead, develop and supervise people. Nursing and nurses across all areas, be it primary or secondary health, have a vital role within the delivery of care to this population. Most of the wards are staffed by nurses, most of the areas like the emergency departments are staffed by nurses, and medics, obviously, as well.

I think nursing has a vital role to deliver and enable the population and ensure that they can actually do what they should be able to do, get the interventions that they should be able to get—medical interventions, psychological interventions and social interventions. Nurses are instrumental with the multidisciplinary team in leading on those sorts of issues and delivering care. Basically, if you get sectioned, one of the first people you're going to see, apart from the sectioning doctor, and maybe the social worker, would be a nurse. It's the nurses who deliver the interventions that make people better, to an extent, with the extended multiprofessional team, and they've got a gamut of skills. You could argue that there's really not enough of them knocking about at the moment, be they mental health nurses or general nurses.

Can I just pick up on a point you mentioned, Lisa, about the workforce? I'm just thinking about what actions and priorities you think need to happen from Government in terms of supporting the workforce, particularly when there are perhaps mental health issues that some of the workforce are facing themselves. What are the priority actions that need to take place to support the staff themselves, particularly thinking in terms of the workforce and retention issues that we have?

Yes, well, okay, a number of things: I think the first thing is about being seen and being valued and recognised. So, that is about planning. That is about having a postgraduate, specifically mental health workforce plan to provide those kinds of career structures and access to continuous professional development, so that people can feel that they’re going into a career and they’re recognised. So, what I would say—. I think that is an important point about value and recognition, and access to CPD is important.

I think other specific points about supporting the workforce that might be helpful and necessary is that we have seen during COVID the use of counselling telephone helplines for staff and they have been extremely well received, and I would suggest that that is a good initiative. I would also suggest, and I think it would be remiss of me not to mention this: if you are going to demonstrate to your staff that you value them and it’s an important career that you want to provide—a service you want to provide to the people of Wales—you do need to pay nurses effectively and reward them for their job. Because if you’re asking people in a situation like this to make decisions about human rights, to make decisions about therapeutic interventions, you’re making decisions that are genuinely lifesaving and life-altering. You’re talking about a high level of decision-making skill, experience and knowledge. And you’re also talking about a very high-challenge environment—high-reward and high-challenge environment. If you want people to go into that as a career and stay in that career, you need to reward them appropriately for the job that they’re doing and the Welsh Government has to recognise that as a significant issue in the years ahead. And that is currently not happening at the moment.

So, we do have a situation where—. I have to say, the Welsh Government has increased the number of mental health commissions for mental health nursing, so we are producing more mental health nursing graduates, which is a good thing and it is something that we should be very pleased about and we do recognise that. But producing them is one thing; keeping people in the profession over the long term, once you’ve invested that public money, you need to actually then educate and keep people in that for the longer term—not just for five years, but for 10 years, 15, 20 years, over their working life. And to get those skills and that population, they need to be rewarded appropriately.

That's a clear message. Did you want to add anything at all in terms of workforce well-being?

From general practice? Yes, I think supporting the care givers is probably a huge priority that we all have to recognise. We’re human too. Okay, we’re trained, we’re professionals, we are taught and supported, to some extent, to monitor situations and manage stress and deal with very high-risk situations, but it is absolutely essential that the workforce aren’t forgotten when it comes to managing their own stress, providing them with support. It’s not just financial rewards; it’s 'Thank you for doing the job' and some recognition of what we do and how we do our best to deliver the services, albeit whatever constraints there are at the time. It’s vital to support all members of the NHS workforce and social care workers, indeed, in my view, but that is a huge, huge issue.

And there are lots of ways that pressure could be taken away from primary care when it comes to supporting patients with mental health problems, for example, to try and reinstate and greatly increase our social prescribing access. That was an absolutely wonderful huge plus. We see so many patients. I did a straw poll of one of my surgeries a couple of weeks ago and 40 per cent of patients in that particular one surgery, which isn’t uncommon, basically required some social support, which wasn’t necessarily medical intervention from myself or my extended team or secondary care; it’s just to have some positive activity to improve their physical health and their well-being and promote good, psychological health as well. And, sadly, there were wonderful seedlings of social support for people pre COVID and, again, they’ve disappeared. So, I think there should be a huge emphasis on redeveloping those accesses for people to have that support, and not just from primary care signposting people, as there are lots of people in the extended team who can do the job. Community pharmacists could take a role in that, for example. They see lots of people coming in wanting Kalms tablets or antihistamines to help their sleeping and can have that conversation with them in a quiet area as well. But I think it will require a lot of joined-up thinking to give people the support for their physical and mental health to take things forward in the future.

Thank you. I know we've got a lot of questions to get through; do you mind if Members interrupt you if we're not quite getting to the nub?

That's fine.

Thank you very much for that permission. Mike Hedges.

