Children, Young People, and Education Committee

We'll get on to the first item on our agenda, which is our evidence session 3 on mental support in higher education. I'd like to welcome all the witnesses that have joined us here this morning. We have Andy Bell, deputy chief executive officer for Centre for Mental Health; Sian Taylor, clinical lead for primary child and adolescent mental health services, Aneurin Bevan University Health Board; Angela Lodwick, head of service, s-CAMHS and psychological therapies, Hywel Dda University Health Board; Richard Maggs, medical director for adult mental health services, Swansea Bay University Health Board; Andrea Parry, team leader, Iechyd Da youth health team, Hywel Dda University Health Board; and Emma-Jayne Hagerty, clinical lead specialist, eating disorder service, Aneurin Bevan University Health Board. Thank you all for joining us. We've got a large panel this morning and lots of questions to go through, so I hope Members and witnesses can be as succinct as possible. As a rule, I'll generally go to you, Centre for Mental Health, to answer the questions first, and, hopefully, the relevant health board representatives perhaps can each take a question unless it's directed at an individual. So, we'll move straight into our question session this morning, and the first set of questions is from Buffy Williams. Buffy.

Thank you, Chair. Thank you all for joining us this morning. My first question is: to what extent are there gaps in the information about mental health conditions from students in higher education? How should these be addressed and, also, by whom?

Andy.

Thank you. It's a really interesting question. I think one thing we do know that is positive is that young people and young adults are more aware about mental health and have more understanding and language around mental health than ever before, and that's due to the fact that we've had quite a significant cultural change in our willingness and ability to talk about mental health, and a lot of the awareness and anti-stigma campaigns have, I think, opened up conversations, but, inevitably, there's a gap around mental health literacy, and there still is a lingering issue around stigma and not really knowing what to do with that.

I think, inevitably, we need to use lots of different routes to get messages across. We know that everyone receives messaging differently. Different media work for different types of people. We mustn't make assumptions about students and their preferred methods of being communicated with, or indeed communicating with one another, but I think we know that messages from peers are often quite powerful—so, people that they have some kind of affinity with. But I think it's also important we take every opportunity to build up students' knowledge about mental health, whether that's through an information campaign at a very high level, or whether it's a one-to-one interaction with a tutor or somebody that they have a connection with in the university. There's no bad way to do that, as long as it's done well and empathically and compassionately.

Thanks, Andy. Does anyone to come in from a health board? No. Buffy.

Right, I'll move on then. To what extent is the higher education student population atypical and needing targeted mental health support? Do mental health conditions for other young people compare to their peers in higher education?

Andy.

This is a really interesting point. We know that the age group that students in higher education predominantly come from have very high and rising rates of mental health difficulty across the UK. I am drawing on data here at UK level, not at Welsh level; it's important to say that. Other colleagues may have more data that's closer to home. But I think what we know is that rates of poor mental health are rising, particularly in the 16 to 24 age group, and particularly among young women. That's where we've seen the biggest increase over the last decade or so in poor mental health. We know also that people who go to university tend, on average, to have better mental health than those who don't, and, so, while it's really important to understand the particular needs and concerns of young people who are in higher education, we mustn't overshadow those who are not in higher education, who generally have significantly higher rates of poor mental health, and may be missing out on the kind of support that is rightly provided when you are in a higher education setting.

So, clearly, there are some significant differences. There are also big inequalities within the student population. We know that women students, unsurprisingly, given what I've just said, are likely to have higher rates of psychological distress than men; LGBTQ+ students, overseas students, and certainly students who are from more disadvantaged backgrounds, are more likely to experience mental health difficulties than others.

Thank you, Andy. Does anyone want to come in from a health board, before I bring in Ken? No. Ken.

Thanks, Chair. That was really interesting, Andy, what you were saying about younger people in particular showing increased signs of mental ill health. Would you say that this is across all conditions and across all severities of conditions as well? Are we seeing an increase in, for example, low-level anxiety, depression, as well as more serious conditions, like multiple personality disorder and schizophrenia, or is there a specific set of conditions that we are seeing a particular rise in?

A really good question. I think, for young people, mental health diagnoses are often quite difficult to make. So, I think, what we're seeing is rising levels of psychological distress, and whether that comes in the form of one condition or another—. Many people, during their course of being treated for mental ill health, may find that they get lots of different diagnoses at different times. I think we're certainly seeing an increase in prevalence of mental health difficulty.

It's worth thinking of mental health as a spectrum, by the way, rather than a binary thing, so it's not the case necessarily that you're either mentally well or mentally not well; we're all on a spectrum. And many young people are in that area of the spectrum where they may have poor psychological well-being but not necessarily a diagnosed mental illness, or a diagnosable mental illness. So, I think, what we're seeing is more young people going up to the wrong end of the spectrum, if you like. One thing we have noticed, particularly over the last two years, is a very worrying increase in young people being referred for treatment for eating disorders, and that is a very, very concerning issue, and I'm sure that colleagues here will have a lot more intelligence about that, because we know just how serious eating disorders can be.

Thank you. James.

My question is: you said there's a big difference between young people who go to higher education and university have better mental health than those who don't. I know you've said that social deprivation is a factor. Do you think there are any other factors that play into that?

We know that deprivation is probably the biggest risk factor for poor mental health in any society, and, certainly, in the UK today, and, of course, particularly, facing a cost-of-living crisis, that's very acute. I think the other thing about young people who don't go to university is that, by and large, they may well be in a workplace, or they might be in more financial difficulty, certainly with less certainty about the future, and so, there may not be that structured mental health support available. If someone goes into an apprenticeship, for example, or into employment, it then depends on how good the workplace is in terms of supporting their mental health. And, of course, for many young people who don't go into higher education, there is that greater uncertainty about what prospects they may have in life, and they may be dealing with quite a lot of other difficulties, and just knowing, in a sense, that they're missing out on something.

Yes. Sorry, Chair, if I can just jump back in there, I think that's a very important point. Because of the way work life is set up at the moment, almost every job across the country requires you to have a degree, and I think people who don't go to university do feel that, 'My prospects have been narrowed'. So, it's interesting that you say that, because it’s something that I hear quite regularly.

Thanks, James. Buffy.

Thank you, Chair. We know that our young people find that there’s a stigma surrounding seeking mental health help. What do you think can be done to break down the barriers? And also, how do you think universities and educational settings can make it more accessible for our young people to access mental health help without them feeling that there is a stigma attached to it?

Andy.

Do you want me to go? I think, again, multiple routes have got to be the answer here. Just to tackle the stigma question, the way stigma works with mental health is complex and we see it in a number of different ways. One piece of work we did talking to students in further and higher education found that one of the biggest barriers to help-seeking if they are experiencing mental health difficulty is a view that there’s a lot of pressure now to succeed at university, both socially and academically, and if you’re seeking mental health support, that therefore implies that somehow, you’re not doing well—you’re not making friends, you’re not a great social success, you’re not getting on with the course. The way stigma operates is really interesting, and we need to see that it’s different in different circumstances, and so, I think there’s something about ensuring that there are different routes to support. Obviously, the use of digital technology allows many different routes to getting access to support now.

We evaluated the excellent Student Space initiative that Student Minds developed in 2020 and found that it had provided a different and really interesting route for students to seek support for their mental health. But of course, you also do need traditional services available, face-to-face support—we know that’s really important for many people. Online isn’t necessarily a simple replacement for face-to-face support—far, far from it. So, I think it’s really finding multiple routes, and a ‘no wrong door’ approach is helpful, and of course, if you’re proactively asking young people about how they’re doing, and you’re creating those conversations in just routine ways, you’re perhaps more likely to identify someone before they’ve reached the point where they’re really hitting a crisis.

Does anyone from the health board want to come in? No? Yes—sorry, Andrea. Angela.

Thank you, Chair. I just wanted to mention the all-age single point of contact that Hywel Dda has established, which is the NHS 111 option 2. I think that gives us an excellent opportunity to showcase the services available within the mental health services, and I know that colleagues in adult mental health have been going out to our universities and our colleges to share what they offer. They’re leaving business cards and the aim is to provide sessions on mental well-being and break down those barriers that stigma carries about mental health. So, I think that will be a really good process for us to use, and I think that will also be supported by the school in-reach services that myself and my colleagues on the consultation are involved with, in that we are now present in all schools, and that will extend to colleges within our area in due course, and I think that’s a good opportunity, again, to break down the barriers and promote good emotional well-being and reduce, hopefully, the impact of mental health conditions. Thank you.

Thank you. Buffy.

Thank you. We know that there are inequalities in terms of mental health provision across the board, especially for students from ethnic minority backgrounds. How do you think we can address this? Also, I know that all education settings provide their own standard of mental health provision, how can we ensure that each university or educational setting has a good standard and a good quality of educational psychology? Because from my own experience, I know that each college I've visited and each comprehensive school that I've visited, they’ve all got their own way of doing things. How can we make sure that that standard, that good gold-quality standard, then, is met across the board?

Andy.

Thank you. That's a really good question. I'll take the racial inequality point first, because I think that's a really important one. And, again, it's really important to say that we know that people, particularly from black African and Caribbean communities do not, for very good reason, trust mental health services. Very often, you have an adversarial relationship with schools and with the police, and that extends, unfortunately, to mental health, and we know that that means that people aren't getting early support and we know, indeed, that there is a greater risk of poor mental health among people from racialised communities, and their experience of services is very much poorer.

I think what we do know is that, where mental health services reach out and work alongside and in partnership with communities and community organisations, you get a much more accessible, open and safe feeling to the support. So, I think crucially, we need to understand those dynamics, we need to understand how structural and systemic racism work, and so, we need services that respond to that. And, again, if young people from a community see services run by people like them with a similar experience to them and they are outreaching and proactive and they create a sense of safety, and they're informed by an understanding of racism and racial trauma, rather than just assuming that if we say, 'We're here' loud enough, those services will be trusted—. So, I think that's crucial to address the inequalities that we know exist there.

I think the other thing that is really important to say, thinking about the whole institution now, is that there's growing evidence around the importance of what you might call a whole-school, whole-college, whole-university approach to mental health. It's jargon we use a lot in mental health and it's probably worth saying what that really means, which is essentially that the culture and the processes of that institution, be it a school, university or college, consider, think about and support mental health from day one onwards, and for everyone in that community, including the staff members, who often get forgotten in this conversation. So, you create a nurturing environment, you create an environment where people feel safe, where there are positive relationships and where everyone is supported where possible to enjoy good mental health in schools. It's about putting it on the curriculum as well, of course. And I think if you're doing that consistently, then you can begin to create a culture where mental health is supported. It's not about creating extra work, it's not about putting yet another burden on people who are already working very, very hard, it's about creating a supportive and nurturing environment. And that takes time. You can't do that overnight. But I think once you start to bring those principles into practice you've got a much better chance of creating a good, supportive environment for people.

Thank you, Andy. Anyone else from the health board? No. We'll come on more to mental health support within universities later on as well. Thank you, Buffy. We'll now move on to questions from Sioned Williams. Sioned.

Thank you, Chair. Good morning. I'd like to talk a bit about factors influencing student mental health. I'd like to know what your opinion is about what the main factors are that affect student mental health. We've already talked a bit about stigma and the social pressure and academic pressure on students, but I'd like to know what proportion of those main factors are responsible for mental health problems in students and how many derive from social factors or environmental factors more broadly, and then how many of those things are affected by the university experience itself.

Andy.

Gosh, that's a complex question, isn't it? It's really difficult to disentangle the different factors. So, we need to be mindful that they interact with each other. And I think one of the things that is really interesting is, when you look at surveys or you look at qualitative research with young people—and we're predominantly talking about young people; not all students are young, of course—but when we look at the age group that's predominant in higher education, and particularly those who are in a higher education setting, very often, it's the same things that affect everyone's mental health: it's worries about money, and I think that is particularly acute right now; it's worries about relationships; it's feeling insecure; it's experiences of discrimination, exclusion and isolation. So, we know there's a big list of risk factors for poor mental health. And of course, the more of those risk factors you have, the more severe they are and the longer they go on for, the greater your risk is of having a mental health difficulty.

So, although it's very difficult to isolate them or say, 'This one is more important than that one', I think we do know that financial exclusion is a really major one. And I think, again, for anyone at university, there is now greater pressure because of the knowledge that you're racking up a lot of debt, the knowledge that the future labour market may not be as welcoming of people graduating from university as it used to be. And I think, inevitably, there is the extra pressure for students who are away from home, again, to settle into a new place to learn the things that you have to do as an adult away from the supportive environment you may have been in.

And of course, there are very, very particular issues for care-experienced people going into that environment. It's difficult when you've got a family environment you come from and go back to; anyone who has been in the care system will know that that is a really vulnerable time in your life. It is just an age where there is a lot going on that can affect your mental health. So, again, some of it's about the university experience, but a lot of it is about the experiences that young people bring with them and the anxieties they have about their future.

Anyone else? No. Sioned.

Thank you. I just wanted to talk a bit more about the environmental pressures, for example the pandemic and of course the cost-of-living crisis now that's going to worsen perhaps some of those circumstances we discussed in the previous answer. What can the Welsh Government do to better support students in the context of those recent concerns regarding the pandemic and also the increasing financial pressures? Can you describe for us how the pandemic and the cost-of-living crisis, specifically, have perhaps exacerbated some of the things that affect the mental health of students?

We've done a lot of work looking at the impact of the pandemic on mental health for people of all ages, and we looked particularly at students when we were evaluating Student Space. I think what's clear is that it has created multiple pressures, and again, they're not all applied equally.

For every student, of course, their education has been disrupted massively and that's a fairly universal experience. Young people who were at university during the lockdowns will have either not been at university or been in really, really pretty awful situations, particularly overseas students of course. All of that university experience will have been completely blown to pieces for some students, or a large part of it. Those coming to university now will have been at school or college during that time, so, again, that will have affected their experience coming into university. But again, it's not equally experienced. There will be young people who've experienced traumatic grief and loss; there will be students with health problems, both physical and mental health problems, who would have been at greater risk from the virus and indeed from the restrictions that were necessarily created around it.

And then, of course, the cost-of-living crisis comes on top of that. And, again, one of the things that we were concerned about in relation to the pandemic was the economic effects. What we're now seeing is more and more people being pushed into poverty and those who are in poverty going deeper into poverty. We know that that creates a risk to mental health; we know that that has a major causative effect on experiencing mental health difficulties—it's not an association, it's not a coincidence.

In terms of things that the Welsh Government can do—all Governments can do—the first thing of course is to protect people from poverty, and if you can't protect people from poverty, protect them from the worst impacts, so make sure people are getting what they're entitled to, that there is as much financial support as possible, and indeed, that mental health support is there, available, easy to access, and that there aren't long waiting lists and long waiting times for getting hold of mental health support when you need it, and if you do have to wait, that there is support while you're waiting, and that that support doesn't presuppose you have access to the right devices and internet connection. Because again, we can create a new disadvantage for people that are financially disadvantaged if we're relying on online access to services to get you in.