I want to talk about the accessibility of services. We've heard that GP appointment booking systems and triage systems, such as NHS 111, can be very difficult to navigate. I was supposed to say for 'significant numbers of people'; my experience is that they're very difficult to navigate for almost everybody. This can be due to language—. It's more difficult for people who've got a language barrier, and it's also more difficult for some people with neurodivergent conditions, but it's very difficult for all of us. I tend to get three or four complaints about one surgery a week, about being able to get appointments. But how could services be made more accessible to diverse groups of people, who are lower down the list of being able to get through? They're not the ones who do 80 phone calls between 8:00 and 8:20 in order to try and get in. They sometimes will have one go, can't get in, and just give up.

I agree with you that there is a lot of pressure in primary care at the moment. In my practice, for example, we've had a telephone-first model, where patients phone and speak to a GP and a GP will phone them back within an hour or more urgently than that, if it's required based on the clinical scenario that we're faced with. We have systems in place. There are flags on the patients' notes. For example, patients who have learning disabilities or who have chronic or severe mental health problems, patients who have a new diagnosis of cancer, as well, patients who are palliative, there are alerts so that they're automatically diverted straight through to a GP. Patients can use technology, if they so wish, although a lot of my elderly patients are not particularly into that, which is perfectly reasonable. They can contact us via the practice website. They can actually come into the practice and go to the receptionist and say, 'This is my issue, I need to see a member of the team; can you sort me out please?' and the answer is 'yes.' They may have to have a seat for a few minutes, but they will be directed to the appropriate person. Everyone is seen the same day if they need to be seen. It's a negotiation between the GP or the practice nurse or other healthcare professionals in the team and that individual as to how best to manage the problem, whether that be in person or on the phone, or send it on to another service as appropriate.

Thank you very much. That's not necessarily a common experience of most of my constituents who contact me. I won't name the surgery, but I get three or four complaints a week about one surgery, about not being able to see a doctor. People now use the accident and emergency triage system because they can't get in to see a GP. I think what you've outlined is a really brilliant system; can you share it with some of your other colleagues, and perhaps they can do the same thing?

Maybe there's an advantage of not having an A&E and being in a rural practice, because it's beholden to us to manage whatever needs to be managed in our community and to be committed to our patient population and their health needs.

Thank you.

I think what we would add is that there are services that are designed for people to access. So, A&E is a good one and a GP might potentially be another. I think, rather than trying to retrofit that service, you might want to be thinking about, if you're thinking about interventions or reaching out to different groups of people, you might be talking about putting people or different types of practitioners in an entirely different place. So, you might actually be then talking about that kind of community work where people are. So, I'm going to turn to my colleague now, who may have some specific examples of that, but if you're talking about youth work, if you're talking about working with people who've just been released from prison, talking about different populations, you might be talking about actually trying to reach that population in a different way.

Yes, most certainly. I was the first episode psychosis lead for Wales for a number of years, and one thing we attempted to develop was to remove the location of the service away from the traditional mental health delivery, i.e. St Cadoc's, Whitchurch, et cetera, et cetera. There's a service in Australia, in Melbourne, called Orygen, and they've developed shop-front services in big shopping malls and shopping centres and things, really, so you can co-locate services in completely different areas, and then people feel a lot more comfortable to go to them. You can deliver services in gyms, in leisure centres, et cetera, et cetera. So, you need to slightly think outside the box, so instead of going to the traditional mental health area that has some level of stigmatisation to it—and even with young people it still has stigmatisation—you go into a completely different area, staffed by different staff with a different experience and a different skill set, really. So, you're integrating, to an extent, primary care and secondary care, but delivering it in somewhere that's different, like popping into the nice big shopping centres in the middle of Cardiff and you've got a unit there. You can pop in; people don't know what it is. It's completely unstigmatised and you can walk in; it's not a problem. My wife works at Swansea University and volunteers in a dementia hub in the shopping centre in Swansea every Sunday, and people just pop in for a chat and a cup of tea; you know, it's different.

Many years ago—one of the disadvantages of being in a role for this long is you have good memory—we prepared an extensive briefing for the health committee at the time that I could revisit, which was looking at the evidence that emerged from the walk-in centres that were introduced in England back in the sort of 1997-98 period. What emerged from that evidence was while they did not solve the policy question that they were created for—they didn't magically reduce pressure on A&E—what they were very good at is exactly that. So, where they were very good is where they had a specific population and an issue like sexual health or respiratory health or mental health, they were actually taking the services to the population with specialist practitioners. So, that model clearly works.

Another thing—

Professor Hails, do you mind just moving your mike a little bit closer? It's one of our witnesses; one of our Members is just having difficulty hearing. That should be fine.

Another thing that we've done in CAMHS services is we've sort of amalgamated—. The majority of health boards now provide a CAMHS service that is primary care and secondary care based, and they've all got a single point of access with a 'no bounce' policy. So, people come into the single point of access and they get directed to where they need to go, and it's a single point of access for health, for social services, for education, et cetera, et cetera, so you've got all services in one area, provided in one easy point to actually access.

Another thing that we're trying to develop now are places of safety. Instead of going to the emergency department or going to a 136 suite, you can go to a sanctuary instead of being admitted to the units, because as you know it's very difficult to get admitted to any of the mental health units, really, and from a CAMHS perspective, it's virtually impossible. So, you can go to a non-threatening, non-judgmental area that's again removed from a hospital situation and you can stay there overnight, and then again in the morning, you can go home instead of being admitted into hospital. So, lots of the health boards—supported obviously by the Government and other areas—are trying to develop really rather innovative and new ways of delivering service. And I think it fits in with—

It's music to my ears to hear that. Unfortunately, I'm in an area, as I know a lot of my colleagues are, where these services do not exist. It's still very fragmented; there isn't joined-up thinking. I would love to have a single point of contact for access for mental health care services. At the moment, we're so understaffed locally in secondary care, it's impossible to find the same person there from week to week at times—

Yes, I agree.

—which is very distressing for us as well as our patients. So, we need to have a concerted approach to have joined-up thinking and have a single point of access, and services that are dictated by local need. They will be different. Wonderful that you have psychotherapy services; you wait for almost three years in the area I work in for psychotherapy services. We have no ADHD assessment services, for example; CAMHS is not joined up; a lot of the work is done by primary care as well as our secondary care specialist nurse. There has been no consultant in post for years; we now have a locum consultant, thankfully, and we end up liaising more but admitting people to secondary care in crisis.

Can I bring Mike back in?

Dementia care in Swansea in that centre is very good; I've visited it. But often these things are just one-offs. You have it in Swansea, you don't have it in Llanelli, for example. I think that's perhaps one of the things we want, which I'm glad you've highlighted.

We're also concerned about the lack of translation services for people, especially those from ethnic minorities, who often rely on their children to translate for them sometimes quite complicated medical items, which are beyond the linguistic skill of children within their age group anyway. We've had a request, where we went on a visit, for a medical translation service.

There is a medical translation service, sometimes pre-organising appointments, so if it's an acute event, it can be quite tricky, but you can pre-organise them. Likewise for patients with certain disabilities; if you need a sign interpreter as well, that can be arranged. It's not a problem.

Can I just say that my sister is profoundly deaf? I know just how difficult it is to get someone to come along and sign. I also know how incredibly difficult it is, having arranged for somebody to come along and sign, to actually have them there at the appropriate time. If you go to the Welsh Government, talk to lots of people, we've got this wonderful system, but, with things like signing, it can be very difficult to get somebody there at the appropriate time, even for an appointment that has been made for some time.

I appreciate that. Thankfully, we try to remain flexible in our approach and our practice, certainly, and if they turn up an hour late, so be it, they're still seen, we still carry on with the appointment, because it is important. We need the help of another professional in those circumstances.

Thank you very much. I'll just finish with this. I think that the way you deal with your services would appear to be an exemplar for other GP services across, certainly, Swansea, and I would imagine through the rest of Wales. Is there any way that you can use it as an exemplar?

I think we do our best, but there are lots of practices out there who do their best, and I'm very assured of that. I'm very fortunate to visit lots of practices as a GP appraiser, and there's a lot of good practice out there. But it's important to highlight what can be improved, and feedback from patients and their families is always welcomed to help us improve our services.

Sorry, Lisa, I've stopped you twice now.

No, it's a really important point. I suppose what I would say is I would, first of all, start by echoing your earlier comment, which is that it is around national planning. We are able to see from the census the languages that are in use in very small areas of Wales. We can pin that down. So, the question remains: why is this not being taken into account in our workforce planning? The Welsh language is a big example of that, but there are other examples as well, like sign language and also other languages. But if we can actually, again, encourage and reward people for linguistic skills. If people are comfortable during the period of education, they've had access to resources in different languages, they're comfortable in those different languages, then they can actually start potentially to deploy them. But this needs to be recognised as a very specific skill. Again, I go back to my point that if you're going to ask people to use high-level skills, you have to reward them for that. But there are things that we should be able to do with both the pre-reg and post-reg education, and access to CDP, to ensure that people, if they're in the area and they suddenly think, 'Well, do you know what, I would like to develop my skills in a particular area. I'm serving a population with this language need. I'm going to go and refresh some of my skills', because, when we're talking about mental health interventions, two very different types of language can make a profound difference. If you're talking about psychological therapies, you're talking about, of course, a very advanced level of fluency, but if you're talking about, for example, making someone comfortable at home, feeling welcome or feeling trusted, then you are potentially talking about a relatively low level of being able to be comfortable or familiar. The Welsh language is particularly significant when we're talking about dementia care, for example. I think it's worth highlighting those points, and it goes back to HEIW and planning.

I think it's an interesting point, as well, because if you take your argument to its logical conclusion, if you're dealing with people, or you're working with people with a serious and enduring mental health problem, or a learning disability, and they have communication problems, the whole difficulty is just ramped up. And if you've got a workforce that isn't able to actually (a) deal with the information or the talking difficulty, and (b) the mental health or the learning disability, then you're in a very difficult situation and the person's going to feel frustrated, they're going to leave, they're not going to get treated. So, you do need a highly skilled, multifaceted workforce to actually deliver that level of intervention to that level of population.