Anyone else, to add to that? No.

Just to go back really quickly to the point about protecting people from poverty, of course, a number of the measures that have been introduced by the Government are ones that relate to means-tested benefits. A number of students may not be eligible for them. Do you feel that that should be considered?

The means by which you could do it is outside my area of expertise. I think the thing that I would say as clearly as I can is: if students are facing poverty, and in a really serious financial situation, if they're really worried about being able to keep things going over the winter in particular, particularly students who are more vulnerable, then you are going to create suffering, and if you can create buffers against that, and you can create a system where there is a degree of certainty about your ability to get through and cope financially, then that is going to help to support their well-being at a time when there may be a very inflated risk.

Thank you. Just to go, really quickly, back to what you touched on in terms of digital exclusion, during the pandemic, of course, the use of virtual tools increased and also phone calls were held to replace face-to-face interaction. So, what are the challenges and benefits of increased use of online spaces for health providers in supporting people with mental health needs, especially students in higher education? I'd be interested to hear from some of the health boards on this topic also.

Andy, do you want to start?

Yes. This is really interesting. I think mental health services had been kind of toying around the edges of working remotely and providing support through digital tools for some time prior to the pandemic, often on quite a small scale, and I think what the pandemic did is suddenly make that the main route by which the majority of services could reach people.

Very interestingly, some data that was published yesterday across the UK showed that for mental health services for all ages, we're now back to about 50 per cent of support being provided face-to-face, but only 7 per cent is being provided online, so the remainder, about 40 or so per cent, is being done by phone, which of course is a rather old technology. This is for people of all ages. Services for young people have tended to favour online and digital routes, but nonetheless, across the whole, we're seeing a lot of use of phone. I think inevitably, working remotely with different types of media—. And for some young people, or people of all ages, text-based support is a really helpful adjunct, or, indeed, a different way of getting support. So, there's no way of saying, 'This group of people benefit from digital, this group of people prefer phone, and this group of people want face to face.' It doesn't work that way; it's often about individual factors that determine what your preference is and what you find most helpful.

I think what we know is where we are having remote-based support, you really need safeguards around that. You need to ensure that the person feels comfortable, that they have a safe space where they can engage with mental health support—not everybody does. Not everyone has a secure internet connection or the right kind of devices, so, again, we need to think about how you wrap support around someone who might like to engage online but that's not straightforward for them. And, of course, you need to ensure that the people working in that service know how to use that medium properly. Again, there may be some forms of mental health support that can be done remotely, and some that can't. It's very hard to support someone with their physical health, for example, remotely, but reminding people about appointments and, indeed, some peer-support groups can work very well online. For some people, it's very much a preference, because it's more convenient, particularly if you're in a rural area and you've got a good internet connection, which, itself, is a bit of a stroke of luck. But, again, where you don't have to travel, that can make mental health support more accessible to someone if it's really quite difficult to get to the kind of places where it tends to be provided.

Thanks, Andy. Anyone from the health boards, Sian or Emma-Jayne? Would you like to come in?

I agree with everything Andy said. A lot of it is personal preference. For us, we have to still see a lot of our patients in person because of the physical health monitoring aspect involved, but we do continue to provide support to any of our patients that move away to university virtually. There is a challenge, because a lot of our patients, just because of the body image concerns and things, don't like to be seen on screen or see themselves on screen. We're just in the process of purchasing a licence for an eating disorder evidence-based Recovery Record app that allows us to interact with patients on a daily basis through that app as well. We've used it a couple of times with some patients, so it's going to be really good that we will be in a position to offer that to everyone.

That sounds really interesting. Does anyone else want to come in? Angela.

Thank you, Chair. I think the pandemic enabled us to use the digital resources that we've developed much more effectively. Certainly, across mental health services within Hywel Dda, they were classed as front-line services, so face-to-face assessments and interventions continued, albeit supported by the Attend Anywhere and consultant—[Inaudible.]

We might have lost Angela—

We've also got a number of new digital resources to use now, such as Kooth and then also SilverCloud for cognitive behavioural therapy online. So, we're able to offer young people a range of support and interventions. That, I think, is a good thing, and is based on preference and that blended approach. Thank you.

Thanks. Richard, did you want to add anything?

I'd just echo that, really. We obviously accelerated the use of digital platforms during the pandemic, but continued to offer face-to-face. It's a variety of online resources that have been described that I think most health boards probably use. The roll-out of the '111 press 2' gives people access to immediate contact with a mental health professional, so they can triage their level of need, so that they can fit into the appropriate tier of the service. I think it's important to distinguish people who have or are maybe developing symptoms of serious mental illness, so that they would have access to early intervention, psychosis-type services—[Inaudible.]

Sorry, Richard. We can hear someone else on the line at the same time, so it's not very clear. You might need to use your headset, I think, perhaps, Richard.

Sorry.

It's okay. Try now.

I've pretty much finished now, really. I was just talking about the 111 early intervention in psychosis, distinguishing between different tiers of mental disorder and the different services that are available depending on the severity of your condition. Earlier, there was a discussion about incidence and prevalence of various disorders, and, I think, the incidence and prevalence of serious mental illness tends to run fairly steady over the years. I think it's probably worth acknowledging that there's clearly a rise in anxiety, depression, et cetera, et cetera. One thing that we've seen in Swansea bay is a massive increase in referrals for attention deficit hyperactivity disorder assessments from the universities, which I think is quite an interesting phenomenon—probably multiple explanations for that. I'll stop there.

Thanks, Richard. Sioned.

That's it. Diolch, Gadeirydd.

Thank you, Sioned. Questions now from Laura Anne Jones. Laura.

Thank you, Chair. On mental health support within universities, and following on from what Buffy said earlier, evidence has highlighted the importance of giving students a consistent standard of support, regardless of where they live or study. We've heard some great examples of best practice already today, and also I'm aware of something in the Aneurin Bevan health board that offered peer-to-peer support online, which I thought was a great scheme. How can Welsh Government ensure a consistent standard of support, given the diversity of the student body and the range of providers who are involved in providing support? Thank you.

Andy.

I think that's really challenging, isn't it, because there isn't clearly just a single route; there isn't just a single model that you can use. To some degree, of course, it is about ensuring that you are commissioning the services that we know provide good-quality clinical support. As Richard mentioned, if you're a young person with the early experiences of psychosis, that's very serious and you do need to make sure that you've got access to evidence-based interventions, using an early-intervention-in-psychosis-type model, for example. So, it's about ensuring that you're using the evidence base, which is always emerging and always changing, that you're using the evidence according to how it should be provided, and that those services are faithful to the model. That, again, is really important.

But, inevitably, I think it's also about understanding the student experience, and ensuring that there are ways of hearing from students about how effective the mental health support they've got has been, and ensuring that there is always that kind of feedback cycle involved. There clearly isn't just a single approach that works, so it is about having that range of different types of support, and ensuring that, when you're seeking feedback, groups that don't often get heard so much or whose needs are not considered so well, an example of which might be the overseas students, for example, that their voices are heard in that.

I think, as colleagues were mentioning earlier, there is also the crucial factor of young people who are coming to university who are already in contact with mental health services in their home area. There is a real challenge about ensuring that there is consistency of support, if they're going to university somewhere outside their home area, and, indeed, of course, going back, because it's not a one-way journey. So, again, really thinking about systems of support that follow the individual—easy to say, fiendishly difficult to do. It's a really complex area to have that assurance that the services are meeting people's needs, but the best way of finding that out is probably to ask.

Sounds good. As Laura mentioned Aneurin Bevan in her question, Sian or Emma-Jayne, do you want to add anything?

A lot of work has been done with public health, going into colleges and linking with students and with student unions, and with trying to find a better way to provide that support. You were talking about the whole-system approach, I'm working in CAMHS, and very used to parents being a big part of the support system, and I wonder do we think enough about who to put in the room, and how we think about parents, because you don’t stop being a parent of a child just because they turn 18 or go off to university. I think the relationship’s different, but I wonder we how we also use parents as a resource, and to support parents going forward in having a role, because I think young people are in contact with their parents a lot, or can be. Just thinking about supporting parents and what their role could be there, too, as well as peers. We’ve talked about the peer support that’s needed, and I think that’s really, really important.

Thank you. Laura.

Thank you. That’s a really valuable contribution, I think, and something for us to think about. Following on from what you just said just now, it’s really important that we don’t create a postcode lottery of support. Just to diversify a bit, is there a way that best practice, and things that are working, are shared across Wales? Is it shared well enough, in your opinion? Or should there be something established along those lines? Thanks.

Andy, did you want to—?

I’m going to have to leave that to colleagues who are based in Wales, because obviously it would be unfair to even venture a comment.

Okay, thank you, Andy. Aneurin Bevan. Oh, we can’t hear you, sorry. Oh, we’ve got you now.

Sorry. I can only speak, I suppose, from the eating disorder service perspective, but we link up very closely across Wales. We have a number of different forums where the eating disorder services, adults and CAMHS, get together. When we have transitioned students from one eating disorder service to another in Wales, that goes quite smoothly through the care treatment programme approach. The challenge is more when it comes to transitioning outside of Wales, and services there. So, we have good forums, we have an all-Wales special interest group for eating disorders, and our sub-group meetings and things, but I’m not sure about more general mental health.

Just in terms of the schools in-reach, my understanding is that the schools' in-reach teams are starting to be formed in schools right across Wales. There is a national forum for that to be shared, but you’re right, it is a bit bitty, and there isn’t one place that all the best practice is shared, and I think that would be a really, really good idea.

Angela or Richard? Do either of you want to come in? Richard.

Yes, just in terms of psychological therapy, Matrics Cymru gives guidance on delivering evidence-based psychological therapy across Wales, which I think is applicable to every health board. So, there’s a standard, if you like, of evidence-based practice that all health boards are expected to deliver on and report on, and that will also include waiting times.

Thanks, Richard. Laura.

Thank you, Chair. Sorry, I believe we might be going on to a bit more of this later, but maybe it’s something to consider, the cross-border issues there. To the Centre for Mental Health, you’ve evaluated the HEFCW-supported initiative Student Space; how effective has the service been, and are there other practical interventions that the Welsh Government and the regulator could take to ensure students receive that consistent standard of support? Thanks.

Andy.

Thank you. We’re really impressed with Student Space. Inevitably, it was quite challenging to get data on the extent to which students have found the actual interventions available on the portal helpful, and that was beyond the scope of what we could do, but I think what we were able to find is, first of all, that it offered a valued and valuable extra form of support, particularly during a difficult time, and actually it’s a resource that should and could have longevity. I think we were particularly impressed by the fact that Student Space had worked very hard to produce high-quality information and advice, that they linked with higher education institutions in doing that—they didn’t just go off and do something separately—and that they had a really strong sense of working with particularly marginalised and disadvantaged groups of students and providing resources specifically to meet their needs. So, I think, for us, Student Space has really created a positive and compelling resource for students’ mental health. It’s got a lot more potential to be used much more widely than it has been, and we hope to see it grow over the coming years. So, again, it’s not about seeing online support or this resource as being a replacement for other forms of support; it’s about being an additional resource and something that can help, potentially, to link students up to support available locally, by providing that connection. We’ve been incredibly impressed by what was produced with actually a very, very small resource.

Thanks. Laura.

Thank you. The new commission for tertiary education and research will play an important role with regard to student mental health. How would you like the new commission to approach working with the healthcare sector, and do you have any recommendations for the commission as it begins its work? Thank you.

Andy.

Well, I’m sure colleagues here from the mental health sector will definitely have views about how they would like to work with it. I think the crucial thing is that we bring together the different forms of knowledge. There is that intersection here between the education world and the health and care world. That, often, is where we struggle to create the right support. They’re often not even speaking the same language. We found that particularly with schools, when we’re talking about school mental health. Often, healthcare and education professionals don't really have the same understanding of what we’re talking about. So, inevitably, there has to be a coming together, there has to be a co-production of knowledge and, crucially, of course, the partners in that have to be students themselves, and diverse groups of students themselves, because their views and understandings will be incredibly important.

We do sometimes find that how services are perceived by young people in particular is very different to how professionals believe they are perceived by young people and, indeed, parents. So, it’s fundamentally important that any solutions are properly co-produced and that students themselves are right at the heart of that process. It shouldn’t just be that they’re the end product, if you like.

Absolutely.

Yes, absolutely. Does anyone from the health boards want to come in? Angela.

Thank you. Yes, I think Andy’s right in the sense that it’s really important that we hear the voice of young people and students in particular when we’re developing new services. I think we can learn from the work that’s been undertaken with the school in-reach projects across Wales at the moment. There has been a robust evaluation of the pilots, and hopefully we’ll have a further evaluation of the impact of that on not just students, but also on the educators as well, because the whole system is being supported. So, I think that’s a really important way forward.

That sounds really interesting. I think it would be good for the committee perhaps to see some of that evaluation as well, if that’s possible. We’d be very keen. Laura, did you—

Thank you, Chair. That’s great.

Lovely. Thank you. Ken Skates.

Thanks, Chair. I’m going to ask about interactions between healthcare and education providers in a moment, but before I do, I have, perhaps, a question for Andy. It’s a bit of a difficult one, and apologies for asking such a pessimistic question, but is it the case that, no matter how much intervention is made on the part of the Government, healthcare providers and providers of various mental health support services, we’re going to see over the next decade a continued rise in the numbers of young people and people in general in society presenting with poor mental health and mental health conditions, as a consequence of the pandemic and of ongoing anxiety over the cost-of-living crisis? And is it the case that interventions will only, if you like, flatten the curve—they won’t halt that rise in numbers over the next decade—or are you more optimistic? Do you think that if we do have an overwhelming and really concerted intervention and collective effort, we could actually slow down more quickly and turn the corner faster in terms of that increase in mental ill health?

Thank you. I work for a charity, by nature I’m optimistic. You’re right, if we look at what we are projecting in terms of the long-term impact of the pandemic on mental health and the impact of growing levels of poverty and financial difficulty—and indeed, we have to include within this the climate crisis and conflicts as well—there are numerous pressures on particularly young people's mental health, but actually across the population. The inequalities that we've seen and described will only get worse if we do nothing. I think, inevitably, a mental health difficultly prevented is much better than waiting for something to become either really serious so that a person goes to crisis point or will need some kind of support.

One of the things we strongly recommend—and I think with the Well-being of Future Generations (Wales) Act 2015 Wales is a step ahead of other parts of the United Kingdom here—is, if you think about policies from the perspective of what would support good mental health in the population and what would reduce inequalities, then the policies being made would hopefully have that test of what would help to produce good mental health in the population and what will help people living with mental health difficulties to have a better, fairer chance in life. So, I think there are things we can do to prevent problems in the first place.