And confidence as well. I can't speak specifically to mental health nursing, but we do have statistics from our membership that show, for example—and I know the point is wider than purely the Welsh language, but just to illustrate—we have about a third of our members that speak Welsh. That isn't the same necessarily as having the confidence to utilise that Welsh professionally. So, again, that's something about not only the desire to support your team, but the time. Everything we're talking about here is about time. Outreach, CPD, skill development—if you don't have the time to do that, because there's not enough of you, all of that stuff goes by the wayside, because you're down to the very, very minimum that you can possibly do. And that's when things start to slip, the services start to suffer, and we see poor care being delivered. And it's one of the reasons why, of course, one of our recommendations is about the extension of section 25(b) of the Nurse Staffing Levels (Wales) Act 2016, because we want to see some priority given to safe and effective care specifically in in-patient mental health—because of that.

Thank you. Are those all of your questions, Mike?

Yes, that'll do. Thanks.

There we are. We've had about 10 minutes for each, and we've got three sections left, so about 10 minutes for each section, just to give an indication. Gareth Davies.

Thank you, Chair. I want to focus my questioning on awareness and training. Just to kick off, do you think that mental health is adequately covered in medical and nurse training? And what proportion of that training is allocated to mental health in undergraduate medical training, GPs, adult nurse training, children's nurse training, et cetera?

Very quickly, just to go back to the point, I think it's worth bearing in mind the difference between those who are graduating after following a mental health nurse route, so they would graduate as a mental health nurse, and those who are following adult, child and learning disability routes. And there are differences and commonalities there, but just to illustrate that point. And then, afterwards, of course, you would do various levels of Master's, PhD or different qualifications, so just to say that there is a range of skill levels in nursing.

Yes. I'm aware of that, but in terms of general nurse training. So, I'll redirect my question and ask: in generic training, what proportion of mental health awareness is there in those courses?

Again, it's a good question. I spoke at a conference last week in the Hilton and we had student nurses in the audience and I asked them, 'How much mental health training have you had in your training?' and they said, 'Virtually very little, if any at all'. And then I clarified and said, 'Have you had any CAMHS training?' and they said, 'No, we've had no CAMHS training'. So, you could probably look from the whole point of view of general nurse training, and you will have mental wellness, you will have some mental health and you will certainly have an introduction to mental ill health and serious mental illness, but it doesn't form a large percentage of the course—you could be looking at days, hours, more than weeks.

And then, what you're talking about when people are actually in place is the placements that they do, so there's the education in terms of what they receive and then there are the experiences that they have, which are also part of that education. So, for example, if you had a situation where, say, a nurse who was being trained as an adult nurse or a child nurse, they could do some mental health placements, they could learn from that environment. And then, of course, you've also got the issue of once they've actually graduated and they're in place, have they got access to continuing professional development? So, they could be working in an A&E environment and they could think to themselves, 'Do you know what, what I actually need in this environment is some extra education and training about how to do interventions with some of the people I see, or how to refer people or how to recognise issues'. So, then the question is: how does that person access that? So, all of those things, we would say, absolutely need to be improved—at all of those different levels, improvement needs to be made to ensure that people have access to those skills.

Part of my role as a consultant nurse is to train, supervise and enable non-mental health nurses to deliver low-level psychological interventions and mental health work. I've developed a 20-credit module for school health nurses and health visitors at the University of South Wales on their advanced practice course—basically, how to do low-level cognitive behavioural therapy. But apart from that, they hadn't had a lot of training. But from a mental health perspective, working with our general nursing perspective, we do offer support and we do offer supervision and we do offer training. It depends whether or not they've actually got the time and the space to do it, because everyone is somewhat busy.

As you'd expect in GP training, we're generalists. Mental health issues feature very high on our curriculum—not just diagnosed mental health conditions, but bearing in mind that, for at least a quarter of our patients, there is a psychological element to their presenting problem, even though that may not be the reason why they've lifted the phone or come in to see me today. We put a big emphasis on training on psychological health and managing mental health issues. Most GP trainees have the option to do a formal psychiatric post for six months if they so wish, and that could be in adult mental health, it could be in older adult mental health, child health or whatever is available, depending on the scheme in Wales.

We put a very big emphasis as well in GP training, including, as part of the half-day release education programme organised by the programme directors for the local schemes, on mental health problems, how to manage them and giving people a flavour of what's available in different areas, because assuming the generic, 'This is what you can do' doesn't mean that it's available to all, sadly, when they qualify, depending on where they end up working. We also have a system of self-directed learning, where trainees have a dedicated session every single week, and a lot of them use that to gain skills—for example, to get an insight into what psychotherapy is about, what the CAMHS service can deliver or what a learning disability service delivers, et cetera. So, we try very hard to make sure that people get exposure as part of their formal training, if you like, but also on the job, because a large part of what we do does involve mental health issues, and at the end of every surgery, trainees are debriefed by their trainers and supervisors and have the opportunity to discuss mental health issues, and to identify learning needs and also the facilities to negotiate, to address those, both within and outside the practice. So, I think we work very hard to try and make sure that we look after our GP trainees. There are lots of CPD activities for established GPs, and the multidisciplinary primary care team as well, and they are well accessed. With remote meetings now, they have been even more accessible than they've ever been, which has to be a good thing.