Inevitably, the real challenge for mental health services is that, across the board, they probably only meet about a quarter to a third of mental health need now across the whole population, and that's the case consistently across the UK. That's very challenging to hear, but it is the reality, broadly. And so, inevitably, there is always unmet need and that unmet need unfortunately can sometimes lead to people getting into a crisis and, therefore, the care they need is much, much more expensive than if you'd met that need early, as well as someone experiencing huge amounts of distress. And of course, the more you focus your services on meeting people's needs in a crisis, the more people will end up in a crisis and so services get stuck in a really—. I mean, this is an awful position and this is not the fault of the commissioners and service providers. We know that where you have austerity policies around mental health or indeed public services full stop, you create actually more expensive services in the end, because more people need more expensive help.

We really do need to find a way of shifting the focus towards earlier intervention, towards relatively inexpensive services that can help people quicker. I think what colleagues have described about the in-reach with schools is a good example of how you can begin to shift that dial. It's good that it's being evaluated robustly and there will be opportunities to learn from that first phase. I've always been impressed by the fact that Wales has policies around having counselling available in schools. It's in secondary schools. Why it wouldn't be in primary, I don't know, but at least it's in secondary.

Andy, that's really, really interesting. Would you therefore advocate increasing significantly the amount of counselling available in schools and for all ages of young people?

Yes. Obviously, there is no reason why primary schools should benefit less from counselling than secondary. Counselling will meet some people's needs in some ways some of the time, so it's a great service to have within schools. That shouldn't be the only thing. You're not having a whole-school approach to mental health if you have a counsellor and do nothing else. But if you don't have counselling available, you probably can't say you've got a whole-school approach.

I'm just going to bring in James Evans for a second, Ken.

On this point, it is very important that people get help when they ask for it. We are seeing that the referrals are going up—they're going over the four-week wait time and that is even for counsellors in schools. So, I'd like to know what your thoughts are on where the third sector can fit in this as well. What can healthcare providers push to the third sector to actually give those young people that initial conversation, that initial assessment? When people reach out for help, they should get it straight away, because they've obviously reached crisis point to get there, and then the delay of getting that person seen can be critical. So, I'd like to know how you think the third sector can do more to assist the healthcare profession in seeing young people in a timely manner.

There's a huge diversity now of voluntary and community sector services supporting mental health, from well-being support, if you like, at the very, very preventative end, through to some clinical services that are probably working at just the same level as NHS or local authority-funded services. I think we've been certainly impressed with a lot of the voluntary and community sector organisations that we have had the good fortune of evaluating around young people's mental health. We think that the early support hubs using the youth information, advice and counselling services—YIACS—model are particularly impressive, because they offer early, easy-to-access help without need for a referral or an appointment for young people. We think that is a particularly attractive model.

But there is no single approach. I think a lot of community-based organisations in particular provide valuable and valued support for young people who just don't want to go near statutory services. Unfortunately, what we often hear is that parents battle to get a young person help from a statutory service. They go along, it's very, very clinical, it's an environment they don't feel comfortable in, and sometimes, there's only one contact, because they don't actually find it meets their needs. And so, for some people, it may be that a different type of approach is more helpful. So, again, I think what voluntary and community organisations can do is bring that diversity of types of help to the system, working alongside in an equal partnership with statutory services, who of course are providing those vital services that meet people's needs when they most need it.

I am going to get onto the questions that I was going to ask about education providers and health providers. Just one more really quick question, though, Andy, and it concerns unresolved shame. I think most policy makers appreciate the contribution that unresolved trauma makes to lifelong mental ill health and poor mental health. Do you think policy makers fully appreciate the role or the contribution that unresolved shame can make to poor mental health? It's something that I think practitioners would probably recognise, but I'm not entirely sure that policy makers really appreciate the role that shame can have in contributing to poor mental health—or am I being unfair?

Good question. I don't think I know the answer. I don't think it's talked about very much. I think we're only beginning to really understand what trauma means. We continue to, for example, imprison women when we know the huge proportion of women who go to prison who've experienced trauma in their lives; we put people in restrictive environments. I think mental health services are still only just learning to deal with trauma, let alone other issues that people have got.

But, again, if we take a social model of mental health and we think about poor mental health as being a function of the lives we've lived and the things we've been through and the experiences we've had, and we think about mental health services as being there to support people to deal with those things and to have a better opportunity in life and to resolve whatever those difficulties are, then we can begin to build services and policies around that. That's really important, I think. But for many, many people working in health and care services, the experiences of the last two to three years of the pandemic are going to be particularly challenging for them. We know that there are phenomena like moral injury, for example, that can affect people very, very long term. So, there's a lot of stuff to work through.

Thanks, Andy. Unfortunately, we've run over time here, so I think if everybody is okay, we'll write to you with our further questions that we have. We really appreciate you taking the time today, but obviously, lots of Members had lots of things to say, and we really appreciate all the evidence that you've given. So, I'm just conscious of time, and I know we have a number of questions that we would like to ask, so we will put those in writing. But thank you very much for joining us this morning. We will be sending you a transcript for you to have a look through in the coming weeks, but we really appreciate your evidence that you've given. Diolch yn fawr.

To Members, we're going to take a very quick five-minute comfort break before our next evidence session.

Welcome back, everybody. This is our fourth evidence session on mental health support in higher education. I'd like to welcome our witnesses here this morning. We have Dr Liz Forty, Royal College of Psychiatrists in Wales; we have Dr Julie Keely, Royal College of General Practitioners; and Dr Kim Dienes, lecturer in psychology at Swansea University. You're very welcome here this morning; we really appreciate you coming in to give us evidence. Obviously, Members have lots of questions to ask you and lots of things to get through, so just to remind Members if they can be as succinct as possible, and if you could do likewise in your answers. I'll start with the RCGP to answer questions first, followed by the Royal College of Psychiatrists and then Dr Kim Dienes, unless the questions are directed directly at you. So, just to let you know that. We'll make a start, and we've got some questions from James Evans.

Diolch, Cadeirydd. This is for Liz and Julie, and I'll be very brief. What are the main challenges that you face in supporting the mental health and well-being of our student population? If you could ask for one thing from the Government and health boards, what would that be?

Shall I go first? One thing—that's challenging. Obviously, for us it's the increases in student numbers in terms of students accessing support through universities and their ability to get access to services through the NHS. Sorry, I'm not sure I can do one thing—

Go on, that's fine.

In terms of the main things that we're struggling with at the moment, it's providing access to services, so psychological therapy, particularly things like CBT and trauma-focused therapy for students, and getting that in a timely fashion. At the minute, the waiting times are just too long for students to be able to access that whilst they're at university. And then the other thing that we are struggling with is screening for neurodevelopmental conditions, so things like ADHD and autism. Those, I would say, are the main things.

And if the Government could help you, what would you—?

One thing that has started to help is the mental health university liaison service that has been funded. That, I think, is key to us moving forward to improving the links between the university and the NHS. That's probably a really good resource in terms of thinking in terms of moving forward about how we can deliver those clinical services, but within the university setting, perhaps. So, that's something that would benefit from having a longer-term vision about how that's going to develop going forward so that we can be aware of how we can implement that and use that to the best of its ability within the student population. That's probably the main thing for me at the moment. There is one other thing, actually—

Carry on.

The other main issue we have with our student population links particularly to our students on healthcare courses—so, medics, dentists, nurses, these kinds of professions. We, until very recently, for our medical students, for example, had access to psychological therapies through HHP, which is now called Canopi. That's been extended to health and social care professionals, which is really good, so that service is for all health and social care professionals now, but it's no longer providing a service for students. Actually, because students are the most vulnerable population in terms of developing mental health conditions, it, to me, seems not very sensible to not be allowing the students to be accessing that at an early stage when they're most vulnerable, so waiting until they graduate before they can access that service. It should be something that's available to students. Canopi is set up to deliver therapies on a large scale with clinicians. So, actually, to me, that seems like you've already got a service there that could increase capacity and deliver services to students as well—the healthcare students.

Great. Julie, do you concur with Liz's comments?

Yes. I completely concur with you—what you're saying—Liz. I think, probably, at the top of my wish list is to emulate what Cardiff University have actually done. I know it's been described as 'bridging a gap'; we'd like it to be a permanent bridge of a gap, and not just Cardiff University to get on board, because we desperately need access for students. I'm a GP in a rural area, so most of our students, they all go away to university. But they struggle to register with the GP; they're homesick; it's all new; managing your time, your money; getting on with new people and all that, and that's really tricky. And when you don't have that network and support of your family and your friends and your practice—. We were very strong advocates for what we call 'relationship-based care', which the college has published a paper on recently, and it's so important, particularly with mental health, that people have that confidence and trust in other people, so they're more likely to open up and be honest about how they're feeing.

I certainly know there's a huge problem with students who go to universities, at the minute, registering with a practice. My daughter's a prime example: Aisling is on her second university course, but in the first one it took her three months to actually register with a practice. Thankfully, she was fit and well; she was just on some repeat medication, which wasn't a big issue. But some of her friends had quite severe psychological problems, including those who already had diagnoses, who just couldn't even register with a GP and, therefore, couldn't get access to services. So, she was involved in trying to help set up—. In the student support services, she was the chair of the committee for that, and they worked really, really hard and were innovative, got a nurse to join the team, and the chaplain was a trained counsellor. So, they had some pathways to just have a bit of tea and sympathy, if that was all you needed—'I'm having a bad day, and I miss everybody, and it's awful, and what am I doing?' through to 'I really need psychological help.' But you need to have that professional, that triage level—. Signposting is great, but you need to pick up the people who need that more intensive input, and that's a huge issue, and the continuity as well.

Liz mentioned medical students. Students these days are on a lot of courses where there's a vocational element, so they may not only be living at home and living in the university town, they may be away on attachments for several months at a time, and that continuity is lost. We don't know what's happened either way; we don't get any communications about what's happened; and getting information, even from their practice, if they do manage to get registered and be seen, is basically lacking. There isn't a joined-up system to get that information, so we're doing a disservice to these young people at the moment.

That's very important, and, I think, you said that continuity as well—.

Yes, it is.

That's very important, and it comes on to my second question. What we talk about in Wales and across the UK is the 'missing middle', isn't it?

It's huge.

It's people who are going from the specialist services—from CAMHS—and then they go into adult services. It tends to be that student age, doesn't it, where people are lost in the middle. You talked about Canopi, for example. What sort of services do you think could be set up to support those people when they go at 17, 18, 19, 20, 21? They're going through university; they don't seem to be picked up now. What sort of service would you like to see implemented, that could actually help those people to transition to adult services—the people who are in severe trauma, that type of thing—who do get missed? How could we put something in place to eradicate that with our students?

Currently, a lot of it depends on them getting registered with a practice and, as a practice, as with my own patients, I can communicate directly with the new practice as to what's going on. We give people physical copies of their records to try and enhance that continuity, but it's really tricky sometimes. But, if they haven't even managed to get registered, it's very, very difficult. But they need signposting on site to what's available, and they need someone who has that quick access into the more specialist services, because, often, I don't know what's available in Oxford or London or wherever, but there needs to be somebody on the ground, so to speak, who does, and who can do that assessment and signpost them on. I think that's crucial to develop a service that is fit for purpose.

I think there are particular issues as well with the students maybe coming from England or Scotland, actually, as then the transfer of information is even harder.

It's awful; it really is awful.

So, they're starting from scratch almost, if they're students coming from England and Scotland to Wales.

Often, by the time we've actually got the information or they've been referred to services with waiting lists as they are, they've moved on to somewhere else by then, and then they start all over again. So, it's pretty difficult for them at the moment.

Obviously, the Welsh Government have got their 'Together for Mental Health' plan—

Yes, fantastic.

—which does raise all these issues. I know that the National Union of Students have said that they want more of a focus in that plan on actually supporting young people in universities. How do you think we can get more emphasis in the 'Together for Mental Health' plan around supporting our young people in our higher education settings? Anyone can start on that. Kim, we haven't had—[Laughter.]

Absolutely. I can go and I can jump in. So, right now, we have a situation where we have about 3.7 per cent of people actually using mental health care when they enter the university. At the same time, if you look at statistics, 31 per cent of people actually have mental health issues while they are in university. So, we need to actually have that transition in care and it's a really serious issue.

Possible ways to do it: you have the barriers to information transmission that actually need to be addressed, okay? That's something that actually could happen at the level of the Government, because right now we do have these kinds of barriers to information transmission. That's something that I can't speak to specifically, but we definitely need it. We are seeing it in our students right now. I have already had three come to me this year. It's been two weeks. So, this is something that we definitely need.

One thing that I think could happen is, when you actually have the admission process at university, identification of mental health issues upon admission is something that could really help. So, not just having a centralised admissions team that just puts the students through, but actually having some sort of process that would enable students to identify themselves as possibly needing mental health upon admission. At the same time, we see skyrocketing rates, in that first year, of mental health issues. It's one of the most serious things that we see in ONS data.

The transition, which we'll talk about later, has a lot of identified stressors that contribute to elevations in mental health. So, what we need to do is possibly implement some universal guidance to academics—who are usually the first point of contact: they go to their lectures; they are mentors—some sort of module that academics could take that would provide them with an ability to communicate about mental health resources available, which currently does not exist. We have one on money laundering, but not mental health.

Another that might help is actually some sort of mandated mental health module for first-year students. So, when they actually attend university, something that would actually help inform them about both the rates of mental health issues in first-year students, how serious an issue this is, and also for the individual universities, signposting them towards things that they can actually do to get help.

Now, the help available is a separate issue—the number of resources available—and that's something that I'll speak to later. But I think that communication is something that's lacking right now, and targeting that communication and that information transmission is what we need to do.

Can I say that I just think that it needs to be part of the fabric of the university and the culture there that it is good, if you have mental health problems, to seek help, and this is how you go about doing it? I think that that needs to be integral in any service. If there's some way of making universities accountable for actually providing that service and that initial triage assessment, and making sure that the person gets to see the right therapist, appropriate to their condition, as well.

The university should be responsible for promoting the good physical and mental health of the students—it's not just mental health issues; it's just in general—and trying to highlight those issues and to encourage people to register with a GP and to access services. But if they are on site, I think that the majority of students will probably access them a lot quicker, and hopefully it will be a faster route. I know that we are all resource poor at the moment with these things, but it certainly is worth trying, and that would be an ideal service, really.

I think that 'Together for Mental Health' could promote the links for more joined-up working between schools, FE and HE. At the moment, it feels very separate to me, and I don't think there is much cross-working, and there certainly isn't any kind of information sharing, really, going on. A lot of the students that we see, it's not the first time that they are having issues. They have experienced issues in school and in further education as well, and I think that improving working relationship, going forward, would be important, and I guess that's something that could be led by 'Together for Mental Health'.

Also, working with key stakeholders—so, all of those groups and students—to look at 'Together for Mental Health', which I guess you will be doing, is important as well. Some of the things that we need to think about are the particular student groups as well. So, we know that some student groups have lower rates of declaration. So, engineering students, for example, and medics and dental students have much lower rates of declaring mental health issues when they start at university. So, maybe targeting specific groups of students, and those that are more likely to have mental health issues—so, LGBTQ students, international students. There is robust evidence around certain groups experiencing higher risk, and we could be targeting those groups better.

If you'll permit me, Gadeirydd, I have one more. I'm sorry if I'm going to jump on somebody else's question. So, do you think that there should be more of a standardised approach across universities in Wales as to how they share information and how they provide support for people? What I'm hearing from you, and what we've heard from other evidence, is that it's quite sporadic across Wales. Certain universities are independent in their own right, and they can provide the level of support that they want. So, do you think that, from Government, there should be that standard level of service that is mandatory right across the sector—that we should do this, and information should be shared, right the way through? Is that something that you would like to see?

That would be fantastic to see, yes.

I apologise to colleagues if I jumped in on their questions, because I do feel like it was an appropriate time to raise it.

It would be lovely to see, but also, if they could communicate with primary care as well. I must say that, particularly during the pandemic, we had lots of patients all over the country and further afield in university, who were still phoning the surgery, where they knew people, for support. It's very difficult then to deliver the on-the-ground needed further therapies because we don't have access to them. But communication would be very much welcome.

Could I just say too, in reading 'Together for Mental Health', there are eight areas, and young adults aren't mentioned? It's left out, and I think we know that, and I think that's why we're here. Actually having that revision, which I think you're trying to do now, is something that would really help further something that could be universal, for universities to have that standard of care that is needed and, right now, is very absent.

Lovely, thank you.

Thanks, James. Ken Skates.

Thanks, Chair. I was really interested in hearing about how there could be mental health checks upon arrival at university, but in terms of the roles that education providers have in terms of promoting good mental health and taking care of those who have poor mental health, how useful do you think it would be to have a consistent threshold or guidelines on where the responsibility of healthcare providers begins with regard to mental health conditions?

Who wants to start? Liz.

I think in theory that would be useful. In developing that, again, it will be key to involve key stakeholders in that process, because sometimes it's very clear cut and then there are individual student cases where it's not so clear cut. So, I think having, again, clinicians, academics, university staff and students involved in developing any kind of plan like that would be really important. But I think, generally, having some shared agreement, particularly within Wales, about where those kinds of boundaries are would be really useful for students in particular, as well as healthcare and academic staff.

And often they don't know where to go, or where to start.

Kim, did you have anything to add?

Absolutely, I think that consistent guidelines for that would be very useful. Unfortunately, there's a lot of variability where students need healthcare providers to take over, if that makes any sense. So, while it would be useful to have a standardisation, because there's so much variability in where individual students might need a GP versus not, I think that might present difficulties in some ways as well. Again, the most important thing is the communication pathways, so, being able to get the person help when they need it, which right now, we're talking three-month waiting lists—it's not there.

Ken.

Thank you. What are the barriers to effective information sharing between health and education providers? How would you address them?

I think some of it's about understanding, from the healthcare professionals, from students and from university staff about—people are very worried. There's still stigma around mental health, and students in particular have concerns around sharing information around mental health, particularly those that are on professionally registered courses where there are concerns around fitness to practice and things. I think healthcare professionals in universities, sometimes they're not clear on exactly in which situations they can share information, how they share that information, and what they can share. So, again, I think guidance for staff, clinical staff and those in academic settings, and for students, about when information might be shared, how we can share that information, and how we can do that securely would help people in terms of their confidence in terms of sharing information. So, education and training, I think, is probably key there. And again, maybe developing a working group, an expert group, that has knowledge about that kind of particular sharing of information, so that they can help develop the guidance and also provide advice to staff where needed.

That would be very helpful. But also, the electronic transfer of records, we have a huge issue in primary care regarding that. I have patients, some in university who are new to the area, and some people who've just moved to the area, but it could be six months before I get the medical records, which is astoundingly bad. You may be lucky enough to get a one-page summary that isn't accurate and doesn't give the whole picture, so it has limited usefulness for us. It is so slow. It's incredibly cumbersome.

So, would a student NHS passport help, do you think? Is the creation of such an information portal even possible?

We have piloted something like that in Cardiff, actually, and so it has been piloted amongst a few students, and for some students, they find that really useful. Whether it would be for all students, again, it depends whether students are happy to disclose that kind of information. But certainly it's a more student-led, student-focused way of them having control of sharing that information, and with who they want to share it. And it certainly helps students to not have to repeat verbally that same information, that same history to all these many, many individuals that they currently have to do at the moment. I think that can particularly help where students are in a home setting, a university setting. As we said, we've got healthcare students across Wales, all in different locations and regularly moving locations, and it would really help in that situation. I think the main barrier to that at the moment would be funding and finding an appropriate fee platform to do that.

Julie.

Yes, I think the last thing you need if your mental health is not good at the time is to have to go through the whole story with yet another new person, and I think that's immensely stressful for people of all ages, not just young people, but particularly for young people who feel that, sometimes, we're just being difficult and asking some them things and raising past traumas that they haven't had the opportunity to get some help to deal with. So, it is quite difficult at the moment.

Ken.

Are there any estimates on the cost of introducing this, of rolling this out?

Not that I'm aware of, but that's certainly something we could look into.

There's shaking of heads.

That would be incredibly helpful; if we're going to be making recommendations, I think we're going to have to cost them, and this seems to be a recommendation that we should consider very carefully. Just one last question from me, Chair. Do you think that healthcare providers, such as GPs, psychologists, psychiatrists, need to build closer relationships with universities? And, if so, is there a role for Welsh Government in encouraging and facilitating this?

Okay, we'll go Liz, Julie and Kim, because I'm sure you've all got views on that.

Yes, I think that certainly is important. At the moment, I think most academic and clinical staff would probably say—. Again, we've talked about the information sharing issue. The other issue, I think, is probably the time that staff have available to do that. We've got to be open about that. I think services such as the mental health university liaison service are key in moving forward to developing and improving those links and having established systems so that people in Wales—university staff and NHS staff—know how to do that, and they know who the contacts are, not one specific person who might move, but a service that's set up and is key to that, so that all they have to do is know that that service exists and that's the contact that they have, and establishing that in a sustainable way, going forward.

I think it's very important, looking at the system, that it should be mandatory, in my view, that it's something that that institution or that university should be responsible for signing up to. So, you need to have the will there, as well as the funding. But you do need to have the personnel, particularly. An ideal system would be having a mental health nurse doing the triage, being involved, and integrating that with NHS care so that it would be a lot more seamless. That will take money and time and more staff, of course, which is an issue at the moment, as we're all aware.

Kim.

Right now, unfortunately, we have three big businesses, where you've got the Government, you've got NHS and you've got the universities, and having them communicate across those different silos is quite difficult, and I think that you guys are trying to do it, which is wonderful. But, putting things in place where we can do that would be fantastic. I think the mental health university liaison service right now is just in Cardiff. If we could roll it out in different areas, we'd love to have it in south-west Wales as well. It would be something that would be fantastic. I think also, actually, doing something where you get people from these different groups together, like a conference or something where we can come together, discuss and brainstorm, might be something that would be very useful. So, having stakeholders like this in this environment, but perhaps also finding solutions together, might be something that would be a good option.

I think we should be very proud of the exemplary project as has happened in Cardiff this year, and it's something, if we can get it right and communicate it well to others, that other nations will benefit as well from. It's a system well worth emulating.

Thanks. Ken, was that your final question?

That's perfect, thank you. Thanks, Chair.

Thank you, Ken. Laura Jones.

Thank you. I think the gentlemen have asked most of my questions, but that's fine. [Laughter.] I think we can all agree on the importance of having that consistent approach across the board across Wales for all students, no matter where they live, and you've already touched on that information sharing is absolutely key in that, and the sharing of best practice. A forum for that was one of the things I was going to ask about as well, and then rolling out that example of Cardiff uni, for example. When it comes to something like an NHS passport, something along those lines, it's quite a good idea. How do you get past the general data protection regulation problems of that—of sharing between the UK et cetera?

The patient holds the information and it's their decision to share it or not, and to share the appropriate bits of the information that they see as being relevant.

Okay, thank you. As someone who works in a university—you've touched on this—how effective is the support that's already there for the university well-being service? To what extent can this address the main mental health issues affecting students, compared to services that need to be accessed via the health providers?

The Welsh Government has put funding in to supporting student mental health, and particularly the student support service over the past couple of years in particular, and that has really helped to allow us to provide services to more students and to provide more new ways of delivering services. And that's been really important, and that's going to have to continue, going forward, with increasing numbers of students accessing support. I think where we struggle is where students need more specialised support. So, we have lots of students with histories of trauma and, at the moment, they can't access appropriate therapy. As I said, we have students who appear to have ADHD, autistic spectrum conditions, but we can't get assessment, and if we can't get them assessed, they can't get the support within the university that they need. So, essentially, we're holding back, and that inequality is persisting because these students can't get access to the care they need. Or even, actually, in lots of cases, the kinds of adjustments that we could put in place in university if they could get access to that screening. Similarly with students needing access to eating disorders services, it just takes so long at the moment that, again, those students aren't getting access to those services.

I think student finances, as well, at the moment is quite a big issue, particularly for students who are from less affluent backgrounds. They tend to be quite disadvantaged because many students can afford private therapy. A lot of students now will access private, particularly online therapy, because they can't wait for it through the NHS. But students from less affluent backgrounds can't access that, so they're the ones who aren't getting the support they need.

It's not just true for students; I think it's true for the population in general, and you see it every day—young people, older people. Just getting access to what somebody really needs is the main issue at the moment.

If I may, Chair, I just wanted to ask about—you touched on it earlier—the support for students when they have that year abroad, if that's the course that they're taking, and how they are reached—

Yes, and some do shorter periods abroad. Some of them—let's say, for example, they're medical students—may do blocks of several weeks through to a few months, and move around the country, in Wales, on many occasions in that time frame. And they're constantly playing catch-up. They may have latched into a system and think, 'Wonderful, this will meet my needs', and then they move off somewhere else and they can't access it anymore. Obviously, doing a lot of things remotely has enhanced that, so I suppose there's been some benefit of COVID and how we can now communicate, and we're a lot more flexible in that. But it is a disadvantage to keep moving, and the lists are such that you're just about there and ready to go and then you're off somewhere else and no longer have access, or you've moved out of area.

Particularly abroad, yes.

I think Kim wanted to come in.

Yes, I just wanted to speak a little bit to that point, because there's actually, I think, quite a bit of variability from university to university and the kind of care they can get, so, in some ways, I actually think it's not only the specialised service that they need. The rates of anxiety and depression skyrocket in first years. That means they can't focus, they can't do their academic performance. You're going to have drop-out, you're going to have attrition. So, actually providing, perhaps, more support—like already is true in Cardiff; it might not be as true for the rest of Wales—to have these mental health advisers, to have mental health nurses, access to some sort of system of care, where students know where to go and have academics who know how to show them places to go is something that we really need. So, it is the specialised care, it is the more severe care, but having something in place that is universal, something that is in place where students incoming—. That first year, that transition to university is one of the biggest transitions in life and it's one of the biggest stressors in life, and it's one that leads to skyrocketing rates of mental health that might not have reached levels where they're going to have psychiatric care or going to have really advanced care, but they actually need the support. So, more mental health advisers and more structured care would be very beneficial, I think.

Yes. Okay, thank you. That's really interesting. How can healthcare providers and education settings collaborate to address the underlying causes of mental health problems and promote good mental health for all students? I mean, Dr Forty was talking about information sharing again between the schools, FE and HE, so I'm thinking that would probably help, but how do you think the new commission for tertiary education and research could contribute to that collaboration?

With the universities having some system in place where people who have all degrees of mental health, if you like, have someone to talk to. There's the example, as I said, with my daughter and what they set up, which worked really well. They trained up peer supporters with basic counselling skills, just to be a listening ear and a friendly face, and to know what to watch out for—how to promote active listening and to actually signpost people, but also pick up on red-flag warning signs, where this person needs more input, and having a structure then to pass them on immediately—and 'immediately' is the important bit—where they have a further assessment by someone who's specifically trained to do that, and then send them on to general mental health services, or the more complex problems need specific services. So, it's trying to develop those links, and having someone who has an overview on the ground, really. But universities are completely diverse, and Cardiff are very lucky as they've got a great system, but there are a lot of universities where there's virtually no system, I'm afraid.

Thank you. Thanks, Chair.

Thanks, Laura. James, did you want to come in?

Yes, on that support element, on the third sector as well, do they think they can play a big part in actually supporting the healthcare profession as well?

Yes, they certainly can.

Because we tend to hear that sometimes the third sector feel a bit pushed out. But, they can actually deliver those initial conversations and initial assessments. Like you say, with mental health support for young people, people are waiting over four-plus weeks now, which is against target times. If those young people could be seen by someone very quickly in the third sector, do you think that could really help as well?

I think it would help a lot, provided the person has the skills, the training and the confidence to identify when someone needs more intensive help. That's vital as well. But, yes, I think a lot of—. Certainly, listening to the peer support group, they were very much—. There was a lot of tea and sympathy; they went through a lot of biscuits, I think, as well. But it all helps if somebody is just lonely and is just having a bad day, or they're worried about the academic bit, or their money, or their mental health in general. All these things integrate together, don't they, really, to add up to an even bigger problem. It's their first time away from home, it's not a great place to be, and with COVID it's been even worse because they haven't been able to see people face to face and make friends, and that's been really tough as well.

Kim or Liz, did you want to add anything?

Yes, I guess just to say that I think that links in back with what we were talking about on joined-up working, really. So, we know what organisations are able to offer, but, particularly with COVID, some things are no longer available. So, we need to be confident that when we're suggesting students go down these lines, that that service is available, that we know what's available, and also, really, that we know that it's got an evidence base as well. So, I think it's about that kind of sharing of information, as we've talked about, amongst those professionals, and looking at delivering those kinds of evidence-based interventions and us being confident that they're available to students when we're recommending them.

I wanted to add too that there also need to be more people on the ground, as we're talking about with tertiary care. There are different things, for example, with improving access to psychological therapies and things like that—a different level of training. Right now, we have assistant psychologists and psychological well-being practitioners. I direct a Master's programme in clinical psychology. We have a big programme at Swansea. They want to go out, they want to be able to help, and a lot of times there aren't jobs. If we could create training for people who are perhaps not clinical psychologists, like the clinical associate psychologist training programme that's being rolled out, that's something that we could really look at linking into college counselling centres or university counselling centres, for example, to get more people trained on the ground.

Brilliant. Great. You're giving us lots of ideas here. We'll move on to questions from Sioned Williams.

Diolch, Gadeirydd. I'm going to speak in Welsh, so if you don't understand, you need to put your headphones on.

Thank you. I wanted to just talk about the factors that influence student mental health. Clearly, we have discussed a number of them already. What I would like to know is your views on what the major factors are in terms of the impact on student mental health specifically. To what extent are they related to societal or environmental factors, for example the cost-of-living crisis, or the pandemic, as we've talked about that too? To what extent are they linked to academic and social pressures within the universities, such as exams, assessments and so on? I just wanted that general picture initially, please.