So, there definitely seems to be a need, then, for role-specific training rather than more generic stuff, and do you think there needs to be a better understanding of the needs and experiences of different groups and communities, and the things that affect different people in different areas in terms of neurodiversity, disability awareness, sensory stuff? I think there's a definite need for that, but how do we get there? What do we need to do?

I think you're absolutely, completely right. I think that's exactly what's needed, and definitely the role-specific stuff is helpful, because it's more practical, it's more, usually, at the right level. What I would say is—again, going back to your point about general nursing rather than, say, mental health services, but it's true for mental health services too—access to CPD is lower in Wales in the NHS, not even in the independent sector, than it is in England. Now, there's no particular reason for that, and it's been that way for a number of years now, because the financial pressures are just as great in England as they are here, yet there seems to be an issue with releasing people, even for 15 minutes, in order to do this. So, there seems to be some sort of cultural issue with access to CPD in the NHS, which I think we need to tackle.

But I think the other thing that's worth pointing out is that nurses don't have any built-in time in their contracts. Even though they obviously do need to do all of the learning and reflection and everything that all the professionals need to do in terms of revalidation, they don't have that built in like some of their colleagues do. So, actually, making those provisions available is a way, because people—. Very often, there is excellent education available on, say, learning disabilities and dementia or specific cultural issues or linguistic issues, and people know that they're in need of it and want to access it. But if you're talking about coming home after a 12 or 14-hour shift and then you've got caring responsibilities, when precisely are we expecting people to do this? So, once again, it's a really high expectation on these people, and yet not necessarily rewarded or recognised or given the opportunity to actually reach that level, just criticised when they don't.

So, what do you think needs to change in that sense, then? Do you think it needs to be contractual things in employment laws?

I'd like to see a performance target for the NHS on CPD, because we know how many people are—. Even their mandatory training, and even issues on the ward like health and safety or refresher courses on CPR, we know that people aren't actually hitting the targets that they're supposed to on that. So, let's make that an actual performance target if that's what we feel, as a country, that we need to make sure that our professionals have got access to skills. If we can't, let's do that.

I think it's the right sort of CPD, because, working in a health board, you have to hit a certain level of mandatory training, and it doesn't really have a huge amount of relevance to what you do clinically, but you have to do it, and if you don't hit it, you can be penalised. But, as a nurse, you don't have to be clinically supervised to practise; you do as a psychologist, you do as a psychotherapist, you do as a medic. So, the focus seems to be slightly skew-whiff from the actual clinical intervention you're delivering more to the fact that, 'Have you done your health and safety training' or 'Have you done your fire training?', which I'm not saying isn't important, but there's a skew-whiff away from the clinical intervention, to an extent, really. And I think if we could redirect the area to that, it would be really, really important.

Certainly, I trained a number of my junior nurses in cognitive behavioural therapy on the Cardiff course and, as soon as they qualified, they were poached to somewhere else because they went to a more senior position. So, you've got those sorts of difficulties, because mental health nursing is a small catchment pool, really, and most people are actually trying to appoint people from the same area. And if you can go to a different health board that supports you in a different way to do what you've actually been trained to do, you'll go there more than staying there where they say, 'Sorry, you can't do that; we're too busy to supervise you.'

That's where the national approach is important. And one little point I would add here to this is the role of the consultant nurse is critical, right, in terms of developing not just the nursing staff, but other staff as well in terms of provision of that education. So, if you don't have those senior consultant roles—and we don't have enough in Wales, and we don't succession plan for them—that tends to fall apart. So, what happens is you might get a consultant nurse moving to another role or retiring and then you have a situation where the health board is, like, 'We can't really find anyone to replace.' That's why we're saying that there needs to be some kind of Health Education and Improvement Wales national plan for actually developing these kinds of skills in the workforce as a whole, because otherwise what we're doing is we're seeing a population need, we're trying to hastily design a service to fit with the people we've got as opposed to actually producing the people we need to match that need.

How do we better diversify the mental health workforce then? I suppose, in Wales specifically, an example of that might be getting more Welsh-speaking mental health nurses in west Wales so that they better reflect the communities we serve. So, how do we make steps and improve that? Is that through education or is it making the career prospects more attractive for people wanting to—

I'm afraid, on this, you'll have to give just a one-sentence answer. I'm sorry, apologies.

Career pathway—most nurses, when they become senior, become managers; they lose their clinical role. So, if you had a career pathway—in one sentence—that covered clinical work, educational work, management work and research work, it would be a lot easier for people, because to become a senior nurse, you become a manager, often.

Thank you. I appreciate that.

One sentence would be: demonstrate to young people in different communities that it's a rewarding career.