Liz.

I think some of these I've mentioned. So, I think, particularly, financial concerns have always been and are increasingly in this current climate a concern for students. So, the university has kind of increased its hardship funds and things, but, actually, that alone is not enough to support students generally and the impact that their finance and their living situation has on their mental health is something that we as a university can find very difficult to support them with in terms of their mental health if those conditions and those issues are ongoing. We know, as we've talked about things like transition and moving away from home, those are evidence-based facts that we know influence the risk of mental health issues in students, and, clearly, again, COVID—so, students not having had assessments, not having had face-to-face teaching. The learning of our current first and second-years over the past few years has been so different. We've definitely seen increased rates of anxiety and depression as a result of that, and students just really having to adjust to different ways of learning. Students already have to adjust to different ways of learning at university, but the impact of COVID has really emphasised that.

I think the other main areas are thinking about those particular groups who are more vulnerable. We know that young women, for example, as we've talked about LGBT groups—. There are risk factors that we know make some people more likely to experience mental health issues.

I think it's multifactorial. It's stressful meeting new people, especially if you tend to be anxious in such situations. There are a lot of pressures, of exams, deadlines, new ways of working, be it due to the pandemic or a new way of organising yourself so that you can do your studies and still have a life and enjoy yourself. They're all tricky things. A lot of people are very homesick and miss that social support they have. That's been compounded by the pandemic, and they haven't had the opportunity to make new friends and new structures for social support with people around them. I think maintaining relationships with family and friends has been very difficult for students at the moment with distancing and not being able to travel as much. Until recently, that's been really difficult.

Another thing that I get quite a few calls from patients who are away at university on is that they struggle with managing their own money—they haven't got much money to begin with—and finding accommodation. Getting a house is a big deal. That is immensely stressful if you're on someone's sofa for a few weeks or months until you manage to get a roof over your head. So, there are lots of things contributing to that difficulty, particularly in the first year, as Kim said.

Kim, did you want to add anything?

Yes, absolutely. We know that there are a number of stressors that are very salient to the transition to university, but one of the biggest is the change in social support when you're going into new environments. The lack of social support is something that's been highlighted in our focus groups with university students, and then of course in ONS data, with increased rates of loneliness from the social isolation, but also just from the lack of the expected social support that they had within the university. It's something that, as we know, has increased mental health conditions hugely.

They've talked about loss—lots of different kinds of losses, loss of financial support. A lot of them are reporting loss of hope, which is very unfortunate, especially in the cost-of-living crisis. They're about to go out and get jobs. There are no jobs, and they're very scared about that. This age group also has had a lack of trust in their Government, a bit, and also in the universities. They kind of feel like the last ones to get the vaccine and the ones that are being blamed for a lot of behavioural stuff within COVID, like they're the ones who are going out and partying and getting people sick. They're feeling very alienated, and I think that's something that has to be addressed through communication, perhaps—a kind of comms initiative—and then also through interventions like you guys are trying to bring out now.

There are groups of students who, I think, are focusing very much on them balancing their life and their academic activities and moving forward to make plans for the future, but there are lots students, I know, who have major caring responsibilities themselves, whether that be children they're looking after, elderly relatives, or people with disabilities. They're probably a group who need a lot more support than we currently are in a position to offer. It can be very difficult to balance all those things.

Speaking about the pandemic, Dr Dienes, your research has looked at the impact of stress on mental and physical health. Are there any lessons that we can learn from the pandemic that would now be relevant in terms of alleviating the stress caused by the cost-of-living pressures?

That's a really good question. That's part of why I do my research; I'm a stress researcher. A lot of the models we work from are things called diathesis-stress models, where you have risk factors already. Some of our risk factors might be the unequal groups that we've talked about, where you've already had discrimination or experiences of discrimination, and you go to university and it acts as a major stressor that triggers mental health onset. So, that's part of the reason, biologically and psychologically, for this increase in mental ill health—that you might have these risk factors that then are triggered by going to university. It's that isolation, but also just because it's a stress that makes your body—. I do cortisol research too. Your cortisol spikes during the time when you go to university. And then part of the problem is that a pandemic comes along, and it's also a chronic stressor. So, what you have is you have a perfect storm for university students of both a stressful time in their lives that’s causing biological reactivity in addition to a psychological response on top of a pandemic and a lot of fears and anxiety. They talked about worrying about meeting people again after lockdown, about leaving their room. We ran focus groups with university students specifically who spoke about the loss of physical activity as being a huge issue in their mental health—so, actually, the ability to go out and engage in physical activities. They talked about the loss of social support, which I’ve already addressed. Pretty much everybody talked about mental health issues.

We also did focus groups with postgraduate taught international students. I think the international student community is one that we could really target. So, we have people who are over here for a year, and we had students talking about not having met a single person other than their doorman during the pandemic. I think we had 100 per cent of our focus groups, which is not a huge amount of people but still crazy, reporting mental health issues from the PG international students, who were from 31 countries, 68 students. And it’s something that is a huge issue that we saw in our research, that not only is this situation that’s already there for university students exacerbated by the pandemic, but then you have these groups that are already at risk, as we’ve already mentioned—young women, minority ethnic individuals, LGBTQ people. Men often don’t seek psychological help in universities. I know this is often not brought up, but this is actually a group that is at high risk of actually succeeding at suicide. Male suicide rates are higher, and this is a group that doesn’t seek help and also a group that might not be as willing to talk about what’s going on. So, this is again a group that we do have to bring up I think as well. And so, yes, we’re seeing a lot more self-reported stress, biological stress reactivity, and we’re seeing a lot of the sources that we mentioned there.

The Royal College of Psychiatrists noted in evidence that there had been an increased use of these new virtual tools with regard to engagement and that the use of those tools had been accelerated, perhaps, during the pandemic in education and healthcare settings. So, what are your views on the challenges and benefits of increasing the use of online spaces, particularly with regard to students’ mental health?

I think we’ve already mentioned some of the benefits in terms of accessibility of learning online. It enables students sometimes to be engaged in social support, so maybe to go home and be wherever they need to be at that time for them and they can still engage in their learning. And I think lots of students now, particularly those who are based throughout Wales on placement and things, for example, are able to access support now that they couldn’t before the pandemic, and that has been really positive.

Clearly, I think there are some students who need face-to-face support, treatment, who weren’t able to get that in COVID, and to a certain extent still have some issues with getting that now. And I think really we probably don’t fully understand the implications of that at the moment. We’re just starting to see, I think, some of the more long-term impacts of the pandemic on student mental health, and I think what we need is research to really look at what those longer-term impacts are and to look at the benefits and advantages of learning virtually, treatment virtually. On all of these things we need research. We’ve got the Wolfson Centre and the National Centre for Mental Health at Cardiff University, research organisations already that are able to look at this, and I think we should make use of those research groups in Wales to be able to look at this, going forward. So, I think that really does need to be a priority.

Julie, did you want to—?

I think for a lot of people with mental health issues, you have to be in, as I’d probably put it, the right headspace to engage with online therapies in particular. There’s nothing like having that friendly face and a listening ear for that initial assessment just to hear you out, help you try to figure out what’s actually going on and what help you need. And I think even that initial contact would benefit a lot of people.

There’s a big survey, the student COVID-19 insight survey in England, which has wonderful evidence on how COVID has impacted the students. I couldn’t find anything like that in Wales, so that actually might be a wonderful survey evidence base, going forward. But actually there’s a big difference between online learning and mental health support online, and I think we have to differentiate there, because I think about 70 per cent of 75,000 students said that they actually want face-to-face mental health support. So, it is wonderful for accessibility. If people have their preference, they usually want to see a person, I think the evidence shows. However, blended learning, online learning, increases accessibility wonderfully, so I think we have that differentiation there.

Just very briefly, if I may, Chair, in terms of thinking about the university setting specifically, Dr Forty, I believe, in your evidence to us, you talked a little bit about a concern with regards to the staff-to-student ratios and that those had changed in higher education and, therefore, there may be pressure on people's time. We know that the workforce at universities is under all kinds of stress as well, and you've talked about that a little bit this morning too—that pastoral care, time to train correctly, is under pressure too. Do you have any further comments on this?

Obviously, the student numbers have not increased at the same rate as staff numbers have increased. Staff have essential teaching and research demands that they have to meet, and quite often pastoral care of students can take second place to that. I'm not saying that's right or that that should happen, but that is what happens.

I think also the demands that we're seeing now in terms of students accessing support and why they're accessing support change, and the support that they need has been changing to a certain extent as well. So, I think providing that training for staff—. And, again, the Welsh Government has helped in enabling that certainly to happen at Cardiff—I'm not sure about the other universities. There have been positive steps in that direction, but that's something that we need to continue so that we can make sure that we're supporting the staff that we have got to feel confident and able to support students appropriately. But really, we need investment in staff in terms of specific support service staff, but also in being able to allow all academic staff to ensure they're able to support students appropriately and have got time in their job plans to do that.

We also need to support the mental health of the staff we have—to keep them well so that they can carry on doing their job. That is a very important issue.

I think this is a really important point. Often the academic staff is the first point of contact for students—it happens a lot. So, this is really something that we need to work on. And there is support there for staff to understand, but there's nothing that structured—there's nothing that I think is really formalised. I'm a clinical psychologist, in addition to being a staff member, and a lot of times I have people ask me what they should do. Even something as basic as a one-on-one suicide assessment—some sort of training to help staff understand how to help students off the bat and to just do a little mini assessment—would be something that I think would be very useful. And I don't think it's something that's standardised right now. I've been at five universities now and there's never been—here and in America too—anything consistent really to help staff understand how to take care of the students, but there's also not the support for it. We're incredibly overburdened with the number of students right now and the staff is stretched tight. We're expected to take on higher administrative roles to help these students, so our time is administrative as well as research and teaching, so they're asking us to take on additional training and then engage in pastoral care on top of that. There needs to be support for that, not just in increased numbers of staff but also time—we need time.

And priority setting as well. We have lots of training that staff could engage with, but until they're in that situation where something happens and they think, 'I could have done with training on this', it's not training that they go and look for. It's there, they can access it, but until that happens, until they're in that situation, it's not a priority.

Mandatory training and protected time are what we need.

Exactly. We have mandatory training, but—

But you need the time to do it properly.

Yes. The mental health training around students isn't mandatory.

Yes, it's research, money and not mental health.

Diolch yn fawr. Diolch, Gadeirydd

Diolch. Buffy Williams now.

Thank you, Chair. Thank you for joining us this morning. How well do we understand the extent of mental health challenges among the student population? And how could our data and wider intelligence with regard to student mental health and well-being be improved?

As we've discussed, there are some well-known factors that we know contribute to student health—we've talked about finance, social support networks. We know what many of the common mental health problems are that our students face and we know what some of the other more specific mental health issues are that students face. So, we've got good data on that. I think what we know less about, as we've discussed as well, is the impact of COVID and how we can best support students in relation to that moving forward and what the long-term impacts are going to be. We do know as well, and we've got data, about specific groups of students who may have a higher risk of mental health issues and would benefit from additional support.

I think in terms of data and intelligence, there are data collections going on in Wales and the UK, but actually, I think that we need to be working together to improve that and make sure that we've got robust data. A lot of data around student mental health tends to be asking students whether they think something's been effective and getting their kind of perspective, which I'm not saying is not valuable—it is—but we need better outcome measures. We need to be looking at longer term outcome measures as well as short-term measures. So, rather than just asking students whether they think an intervention has been effective after they've engaged with it, we need to be looking in the long term and we need to be having more robust outcome measures of whether something is effective or not, so that we've got an evidence base and we actually know how to deliver effective interventions in university and clinical settings.

Julie.

I think it's also very helpful to know what's actually happening in each university. I don't think we know—I certainly don't know—what happens in every university in Wales, never mind universities across the border where people will move to. And I think it's important to have that as a basis, and have a kind of standard data set, if you like, of expectations as to what should be available in each area, and that will hopefully be a good start to look at that.

Kim, did you want to add anything?

I think that we have some really good survey data UK wide, but actually having survey data in Wales might be something that would be really useful. Screening is a very sensitive topic, but it's something to perhaps take a look at in this committee—whether or not it's something that we actually want to do with students when they go to university is something to consider. I know that it's being kind of put out for a lot of primary school students; it's something that is worthwhile considering.

I will say that what we're lacking is more of a qualitative database of actual student experience with our focus groups. We've got a lot of rich data; I'm not aware of any qualitative data that actually spans Welsh universities, so that's something that could be really useful. But I think one of the biggest areas is actually something that Liz touched on, which is that we don't have the evidence base for the actual interventions. So, there is an absolute lack of evidence for what works. And that's something that we really want to do. I think it's something that the pilot in Cardiff is hoping to address, and if we support things like that, where you can actually put in good outcome measures for the techniques that we want to engage and to help students, it's something that we could really roll out in Wales, and do it in Wales in more places than just Cardiff. So, I think that would be a wonderful initiative, with, again, good outcome measures and good research evidence base.

Thank you. Buffy.

Thank you. How do you think that younger pupils—[Inaudible.]—find it as easy as their peers, the older pupils, or do you think that they find it actually more difficult?

Can you repeat that again, Buffy, because you seem to have gone off the screen, and we didn't hear you for a second? Can you repeat that question?

Can you see me?

No, but we can hear you.

I don't know what's happening. My screen keeps going off and on. It's like as if they're knocking me on and off on the other side. Sorry, Chair.

That's okay. Go for it.

As long as you can hear me, that's okay. I was just asking do you think that younger pupils find it more difficult to access mental health, or are more reluctant to access mental health, than pupils in higher education?

Liz, do you want to start?

Yes. I think it does vary. I think some students—and I'm not sure whether it's necessarily younger students or students in higher education—but some students lack the confidence and the knowledge to be able to access services appropriately. So, some of the guidance that they need from universities and the healthcare professionals is actually: what do you say to a GP when you go? Students will go and see their GP, but if they're not open about what their issues are, or if GPs are limited on time, sometimes students might need time to kind of open up about these things, or they're just not sure what to say, or they're not sure what GPs can do, so they think there's no point going to the GP. So, I think some of it's—certainly some students don't know how to access care, and I think that can be certainly a limiting factor for them.

I think you're right. There's a huge issue there, especially if it's a GP you're not familiar with, and you're trying to get registered with the practice, that you'll be thought to be a bit of a lightweight and failing right at the beginning at the first hurdle, and find it very hard to open up. And also, in other areas, there are obviously difficulties with access to these services that we're talking about specifically for students as well, and a lot of young people think they'll just be fobbed off with, 'Have a prescription for some antidepressants, and off you go', without actually addressing that ongoing need for the psychological therapies that they need to cope with the situation and to be able to move on with their careers and their courses and succeed in life.

Kim.

Yes. There's definitely a gap, because you have about 21 per cent of first years, for example, seeking mental health treatment and about 38 per cent of them have treatment, so there's a gap in support seeking, and that's something that we can definitely address. Again, there's this issue of trust that I think has been brought up. But something that we do have to emphasise is that this is actually an opportunity. Students are actually more open to mental health treatment than, perhaps, other people who have gone before them. They're away from their parents, they're hearing about all this cool mental health stuff—social media campaigns, for example. This is actually an opportunity where we can engage them and normalise mental health, creating a generation of young people who are perhaps open to mental health than has happened in a long time.

A lot of first year university students, or a higher proportion, I should say, in Wales, are first generation, are coming to university for the first time, maybe for the first time in their family. This is a chance to educate them about mental health, to normalise mental health treatment and perhaps reduce that gap through that education. So, I think that that could be a great initiative too.

And if we really start pre university with getting these ideas on board, rather than waiting till they arrive.

Different kids, but, yes, I agree.

Buffy, before I bring you back in, James has got another question.

On accessing GP appointments, do you think there should be more of an emphasis in GP training sometimes on mental health elements? I spoke to Dr Alex George, who was the previous Prime Minister's mental health ambassador, I know that he told me when he went through training, there was actually not that much emphasis put on mental health at all in the curriculum. Do you think that's something, perhaps, we could do here in Wales—we design our own courses—that we could actually put more of an emphasis on mental health training for GPs in positions as they come through, so that they understand when a young person comes presenting with a mental health issue, they know how to deal with it, rather than—shall we say, with some GPs, when I've accessed mental health support myself, it's more, 'Here are some tablets, get on with it', in a way.

Yes, indeed, which should not be the case; there should be a range of options for everyone who comes through the door, and they should be the appropriate options for that person and not just a quick fix in the hope that you will go on your psychotherapy waiting list. In the area where I work in, that will take two years for you to be seen, so you'll probably have finished your course by then, and they go on, which is really worrying.

Do you think it should be something that's more embedded in GP training?

It should. More education in psychiatry would be very much welcomed by GPs, and I think that's probably true of most medics in general, indeed. As first point of access, it's also important that we have that support. With all the will in the world, no matter how committed we are, we haven't got time to provide somebody with prolonged counselling sessions or more sophisticated therapies than that in the current climate, in particular.

I'm just going to bring Ken Skates—

—but we need that back-up.

Thank you very much.

I'm just going to bring Ken Skates in for a question now. Ken.

Thanks, Chair. Just listening to all of this evidence, it is quite remarkable what we're hearing this morning. It's incredibly interesting, but it just strikes me that we need to be incredibly ambitious if we're going to respond to the mental health pandemic over many years to come. How useful would it be for young people to have a designated counsellor or counselling practice throughout their journey to adulthood? Every child or every young person has a doctor, or at least a named GP practice that they're able to go to, that they're registered with. I know that there are huge capacity questions attached to this, but as an ambition, shouldn't we be at least seeking to examine the potential of a national counselling service so that every young person has a designated counsellor or counselling practice that they're able to access through their journey?

Do you want to start? Kim.

Oh, okay. I'd got used to the chain of operation. Absolutely. I think that, right now, there isn't the same access to therapy that there is to GPs. We need more access for people in general to trained therapists. There is a lack of clinical psychologists in Wales compared to England, unfortunately, for training programmes for clinical psychologists. That's the most intensive training—. I was the director of a clinical psychology programme in the States. This is something that is incredibly popular; you could flood them, but you don't have enough supervisors to train the students. Unfortunately, there's not enough time for it. But more clinical psychology programmes and then more of those gap people, counsellors, like you suggest, assistant psychologists, more training of that kind of middle group of people who have a Master's degree but might not have a clinical psychology degree yet who could actually provide that support. It would be a wonderful ambition. Right now, we don't have the people on the ground to do that, and we need it, and I think that would be a great ambition.

Liz.

I think it's quite complex. So, obviously, we have the issues with students moving around. We have students coming from other nations—from England, Scotland and Ireland—so, actually, how it would work in practice would need some thought, obviously. I think also, sometimes, the support that students need at different points, so, from school to further education to HE, varies. Some of the support that we provide in universities, for example, the university support staff, the counsellors—we have people who know the demands of the university setting, which is similar but different to the demands in school settings, for example. So, in some ways, I can see that having a counsellor that somebody is engaged with throughout that process could be beneficial, but I'm not sure that that would address all of the issues, really, with students in terms of the support that students—. I'm not sure that it would provide all the support that students need.

Sorry, it wasn't a specific question about students; it was more of a general question about young people as a whole and their journey from 0 to 18 or to 24.

I guess it's similar, isn't it? I think sometimes the issues that affect somebody—. Maybe, but I think the issues that affect people when they're younger change, don't they, and I think, to some extent, it's useful to have people who are specialists at those particular time points for students. The vulnerabilities of school students—school pupils, sorry; you can tell I work at a university—and those in university are quite different.

I'm going to let Julie have the last word and, sorry, but I don't think we'll be able to come back to any questions, then, because we'll be out of time.

The concept of providing that wonderful continuity of care is fantastic, but, in reality, at the moment, I don't think it's feasible that we can actually aim that high to deliver that. I think the services are so overstretched already that it would be very difficult to achieve. Not that I'm saying that it's not worthy of aiming high when we're looking to design systems and improve them.

Brilliant. Well, just, to say thank you so much for coming in this morning and for your evidence. It was really helpful and also you've given us lots of food for thought. If there are any questions that Buffy had, we might write to you, if that's okay, just with those additional ones. But you will be sent a transcript, as well, of today, just to check. Thank you very much for your evidence today. Diolch yn fawr.

Thank you.

Thank you for having us.

Thank you for the opportunity to speak to you.

Take care. Just to say that we're going to break for three minutes now to Members. So, we'll have a quick changeover.

Okay, so welcome back to our fifth evidence session on mental health support in higher education. I'd like to welcome our next panel, which is Simon Jones, head of policy and campaigns at Mind Cymru, and Dominic Smithies, influencing and advocacy lead, Student Minds. You're very welcome and thank you for joining us this morning. Just to say that we've got lots of questions to ask you—Members have. We will be as succinct as possible, and hopefully you can be in your answers as well. I'll go to Student Minds first, and then Mind Cymru. So, we'll make a start straight away, and we'll go into some questions from Buffy Williams. Buffy.

Thank you, Chair, and thank you for joining us this morning. How well do you think we understand the extent of mental health challenges among the student population in Wales? And how could our data and wider intelligence with regard to student mental health and well-being be

improved?

Dom.

Thank you for having me. I think that we are developing our knowledge and understanding of the current state and the challenges that are being faced. I think that it's been improving over the years. I think that one of the things that is particularly challenging is separating out the difference between understanding youth mental health and student mental health, in particular. Often we overlap the two and just seem to try to see what's similar between the two groups when, potentially, there are unique factors for people who are at university that bring about different challenges, different support needs. I think some of the things that are going to be a need for deepening our understanding of the challenges are some more data, particularly longitudinal, that tracks people from before they enter university, all the way through to after they've left. We've got data on disclosure rates on accessing support, but the rate of students experiencing difficulties that aren't disclosing or aren't reaching out for support and are falling through the gaps is something that I think we're still missing. We're losing those data, and we don't really understand the scale of the issue there. So, I think that would be one of my priorities for building our understanding, moving forward.

Okay. Simon.

Yes, I'd agree with that. I think a lot of what we've heard is anecdotal from students, and them talking about their own experiences. I think it would be really interesting to look at what data are collected by universities in terms of access and throughput of their well-being services and what type of support people are seeking. I think that would not only tell us just numbers of students seeking support, but also whether there are pinch-points during the year.

We've certainly heard that, around exam times, there's an increase in the numbers of students looking for help and support. It would be really good to get under that a bit, and is that evidenced, and, if so, do we need a bit more resource at certain points of the year that we don't need at other points of the year. Contributors earlier talked about those first few weeks of the first year, or the first few months of your first year, particularly for young people, being quite challenging when they're adapting to a different way of life and new experiences. So, to be able to look at some of those data and understand, as we do with the mental health system, what the throughput looks like, and then looking at what the outcomes of those interventions were, I think would be really important for us to get a handle on how young people are experiencing the system and what the demand is, and is that demand then being met and resourced.

Buffy.

You work with a wide range—. This is to Mind Cymru. You work with a wide range of people experiencing mental health issues. To what extent is the higher education student population atypical and in need of targeted mental health support? How do mental health conditions of other young people compare to their peers in higher education?

I think there are specific stressors that I think Dom started to talk about in his previous answer. Any point at which you are transitioning in life to a different stage—so, that could be leaving school, that could be your first relationship, getting married, having children—that creates stresses, creates pressure, which can have an impact on your mental health. Obviously, the move from going from college or school and into a university environment where, particularly with young people, maybe they'll be living on their own for the first time, looking after their own financial affairs for the first time, developing relationships, realising that there are some people that you really don't get on with but you have to work with as well. Those are real challenges, and I think those moments do create a situation where young people can feel very isolated, they can feel disconnected and kind of lose who they are a little bit.

I think it's really important at this point that we don't seek to overly medicalise this, either. There are young people who are going to university, and older students as well, who have mental illness, who have a mental health condition that they are receiving support for. There'll be a large number of young people that will experience the stresses and strains of entering adulthood for the first time. That will be much harder for some than it will be for others, and this will be a temporary situation when they are readjusting, they're finding themselves, they're developing their resilience and their ability to cope with all these emotions, and I think it's really important that we don't rush to stick a 'mental health' label on some of that. That is about well-being, it is about support, it is about making sure that there's an open, welcoming approach for young people to talk about their mental health at that point. When you're looking at young people that may be are coming with a history or a background of poor mental health that needs support, the continuity of care, which I think previous contributors talked about, is absolutely critical, because that will be a stressor in itself, in terms of what will happen to my support when I potentially move halfway across the country to access my education, or even if I'm just moving up the road to access my education; there can still be a lot of worry around that. So, providing that wraparound support for young people.

And I'll just finish by saying that I think we've come a long way in Wales in terms of the support we're now looking at in schools. With the new curriculum, with the whole-school approach to mental health being rolled out, with school-based counselling, we can really deliver a step change in how young people think about their mental health, their confidence and their vocabulary to talk about it, their coping mechanisms and all those areas. We need to make sure that that continues into higher education as well, so that young people aren't then going to be cut adrift, to go, 'I've got all these issues, and this is how I would deal with them, and I've learnt these skills', and then there isn't an outlet for that maybe in higher education. So, we need to ensure that continuity.

Thank you. Buffy.

Thank you. How can education and healthcare providers work together to address inequality in terms of mental health, particularly in groups of students who are more likely to experience poor mental health?

Dom.

Building on what Simon said just there, I completely agree around the transitions and not wanting to over-clinicalise the challenges in that. In investing with the right support, we can be building thriving students who go on to be active citizens, but a really key part of that is obviously understanding that the student population is incredibly diverse, and so these inequalities do arise. Two populations that I'm conscious always seem to stand out in the data, particularly around that transition point as well as young people, are LGBTQ students and care leavers, for whom the need for more support seems to be coming through quite clearly in the research and in the data.

I think, when you think about transitions and the age range that we're working to serve, 18, transitioning into adulthood, is a really key point to be providing support for those populations. So, it is really key that we get that right. How it's integrated and how we make sure that the university is taking strategic, holistic approaches to their interventions to provide that support for students is really key, and then working with wider providers and linking up with health services, linking up with schools and colleges to make sure those transitions are working well is really vital, but it's a challenging thing. I suppose what's unclear and what would be useful, I think, is clarity around roles for everyone in how we support young people going through all these transitions when they're moving from college to university, between services, when they're potentially relocating, potentially just up the road, but potentially across the nation, to go to university. It brings up lots of challenges for people, so I think it's key that we get that absolutely right. But there are lots of inequalities that exist. We know that, for students of colour, the data seems to be highlighting quite a lot of challenges in terms of their needs being very different to white students'. We know that they're potentially at higher risk of being exposed to racism, discrimination or prejudice while at university, or just in their local communities. That heightens the challenges when it comes to mental health difficulties.

We know, looking at gender differences with disclosure rates and accessing support, that female students seem to be more likely to disclose having mental health difficulties, which might indicate more of a need with the female population, or it might indicate that there's a reluctance with male students to be disclosing mental health or to be seeking support. There's research that says that both of those things can be true as well in terms of supporting those students.

We know that students from low socioeconomic backgrounds, particularly coming into the cost-of-living crisis this winter, can be a really key group that we're supporting, and making sure they're getting all of their essential needs met in order to fully get themselves embedded within the university community, and taking part in university life is going to be key. There are lots of different student groups—I feel like I could speak to all of them differently—and lots of inequalities to challenge. In the nature of keeping it succinct, I won't, but just be mindful that it's a very diverse population we're trying to serve.

Thank you. Simon.

Yes, I think Dom's covered it all there. There are just a couple of points I'd add to that. I think the impact of stigma continues to be an issue. I think we've come a long way with mental health stigma through Time to Change Wales and many politicians around this table, as well as other people, talking about and being open about their mental health. I think what we need to recognise is that, for some communities and some people, it is still very hard to talk about their mental health, and some of those groups that Dom spoke about are those groups where we know stigma still exists. We know that talking about your mental health can be a very dangerous feeling for some people.

So, I think we just need to make sure that we're not becoming complacent about stigma. There will be both young people and older students arriving at higher education institutions who will carry that stigma. We saw it during the pandemic as well, where Time to Change Wales reported that people were self-stigmatising; they didn't think their problem was important enough, because of the massive global health pandemic, so they didn't seek help. It's very easy to internalise some of these feelings.

The second point would just be around cultural competency in terms of delivering mental health support, particularly for international students or those from racialised communities. This is something that I've spoken a lot about with colleagues in black-led organisations and ethnically-diverse organisations around that the mental health system doesn't support people of colour as well as it possibly could. Diverse Cymru run a cultural competency scheme that helps support practitioners around how they can be more effective around that, but that's something that came out really strongly in terms of some of the young people we spoke to, particularly those international students, about meeting their needs.

Okay. Thank you, Simon. We move on to questions now from Sioned Williams. Sioned.

Thank you, Chair. We've discussed these things a little already, the fact that the cost-of-living pressures are likely to affect students in higher education. We know that they're not eligible, for example, for a number of the support packages that have been announced as they are means-tested and depend on your eligibility for benefits. So, in your opinion, what measures could the Welsh Government and education providers take to provide students with the best support when they're facing these financial pressures? We know there's a connection that we've already talked about between that and mental health problems.

Dom.

Do you want me to go first?

Sorry, Dom, yes.