For primary care, get out there and blow the trumpet and say how good we are at what we do and how we work very well as a team, and we've embraced other healthcare professionals helping us fill the gaps with our GP workforce. The only way forward is to identify people, enthuse them to do what we do, let them come and see what happens and, hopefully, learn from that and get them involved, and particularly at an early age, put emphasis on schoolchildren and people who are about to go to university. It's trying to get people enthusiastic to come and join us and see what we do, and the potential to do even better than we do currently.

Thank you for being so succinct on that to help us get through all of our questions. Joyce Watson.

Thank you. I was waiting to be unmuted. We've had lots of evidence about the very strong link between the prescribing of antidepressants and poverty, the reason being that the GPs have got nothing else to offer. Is that your experience?

Dr Keely.

I think there's always something to offer. We're there and we offer support, and that in itself is a plus. There are some services available for patients, and we try to make the best of them, for example, with this splurge in IT development in the UK, we've now been able to offer more online facilities, things like cognitive behavioural therapy online for patients. Not everyone, I appreciate, can access those. Counselling services are available, but, again, during COVID, sadly, not as available as they used to be, which is a huge issue at the moment, and waiting lists are rising. We all know that, for mild to moderate mental health problems, counselling or CBT are just as effective as medication.

I think, in all honesty, people use the resources that they have and try to give the patient the best deal they possibly can. There are a lot of patients who openly admit that, in order to engage with these therapies they aren't in a good enough head space already, if you like, as they tell me, to actually engage with them. Sometimes, they opt for medication so that it will improve their mood, their concentration and their enthusiasm and reduce their anxieties sufficiently so that they can engage with other therapies, but medicine isn't always the answer. I fully believe that. There are lots of other options, the problem is having them equally available to all of our patients regardless of their background and the issues they're experiencing. It should be a tailored programme of treatment for that individual patient based on their needs and their wants.

Antidepressants do work, they're effective for mild to moderate anxiety and depression, the evidence is clear. But exactly as my colleague has just said, equally effective are other types of interventions as well. I think it has—. I'm hesitating, because a lot of the information that I have is actually pre pandemic, and I think it would be interesting to see how the pandemic has affected it.

What I was about to say is that I think in the last five years, the situation for GPs has improved tremendously. I think they have more access now to available alternatives. I think, certainly, there was a point when it very much was the case of wanting to help the people in front of you, but not having any other thing to do, then you only had that option. I'm hesitating slightly because I think, possibly, it would be interesting to see what the impact of the pandemic is on some of those, and I think maybe some of those interventions—I'm particularly talking about some of the social activities, for example—will have been halted. So, I'm hesitating slightly, but I think that that situation, generally speaking, has improved.

I do think that you make an excellent point about the link to poverty. Poverty in itself is a stressor. Not being able to have a roof over your head or feed your family or do any of those basic needs that people have is profoundly difficult to cope with. We're seeing that in our own membership at the moment, as well as in the general population, so there absolutely is a link between poverty and mental health, generally. I think having the range of interventions available for GPs in those areas is really, really important. Again, I'm not quite clear if we have a national picture of that.

I'm sure we don't, because it varies so much. Even in my neighbouring practice, 15 miles up the road, they have access to different services compared to my practice, and that is the case throughout Wales.

Can I bring Joyce back in? I'll come to you then, Mr Hails, if that's okay.

I'd like to move on, then, to ask—. You've all mentioned the interconnectedness that needs to happen to treat the whole person, not just the problem they're presenting with, so, are there any structural or professional barriers to a more joined-up approach between services that will meet people's needs in a more holistic way?

Did you want to come in first, Mr Hails, or somebody else? No. Lisa.

'Yes' I suppose is the answer. I think, going back to the group that we particularly want to highlight, which is people with severe and enduring mental health issues, or some of the populations we've highlighted—say, for example, the prison population or other areas—you're talking about people who obviously have a range of needs. They have clinical needs and health needs, but also, potentially, issues with housing, holistically with their life, so, access to education or employment. So, clearly, they need a range of services to be supported and they need individuals who can access that range of services.

So, from that, I think it's fair to say that our clinicians—. I think my colleague said, nurses are often in the place that's actually doing the co-ordination between those services and actually bringing them together. Anything that can facilitate that is helpful. So, where there are structures in place to facilitate that communication, where professionals have got the time—and I go back to this business about time, because if you're short staffed and you don't have time, ringing people, chasing people and coming back on that message, all of that is taking a considerable amount of time to organise. So, where people have the time and the ability to bring people together, then that works.

Now, clearly, as well, we also have to watch out for any barriers in the way of budgets. So, facilitating that in one place can be useful. Professor, are there any examples of where there are some good joined-up services?

If we could kick off with Julie first and then I'll come back to Mr Hails.

Sorry.