In the short term, I think lots of what we're seeing people call for, which we definitely echo, is that need for the urgent hardship funding for the students that are going to be struggling the most with the financial challenges that are going to be coming over the winter, making sure that's ring-fenced and protected. But, while having that financial investment is really key, something we saw during the pandemic when hardship funding was released—similar to what Simon said with self-stigmatising—was that lots of students weren't sure if they were eligible for accessing that, or didn't feel like they were the most in need, or felt there would be other students who would be more in need, so put themselves off from accessing and seeking out that funding that they were absolutely entitled to. So, there does need to be lots of good communication around the eligibility for hardship funding and the access to it, especially for certain populations. International students: many international students we've welcomed over the last couple of years, through the pandemic, spoke about, actually, finally they did seek out the hardship funding, but that they weren't eligible. So, there's lots that we need to think about in terms of how we can equip institutions to be ensuring that the funding is available to all the students who need it, and removing as many barriers as possible, so that we're supporting the students through the challenges that are going to be coming.

Longer term, I think there are lots of organisations, including us, calling for some more radical changes to support with managing the financial pressures of university, with the reintroduction of maintenance grants and the unfreezing of loans, just to ensure students aren't having those real-term cuts any more, as we've been seeing year on year. And making sure there's more money in pockets, so students are equipped to fully integrate into university life, are able to afford all the necessary books and equipment they need for their studies, as well as having the money they need for rent, for paying for heating, for their groceries. It's something that seems obvious, that we should be providing for all of those basic needs, so that students can be dealing with all the challenges of university life, which is already an incredibly stressful and hard period.

So, in the short term, I do think we need ring-fenced hardship funding, we need to be equipping institutions with the ability to make quite creative and practical interventions to support students, whether that's free shuttle buses to local supermarkets, whether that's reducing the cost of engaging in local societies and activities on campus, to ensure they can still get integrated and embedded within the communities, or whether that's ensuring that student unions are putting on cheaper, budget, alternative meals for students who are going to be facing the cost-of-living crisis with quite a difficulty. And then also thinking about those long-term changes, to make sure we're not dealing with these urgent hardship measures year on year, but actually addressing the situation more systematically.

Thank you. Simon.

Yes. I think, as well, that it's about tackling the current issue in terms of the rising energy costs, cost of food and all those things, but also recognising that this generation that have gone through the pandemic and are coming out of university during it, they have real worries about their future and about their employment prospects and their future finances as well. So, whilst dealing with the immediate here and now, we need to also think about how we're supporting those young people and older students going through the university process, to actually think about what is going to be available in the future and how they can be supported. That's often something that's maybe a little bit forgotten, once somebody has left higher education, is how they will continue to be supported in the future. And I think, during the pandemic, we saw young people for the first time, in one of our surveys, actually expressing concerns over their own families' finances, and the weight that this places on a young person who may well have no real control over that situation, but are worried about their parents, worried about their financial future as well. So, it's important to address in the here and now, but then also to kind of build it in to what that would look like, three, four, five years into the future as well.

Okay. Sioned.

Thank you. And then, moving on to some of the more specific factors relating to—academic factors, for example, assessments, exams and so on, and you've spoken about them as pinch-points already. Are there any practical steps that higher education providers could provide in order to reduce that stress on people during those pinch-points that are perhaps related to education and the experience in university?

Dom.

I'll go first this time.

Okay. Simon. Yes.

I think there's a really important point about recognising that they are pinch-points, and recognising that they are stressful points for young people, so that, at that point, whether it'll be around exam time or assessment time, there is a really proactive campaign about getting information out to students around where they can seek support, if they are becoming so worried about a situation that they're unable to do the things that will give them some respite from it—what they can do, who they can speak to—and really driving that during times when higher education institutions know there's probably going to be a lot more pressure on students and young people. Because I think what we've heard quite a lot is that there is information out there, but it can be quite passive sometimes. It can be just kind of like, 'A leaflet—there you go', rather than actually a more aggressive, forceful conversation about, 'If you are really worried about something, we're here. We want to hear from you. It is a stressful time.' Sometimes, even admitting it and owning the moment to go, 'Well, you are going to be under pressure. How can we best help you to get through that?', to help a young person build that resilience, build that toolkit to be able to handle some of these emotions that maybe they've struggled with before, or maybe they've actually successfully managed to overcome before, but are struggling with this time because there's a different support network around. So, I think something really proactive around what the support is that's available would be incredibly valuable.

Dominic.

I completely agree with Simon in terms of the support, but I suppose there's also looking at taking a step back and thinking about the whole design of curriculum and pedagogy. There's been amazing guidance and research developed over the last couple of years, published around the education for mental health toolkit, which is around curriculum design, how we embed well-being into how we teach and how we learn, so that we're supporting students throughout the whole process, so that we're designing modules and courses that are challenging, that are stretching, which isn't a bad thing. Some level of stress is good, if it's something that students are equipped to deal with, to handle. If they're equipped to engage in the material, the problem solving, thinking critically, students will actually find that incredibly rewarding, empowering and enjoyable. If they're equipped to deal with the course, they'll get a lot out of it, and that's good for their well-being. The challenge is if it gets to a point where a student doesn't feel equipped, and if they're stressed to a point that they're not actually able to engage in the learning process anymore, if they're starting to worry about their assessments and outcomes. That's when we need to think about what signposting we can do in terms of if a student fails a module, what that means, and actually talking through the process of, 'There are options for retaking your assessments', or completely normalising the stigma of not acing every exam. For lots of students coming into university, we know perfectionism is a real challenge with lots of students—achieving really high marks and high scores in schools and colleges, and coming to university expecting to be hitting those 80, 90, 100 per cent marks in exams when, actually, getting a 60 is still a really good score by university academic standards. So, there's lots of normalising in academic culture that we need to do; there's lots more transformative work that we can do with curriculum and pedagogy, and there's great guidance that already exists out there. And then, as Simon said, there's lots more that we could do with signposting to support when students are in those stress points.

Sioned.

Thank you. They were brilliant answers, so thank you very much. I just wanted to ask you very quickly also about the use of virtual tools to deliver pastoral support in universities and some NHS services also during the pandemic. What have you heard from service users and students about the challenges and benefits of an increased use of virtual spaces?

I think there's a lot of positivity in terms of being able to reach out and get support and get it in a virtual, online way. What we've always said is that the offer needs to be based on what the person needs. So, some people may want online, some people will want more face to face, some people want a blend of the two. I think it's really important that we keep that as the kind of organising, central principle, that it's around the needs of the person seeking help and what type of blend they would want.

Now, during the pandemic, when a lot of support went online, understandably, what we did hear was that people who lived in houses in multiple occupation didn't feel particularly comfortable with it because there was a lack of privacy. Some young people didn't feel particularly comfortable with it, because they were wondering who was listening in to what they were doing. Others were transformed by it because they could access a service that maybe they wouldn't feel comfortable walking into, either off the high street or on the campus. So, it really does come down to individual preferences, but I think there are some things we really need to think about in terms of the online offer and how safe some students, maybe, would feel when accessing that, whether in the house that they're living in or their student accommodation.

Dom.

Yes, I completely echo and agree with all of that. We definitely saw through the pandemic the positive reception of things going online, but with that came some challenges. There are pros and cons with every approach, which is why, I suppose, that blend is so needed and taking a person-centred approach is always going to be key. I suppose, in the positive, something that is really important to highlight is the accessibility of services. We did anecdotally, and through some data actually, hear that that was really positive. With student groups who often were previously considered to be hard to reach or less likely to engage in support, we actually did see slight increases in them feeling comfortable and confident in engaging in a virtual offer of support. So, there are definitely some positives to keep and to not lose, but there are definitely some challenges with the virtual environment that we do need to manage, so I completely agree with Simon.

Diolch, Gadeirydd. Diolch.

Laura Jones. Laura.

Thank you, Chair. I'd just like to ask one small question before I have to leave, unfortunately, and then you'll take over—is that all right?

I'm going to start on my question 2, which is: evidence has raised the need for longer term funding for mental health and well-being services in post-16 education, so what resources do education providers, healthcare settings, and the third sector need to plan and deliver that mental health support? And how could this approach be delivered across post-16 education?

I visited a school recently where—. Newport Mind, in our region. Newport Mind came into the school, and they originally came in to offer support to students for two days, and it ended up being five days because the demand was so high. So, there is an important role for you to play there. Unfortunately, that funding, it was pandemic and post-pandemic funding that's now stopping, which means that service will go. I'd just like your thoughts on that, please. Thanks.

Simon.

Yes. There's a lot of movement around interventions within schools and school-based, whole-school approaches. Newport Mind has certainly been at the forefront of that, with regard to the Mind networks delivery of it, and have done some fantastic work. I think what you're seeing there, Laura, is that when the offer is made the demand is there for it, and that's an appropriate demand as well. I have to admit that I'm not an expert on how higher education commissions its support from the voluntary sector or from within its own institution. But I think there's an important point here about the links that a higher education institution within an area has with the local voluntary sector as well.

For example, a local Mind, such as Newport, would have a number of activities. It would have a number of groups that I'm sure students, both young and old, could access to feel supported, and also to hear about experiences from people like them. I think peer support is an incredibly powerful tool, and actually something that could be looked into a lot more. That's not just to kind of go along and have a cup of tea with somebody; it's training people to be able to talk about their own experiences in order to support others. It's an incredibly empowering and powerful approach, and I think a lot of that is within the local voluntary sectors, and maybe there's some more work that can be done around how we join these things up to ensure that those students who maybe aren't living permanently within the area can access some of that voluntary sector support as well.

Thank you. And it's on the transition of that support, then, to university, because if students arrive at university already having that training, understanding how to deal with things and all that sort of thing, that obviously will impact, when they get to university, what they're used to.

Lovely. Thank you, Laura. Just following on from Laura's question, just a quick one from me. Would you like the new commission for tertiary education and research to ensure that students are engaged in its work on well-being in the post-16 education sector, and do you have any particular concerns or suggestions for the commission as it begins its work?

I think it's a great opportunity. Everything that this inquiry has done has identified the need to transfer knowledge, what works, what does success look like, and how can we share data. I think this new body provides that kind of apex to be able to bring some of that together and look across the sector to identify what’s working. And I think we need to be really careful as well; what might work in one more urban university might not work in a more rural university as well. There will always be a need to respond to the different demands of the student population. But I think there’s definitely an opportunity to look at mental health support. And I think there was a discussion in one of the previous sessions about a minimum offer; what should be the minimum that students should expect from their universities, and then what does that mean in terms of what they access in the community—and I’m sure we’ll come on to discuss that link between what higher education institutions offer in terms of mental health support and then what needs to be, rightly at times, delivered within the wider NHS. If it could look at some of those issues and look at what protocols look like and, with the example that was given earlier around the work going on at Cardiff University and the other south Wales universities, what’s the learning from that and sharing? I think there’s a real opportunity to bring all of that together and to link into the new curriculum and the whole-school approach in Wales to have that seamless view right the way through education in Wales.

Brilliant. Thanks, Simon. Dom.

Yes, I absolutely agree in terms of thinking about the diversity of student populations and the way different interventions are going to work for different students. So, engaging many students in this work is going to be key, and from many different institutions and many different demographic backgrounds as well. That is going to be important.

Building in as well—in answer to the previous question and thinking about institutions and how they’d link up with this work, I think it’s going to be the information-sharing angle, particularly with the third sector. I know that it’s been a real focus for a number of years now, thinking about information sharing between higher education institutions and local NHS and healthcare providers, but building on that to actually be building a wider support network of local third sector organisations that are providing support to some students through whatever interventions—peer support or digital interventions, through web chat, phone services, whatever. I think higher education institutions can be playing a really important role in bringing a lot of these threads together and bringing these people together. I think empowering institutions to play that role to ensure that that support package is being considered and everyone is working together to share that information—obviously sensitively and carefully, but with the best interests of supporting students at its core, I think that could be really powerful, moving forwards. So, I think making sure that there’s higher education institution vested interest in this work would be great, too. But, having a diverse range of students I think is the key point here.

I can see that Simon wants to come back in before I bring James in.

Yes, it was just quickly to add that I think they would play a really important role as well in terms of staff well-being and ensuring that—. It’s so important that, with any institution, there’s a culture around mental health, and a positive, open culture. And I think sometimes we can forget that higher education institutions are staffed by people who have experience of mental health themselves. And I think that’s so important. We know that, where somebody has a good understanding of their own mental health and the impact that poor mental health can have on others, they are more empathetic and supportive to people who they come into contact with who may be displaying poor mental health outcomes. So, I think it’s that the new body might ensure that we don’t lose that staff focus as well, because if you have a healthy workforce that has a healthy culture, that will seep into the culture of the students as well, and they will feel that very positively because they can see that the staff feel supported and well looked after and feel confident and safe to talk about their mental health. So, I think, probably, if there was something for that particular body to really look at, it’s how staff are being supported, because I think sometimes it’s the missing piece that isn’t considered when we talk about higher education and mental health, rightly looking at the experience of the students.

Brilliant. Thank you, both. James Evans.

Diolch, Cadeirydd. I think an important point that Dom made was around the third sector involvement and how they can support higher education institutions with actually delivering mental health support for students. We’ve seen that, if people go through the official channels and try to get a proper assessment, it’s taking over four weeks for those young people to actually see a professional, and those delays sometimes can have a serious impact upon a young person's mental health. And when they’ve asked for help, they need to get it there and then, rather than waiting and waiting and waiting for a health professional to say what the problem is. So, how do you think we can embed the third sector more into our higher education establishments so that when those young people are at crisis point and they ask for help that there is a third sector organisation there that can have that initial conversation and give that initial assessment so that, if that person does need to be referred to CAMHS or to adult mental health services, it can be done quickly and expedited quickly, rather than just this endless waiting game—waiting for help when, sometimes, it's non-forthcoming, and after a while, people just turn around and say, 'What's the point of accessing it anyway, if it's not coming?' I'll go to Dom, because he raised it first.

It's a great question—thanks for asking. I think there's a really important role that the third sector plays in sometimes filling a lot of the gaps in the short term. Often, with the services like those that we provide, digital services at that national level, through Student Space, or other services offered by Mind or the Samaritans, they can offer that immediate but very short-term support, rarely providing, I suppose, that long-term clinical care that the NHS always will be best placed to be providing. So, in my mind, I suppose where I see it sitting nicely, the role that institutions can play is in signposting students to us while students are particularly at the point where they've reached out for support, but they've got however many weeks to wait until they have access to counselling or that clinical care—that they've got someone to talk to in the meantime, whether that be peer support groups or whether that be the ability to have a webchat or phone calls with intervention through third sector organisations. I think that's really important just to ensure that students aren't just left during that waiting period. So, it's about institutions making sure that they signpost to those services so that students can get that support at a point when they need it, because many third sector organisations are equipped to be providing that on-demand, at-point-of-access support that's required.

But also, when institutions are going through their triaging processes, when a student does come forward seeking support and institutions are going through the process of working out what support that student is going to need and how long it's going to take to get them there—at that point, they can make sure that they have conversations with the students, and not just be like, 'Okay, here's where we're triaging you to, here's the wait', but that they're also equipping them with information around, 'Here's what other support is available to you in the meantime. Here's how we can help in the meantime. Here are some organisations in the third sector locally, nationally that you might find useful. And some resources that might be useful for you to look after yourself', and bring in trusted contacts, families, friends and loved ones and past students, to be reaching out to their own support networks. So, to make sure that there just is a whole, holistic package.