Thank you. I agree with you wholeheartedly, Lisa. Time is an issue. Staffing is an issue. In primary care, physical space in your building is an issue. We would very much welcome—. When we had a social prescriber in our practice as part of a pilot a few years ago, it was wonderful. Patients who were poor, who had lots of housing needs—. I'm a GP, I can 'Doctor Google' things like everyone else. But at the end of the day, having this lady, who was absolutely wonderful, she knew up-to-date information about housing and benefits, et cetera, which I'm not a source of information on, really, I'm as good as Joe Public and what I can find on the internet—. But having somebody like that, having the space and the time and the right person with the interest, the motivation and the training to deliver that service, and to keep up to date with what's available and to support patients in general is what's needed. And that is, you may say, nothing to do with medicine, but it's a good place to house such wonderful people in practices, because there's already a structure there. We’re lucky that practice premises, although they are inadequate in size, are developed, and their patients know they're accessible, and they know how to use the services. It would make a huge difference to practices to have that single point of contact, to join up the social and the medical care for patients, because it is a massive problem. And there are lots of people with mental health issues who have low-level mental health issues, who just need that support to help them see the wood from the trees and move forward with trying to solve their problems, and at least getting some support to do that.

Sure. I’ll just bring Mr Hails in, just to be brief, before I come on to Rhun.

I agree. I think if you look at the link between primary care and secondary care—. When I used to work in the Maudsley many, many years ago in London, I was a CPN, a community psychiatric nurse, and I was based in a local GP surgery. We used to work really rather closely with the GPs, and we used to see certain people that they would have seen, or maybe didn't need to see, because they needed to see a mental health nurse. But those sorts of positions don't really exist anymore because of the acuity on the secondary services.

I think a good example of care is the way that the primary mental health services and secondary mental health services have actually come together now, and they provide a seamless level of care virtually from tier 0 up to tier 4 and if someone needs to be admitted, really. I think you can look at most of the health boards and you can find good examples of that. I think, also, if you look at the way that the third sector organisations and secondary care and primary care are starting to work together now as well, I think you've got good examples of innovative and different ways of working. But I think, as we're talking about nursing and medics, enabling medics and nurses to work outside the traditional institution and to work in the community, I think, will actually alleviate and target some of these more pronounced difficulties. If you've got a CPN working in a deprived area, it will help people, because they don't have to go to the GP, where they may not be able to get to, the CPN will come and see them in their home. It just makes things easier for people, really.

Thank you. We'd better move on for time. Rhun ap Iorwerth.

Thank you very much. It's really interesting to listen to you and we've had really comprehensive answers already. So, just to take this a step further on some of the matters that have already been raised, on the point that you were raising there about bringing in the third sector to work side by side with the health service, et cetera, how close are we to being able to say that we're creating a society that supports people with their well-being and mental health? Is that something that we're going to be aiming for—creating this wider community that will support people?

I think I'd like to return to my initial point about, perhaps, the lack of focus at the moment on people with severe and enduring mental illness. In the last decade, there's been a very welcome focus and a sea change in terms of national policy about understanding that mental health is everyone's business and understanding that we can all improve and work on our mental health together. And a lot of very, very important interventions are now being made available for people with mild to moderate anxiety, depression and those kinds of illnesses.

There was always going to be a group of the population that, through trauma or whatever other reason, has actually got much more severe needs. That needs specialist skills and it needs specialist services to support. I think what's important is that we make sure that we have the continued investment in those services, in the people and the capital estate as well that is needed to support and look after that particular group, and make sure that they have the best outcomes and have productive, enjoyable lives because they are us; we are them. This is what could happen to us, it could happen to our loved ones. This is a part of humanity. And I think there is a real danger that some of the focus, the very important focus—and I don't want to detract from that—on prevention has almost got us to the point where we're thinking, 'If we invest enough in this side, we will somehow prevent or not need mental health services', and that's a sort of weird, slippery and not-very-logical train of thought. So, yes, we do need all of those interventions as a society, and part of that range of interventions is caring for a very particular group of people with very particular needs. That, for me, is the aspect that needs to be brought back in to the mental health strategies at the moment, to have this holistic picture of mental health services.

Where do you think we are on that balance between building a society and communities that support people's well-being in general and making sure that we have the more specific interventions?

I think the will is there, I think the message is very clearly stated, hopefully, by all of us in the NHS that people with mental health problems have the same equity and right to access medical care, or social care, or whatever meets their needs. And that is something we need to emphasise. There are certain groups we know—patients who are poorer, LGBTQ patients et cetera, people from ethnic minorities—where there is a certain mystique or disbelief that something can be done to help them and that it isn't really a valid problem, compared to a physical illness. I think that message needs to be given very loud and clear. But I think there is a will for people to come forward, and certainly during the pandemic I think we've seen a huge increase in the number of consultations with mental health-related issues, particularly with young people, because people's lives have changed immeasurably—from, 'I'm isolated, I'm furloughed, I don't know what my work future will be', to 'Now I have no job and I haven't got any money, and that's making me feel depressed and anxious about the future.' And I think people are getting the message they should come forward. I think they're worried there aren't services there to meet their needs, that nothing can be done. I think we need to give a clearer message that we are working together, that something will be done, and the something to be done will be appropriate for that individual to best meet their needs in the current constraints that we have, and hopefully identify services that need further development and work together to do that.

Euan.

I think that, thinking about the third sector and the secondary and primary care sectors working together, there are good examples of that. If you think about many of the first episode in psychosis services developed in the health boards, they're partnered with either Adferiad Recovery or Mind, and they both work together to deliver a state of the art service. But, again, it's to the higher poorly population more than the lower poorly population. Quite a few of the charities or third sector organisations employ quite a number of nurses now as well, and they deliver nursing-based and nursing-focused interventions, working again quite closely with the primary and secondary care services.

Often, there's a mist between the health and the third sector and social services, and sometimes when you're actually looking at more of a behavioural approach than a health approach, that can sometimes get slightly difficult, because health may not deliver that and social services will deliver that, but social services can't deliver that because they're so stretched, then health ends up delivering it. So, I think there are good examples of all of the services working together, but I think so much more could be done. And again, as we spoke about earlier, changing the location of the delivery, moving into a third sector organisation—and if you think about the sanctuary provisions, most of those are actually delivered by third sector organisations partnered up with the health boards. So, I think it would develop maybe an easy to access service, or one that you can access in a slightly different place rather than having to go to the emergency department or having to go to the old mental health facilities, really. I think it would be good.

Thank you. And just one last question. Building on the comments that you made about social prescribing and your use of the benefits of that, just briefly, as we look to make recommendations at the end of this work, is investing in identifying the potential of social prescribing—should that be a priority for us?

A massive priority. It's absolutely vital that we do that. There are lots of people who would benefit greatly and avoid developing chronic physical and mental health problems as a result of that intervention early.

Does that include understanding better what social prescribing could be?

Indeed. It has massive potential. I think it should be area-specific as well. There are generic principles, but it would really make a huge difference to the well-being of the general population, and I think it's essential to have that system and support available alongside conventional medicine, whether that's in primary care, secondary care or community mental health services. It is essential that we have that whole picture and support the person in the way they need to be supported at that time.

I think it's interesting, if you look at the National Institute of Health and Care Excellence guidance for depression, which were republished on 29 June, I think, and if you're talking about someone with moderate or mild to moderate depression, the first thing a GP would be offering them is a social prescription—

Yes, if we had them.

—'Increase your activity, reactivate yourself, join a local gym, go and do this.' They'll consider that before they consider cognitive behavioural therapy, which is the evidence-based intervention of choice, or before they consider any form of medication, really. And if people can access those facilities without having to pay through the nose for them, because if you're looking at deprived people or people without a lot of money, they're not going to go, because they can't afford it. So, that sort of stuff would, you know—.

Indeed, it's hugely important. We all know that exercise, in particular, is very beneficial. Having social contact with other people is very beneficial for mental health as well, and various groups—you mentioned the dementia one in Swansea, which is very successful. It's just having that point of contact support for the patient and also for the families, and that is absolutely vital to improve the health service that we're delivering and the holistic care we should be delivering for patients.

Thank you, all. Thank you.

And Men's Sheds.

Yes, fabulous. We've got Men's Sheds. [Laughter.]

Thank you, all. Just to finish our session, just tell me in one sentence what your key recommendation would be when it comes to supporting reducing mental health inequalities in Wales?

Well, I'm going to cheat, I'm afraid. I'm going to have to say there has to be two. I think there has to be a postgraduate mental health workforce strategy, looking at how we get those people at the right time in the right place. But I also do think it's time to change the law and extend section 25B to in-patient mental health care. We have a lot of laws in the aviation industry, in childcare, in dog kennels about having the right number of skilled staff to look after people safely. I think we've demonstrated that that works very effectively in adult and children's medical and surgical wards. So, I think the same provisions should be made to the very vulnerable population in mental health.

I didn't mind you cheating there, because that was a very good succinct answer. So, thank you, Lisa.

My perspective on it would be, basically, if you think about tier 0 to tier 4, to have the appropriate and correct level of service to the need of the person actually where they can access it, but not forgetting people in tier 3 and tier 4. Social prescribing is excellent and offering education support and physical activities will help, but it still won't mean that people won't become seriously mentally ill in the future. So, I think we need to think about the whole population as a continuum, from low-level psychological-type interventions to high-level interventions, and when people may need hospital as well. So, I think you need to think about all of it, really, not just front-ending it.

Thank you.

I think we need to work on developing the workforce in health and social care to deliver holistic care to the patient, bearing in mind their medical, psychological and mental health needs at a given time, with an emphasis on developing the specialist services equally to supporting patients at the lower level who don't require as intense treatment or interventions, and hopefully, through intervening early, avoiding people developing chronic mental health problems. And also, should they develop mental health problems, that we have mechanisms in place to identify those and intervene early, and that they have the opportunity to see the right healthcare professional to deliver the particular care they need.

Thank you very much. Diolch yn fawr iawn. Thank you for your clear succinct answers to that last question. We really appreciate it. And sorry for having to rush you through some of the earlier questions in order to get through all that we wanted to ask today, but thank you very much. Diolch yn fawr iawn.

We'll take a 15-minute break now because we need to do some technical bits as well, so we'll be back just after 10.45 a.m.

Thank you for the opportunity to speak to you.