It's when it's always, I suppose, all these services acting in isolation individually that actually students are going to fall through the gaps. So, when they're with friends, with family, with the third sector, with institutions, with the NHS all working together, there should be a comprehensive support package available to students. And I think those waiting times are a really challenging gap that we need manage. So, signposting to us to help fill that is definitely going to be key. But also, obviously being ambitious, we do want to be bringing that gap down as much as possible; we do want students to be able to get the help that they need at a clinical level as quickly and as soon as possible, so addressing that challenge too is going to be really important.

Okay. Thank you.

Simon.

Yes. I think it's a really good question, James. I know that some of our local bodies have worked with higher education institutions to support their offer. I think as well it's about looking at how aware are the current welfare services and well-being services—how aware are they of what's available within their area? We know, from our work with GPs that, often, GPs don't know the plethora of opportunities that are available for people to seek mental health support in the voluntary sector on their doorstep. So, there's definitely something about ensuring that there is that proactive outreach in terms of how the local voluntary sector can help, what that looks like and are there particular types of support out there that would help people as well. So, it's probably as much to do with ensuring that the information is available, as well as then shared with the student population.

Ken Skates.

Thank you, Chair. I'm just going to ask about information and the interaction and interplay between the provision offered by universities and the NHS. Do you think that students, and staff for that matter, in higher education institutions really understand the difference between services that are provided by universities and by the NHS or could the differences be better articulated and communicated?

Who wants to start? Dom.

It's hard to speak broadly. Some students will, many students won't, and I think the challenge point that we always see is those first few weeks going into university. Something we always hear anecdotally is that in local NHS providers there, any department seems to have a flurry of students coming in accessing support through them, and students don't know the proper routes, haven't necessarily embedded themselves with a GP practice, don't know what support is available to them, so that when they're at a point of crisis or needing support, the only immediate service they know is available to them is going in to A&E, which nine times of out of 10, isn't the appropriate avenue for the support that they need, and then that creates lots of issues.

So, there's definitely more work to do. Both NHS and higher education institutions are aware that that's a challenge that seems to happen year on year around the freshers period, around the first few months. And particularly with some student populations, too—so, if you think about international students who won't be as familiar or have as basic an understanding of our health system and how you access it and engage with it, how we inform and educate them on how they get support is really key, particularly in those freshers week periods. But we also get a lot of feedback that it's really challenging to get vital information across to students during those first few weeks, because there's so much information that you want students to be told and you want them to absorb, that you don't want to bombard them, so it's a case of having some very clever comms and marketing campaigns that run really throughout an entire academic year that are kind of constantly re-promoting those core messages of what support is available to them, what the difference is, what it provides, how you can access it and how long waiting times are, so that students have that picture.

I think it goes back to my previous point of just highlighting the whole support offer and package across the university services, NHS, third sector, and what you can get with peer-led interventions. It's important that it's articulated, how that's accessed, and what kind of support students can expect. Something we know from research in terms of support being impactful and helpful in terms of addressing support need is students or individuals having a clear understanding of what the support is, what they can get from it, and crucially, believing that support is going to help them is usually a big indicator of whether they will find that support helpful, particularly with mental health interventions. So, being very articulate with things like counselling in clinical care in the NHS, with mental health in particular; being very clear what is on offer and what isn't is actually going to make things a lot more efficient and also a lot more impactful for students in the long run.

I think, as well, this goes to the centre of do we have a person-centred system or a system-centred system, in a sense. We hear a lot, really positively, from Welsh Government, particularly around young people's mental health, having a 'no wrong door' approach. The courage it takes to make that step and go, 'I need some help', is enormous. To then be told, 'Yes, you do, but we can't help you with that particular issue; you will now need to go and speak to your GP', when, maybe, you've never gone to a GP before about it, certainly not on your own to talk about your mental health, it creates another barrier. How can we set up a 'no wrong door'-type approach within higher education?

If somebody is seeking help, that is the most important thing—that they are seeking help. Who provides that help is something that the system needs to work through. It shouldn't necessarily worry the young person about, 'Okay, I've got to go somewhere else now to get my help. I've got to go and have this conversation again'. Particularly when you're talking about young people who maybe have experienced some form of trauma that is new to them, or is historic, having to tell their story time and time again to different professionals is re-traumatising; it doesn't help with their recovery and it doesn't help them move forward in a way that they would wish to. So, I think it's really important that we look creatively around what is that 'no wrong door' approach; what is that entry point that can enable any student seeking help to then be supported to seek help in the most appropriate place? And that is acknowledging that it might not be university welfare or well-being services that are best placed to support that young person if their problem is kind of severe and enduring. It may well be within the NHS. You then, as James touched on, come across the problems of the waiting times for some certain forms of counselling or secondary care are as long for some young people as the length of some courses. So, they're not going to access that. But that is a kind of secondary issue; I think it's about how we ensure that young people or any student gets support quickly, based on their needs, and that that's worked out with them, but kind of for them, rather than them worrying about, 'I've got to enter another system now and tell my story again'.

Ultimately, Simon, who do you think should be responsible for this work to declutter and hide away all of the wiring in the system and create that 'no wrong door' approach? Is it the Government or do you think it is individual health boards or universities?

I don't think it can sit with just one, to be honest. I don't think that would be fair, to go, 'Actually, Welsh Government, you can solve this issue,' because it is about health boards working with universities, working within the framework of the investment available to them and the policy direction, which I think is very positive around mental health and education. But I think it is about those conversations. It is positive that they are happening. From the evidence that I've seen this committee being given and what I've heard, there are those conversations happening where there is an acknowledgement that gap between where university services end and where health services start is acknowledged as an issue that needs to be tackled. It is about looking where those institutions are and what are the links that are being made both to the voluntary sector and the community. How do they become a part of the mental health system in terms of understanding where support can be identified for their populations?

Thank you. Sorry, Chair, just one more really brief question, and it concerns the mental health university liaison service in Cardiff. Do you think that offers the model for improved working between healthcare and education providers, or are there any barriers to that model?

Dom.

I only know a little bit about it. I heard Ben Lewis speak about it just recently. It looks really promising, and I'm excited by the model. Obviously, with all interventions, I'm always hesitant to wait to see what the evidence and the data say as they have a few years of, I suppose, piloting that approach and seeing if it works. My instinct and what research suggests tell me that definitely they're onto something with that kind of model, integrating services into one place, providing one clear point of access to students. It seems to be absolutely the right kind of thing that universities, higher education institutions should be trying to facilitate, trying to do. As ever, though, I want to wait for the data to be sure.

Also, I don't ever want to be prescriptive, because what might work for some institutions may not work for others. As Simon said earlier, for more urban institutions that have lots of different health services available to them, bringing them together can be really useful, but, for more rural institutions, potentially, such an approach isn't as needed or as appropriate, so it's hard to just upscale and say one model is going to work everywhere, because it won't be one size fits all for the whole sector, but I definitely think there's something really promising about that approach and I'm excited to see how it goes.

Thank you. Simon, did you have anything to add?

No, I'd agree with that. I think it's about following it through now.

Lovely, thank you. Finally, some questions from James Evans.

Thank you, Chair. I know we've got 10 minutes, so I'll try and be as short as I can. One thing I did want to talk about was the missing middle, as well, and actually accessing mental health support, because what we do see is people who are in that acute stage, really, who are in CAMHS support, when they leave CAMHS and transfer to adult mental health services, there is this missing middle and they can tend to get lost. So, how do you think we could design a service within higher education so we don't have that missing middle, that no-one gets lost and that people can continue their mental health recovery or mental health support and that nobody does drop off the system? What sort of service would you like to see and how would you implement that? I'll start with Simon, if that's all right.

Thanks, James. That's a really pertinent question, because, obviously, we've done some research around transitions between specialist CAMHS and adult mental health services that we published recently that identified that those transitions are far from smooth in terms of how young people experience them. I think, when we talk about service offer, we need to root this within what young people want and need during this time. The work that we've done through our Sort the Switch campaign identified that young people often felt lost, they felt the system was something that was done to them, their voices weren't heard, and that guidance necessarily wasn't being followed. I think that if you throw into the mix then that a young person may be leaving specialist CAMHS, maybe to go on to adult mental health services, or being discharged completely and then going to university as well, you have an extra pressure. How does that support then follow them through? I think this is where, if a young person is under the care of secondary services, they should have a care and treatment plan. That care and treatment plan identifies a number of areas of life, including finance, education and training. If that care and treatment plan is working effectively, that should be a really key cornerstone document to identify what a young person needs in terms of their ongoing care, whatever part of the country they're going to, whether it's within the current health board or moving to a different area in England.

We know that the quality of those care and treatment plans aren't as good as we would want them to be, but, actually, what you have is a really effective vehicle there already. If that is being filled in, if that is being worked on with the young person, to go, 'Okay, you're going to whatever university you're going to, we will need to have a conversation with them to look at this care and treatment plan, to complete this section around what support you'll need around your education and training, to look at, if it is away from home, how you access support, what are the opportunities, what's the local provision there for you,' so that that young person feels confident, or that person feels confident, that they have a plan in place that they can pick up and take with them. And what we heard from young people who did have that plan in place, where they did feel involved, where they did feel their views were heard, is that was an absolute lifesaver for them because they knew, 'This is what I should expect, this is what should be happening,' and they could give that to somebody, to go, 'Actually, this has all been done.' So, I think, alongside talking about services and systems, there's actually some really key things that we already have in place that maybe aren't being maximised that could really help young people who are moving into higher education with existing mental health problems to access the support that they need.

Thank you. Dom, have you—?

I absolutely echo most of that. I think there are lots of challenges around transitions. I don't have the evidence or data to really be confident in highlighting any best practice, but something we have heard students in higher education institutions and sector colleagues mention is talk around having mental health passports, care passports, with a particular challenge being around the fact that students spend only about six months based locally wherever their institutions is, and then around half of the year back home, just because of term times being so short and holidays so long. So, for students who are going back and forth between them, there's a challenge between where they're registered, where they're accessing care, and how they continue to access care back home or at their higher education institution.

There's been lots of discussion on the need for the option for duality in terms of accessing care, being registered in two places at once and the need for really strong information-sharing practices between services in supporting students with particularly complex needs. Broadly, it would be great for services to be able to provide that for everyone, but, ideally, obviously, empowering individuals to have the onus to have that data available to them, be confident in communicating that, having access to do that themselves so that, when they do go to a new service, or when they are going on, they don't have to reshare their whole experience again, but, actually, they can just be like, 'I've got this app, or I've got this thing and, look, here you go, you can just download all of the information you need. Please continue to provide the care that's required.' Lots of calls for those kinds of systems, and just improved information sharing, I think, is at the core of it, really.

This leads me on to my next question, really, and you've almost answered it, so you can give a bit more information, if you want, or just say, 'Refer to my previous answer.' The National Union of Students have said, with the Welsh Government's 'Together for Mental Health' plan, and the reiteration of that, that they want more emphasis in the plan on supporting higher education students with their mental health problems and support. So, how do you think that higher education student mental health could be incorporated into that plan, to make sure we've got the right support in place and, actually, the key performance indicators and make sure that people, like on this committee, can actually hold Government to account for the actions that they're doing as well? I'll start with Dom.

I'll just add, I suppose, a little bit to my previous answer, because I do think it's largely just understanding what is unique and different in the student populations that we need to be mindful of. It is those kinds of challenges of falling between the gaps in services with care. They're a very mobile population, so I can understand the challenges of having that lockdown for their care. So, information sharing is really key between the services, with services, with the universities and with the third sector as well, as I mentioned previously. But it's also understanding, I suppose, some of the unique challenges that come with student life, with transitions, but I think Simon spoke to much of that in his previous answer. I'll keep it brief and stop there.

Diolch, thank you. Simon, have got anything to add, or not really?

Yes, I think one of the challenges with 'Together for Mental Health' is its breadth. It's from early intervention and support right the way through to people experiencing crisis and severe and enduring mental illness. So, there's a huge breadth that the strategy covers. I think what's interesting is that a number of the groups that we're talking about in terms of those that experience poorer mental health as a student population are those that experience poor mental health generally, in terms of the wider population as well. As Dom says, there are specific environmental and situational things to take into account in terms of the student experience in terms of first time being away, lack of support, emotional development, but actually a lot of those people who will experience poor mental health outcomes, or just experience poor mental health generally, will be the same people that will experience poor mental health in the wider population as well—it's just that they're in a different setting that needs specific support relevant to that setting.

If you look at the work that's been done around mental health inequality, it overlaps. I think it's really important that we take into account that the student experience and people's experiences during their time as students form part of their wider experience in life as well. If they're experiencing poverty, if they're experiencing discrimination or racism, they are going to impact more, and their mental health is going to be impacted on more. So, I think we just need, in terms of 'Together for Mental Health', to think about those inequalities, and think about them within the context of higher education as well, so that it has that focus as well, rather than trying to identify lots of different settings where we might need to think differently.

Okay, thank you. I've got one more question—this will probably be quite succinct, really—for all of you. If you could ask one recommendation of the Government on how we could improve mental health support in the higher education setting, what would that recommendation be? I'll start with Dom since Simon finished the last question.

I think it would be really powerful to have Government support for institutions going through the university mental health charter. It's already quite a thorough approach that looks at everything we've spoken about today in terms of information sharing, academic curriculum, pedagogy, embedding well-being, and taking a holistic, strategic approach to this issue but thinking broadly outside of the institutions as well. It's an improvement framework, so it's obviously going to be designed to make sure we're not using a charter mark to name and shame any institutions that are behind, but, actually, it's going to be a way that we're providing feedback to institutions to improve their practice, to grow, to learn, to develop for the better for their students in the long run. So, having your support behind schemes like that, behind guidance and resources that are published by and for the sector, is just going to be really useful in empowering the work that's already happening. That would be welcome.

Diolch.

Simon.

Yes, I'd completely support Dom in terms of the charter. As I said earlier, culture is so important in any institution in terms of their approach to mental health. I guess the one that I would add would be around those young people in particular, and anybody who is going to university, with an existing mental health problem and where a care and treatment plan is in place, that there is a lot more work done around how that care and treatment plan can be effectively used to map and lead the support for that person during the time that they're at that university, because I think it can be just a really useful tool to help give the students themselves confidence as well as those that then are seeking to support them about preferences and ways in which they would like to be supported.

Thank you. Thank you, everybody. Thank you for joining us, and for your evidence today. We very much appreciate it. You will be sent a transcript in due course, just to check, from today. Diolch yn fawr.

Just to Members, we move on to the next item on the agenda, which is the papers to note. We have six papers to note today. Full details of the papers are set out on the agenda and in the paper pack. Are Members content to note these letters together? Yes. I can see all Members are content.

The next item is to move into private session. So, I propose, in accordance with Standing Order 17.42, that the committee resolves to meet in private for the remainder of this meeting. Are Members content? I see Members are content, so we will now proceed in private.