Health and Social Care Committee

I move to item 3, and under Standing Order 17.42 I resolve to exclude the public from items 4, 8, 9, 10 and 11 of today's meeting. Are Members content with that? In that case, then, we'll reconvene about 11:10 or just after, when we'll be having our first panel in regard to our inquiry into mental health inequality. So, we'll now move into private session.

Welcome back to the Health and Social Care Committee. I move to item 5 today, and item 5 is the first of two items today where we're taking oral evidence in regard to our new inquiry on mental health inequalities. I would be grateful if the witnesses for our first panel today could introduce themselves. Perhaps I can come to you first, Andy Bell.

Thank you. My name's Andy. I work at Centre for Mental Health. We're an independent, not-for-profit organisation, and our work is all about using research and evidence to eradicate mental health inequalities.

Hi, I'm Antonis Kousoulis. I'm director for England and Wales at the Mental Health Foundation. We're a UK-wide charity of over 70 years, focusing on prevention and inequality.

Lovely. Thank you. I'm going to ask a very, very general question, but I think an important one, at the very start of this first session that we have on mental health inequalities. What does it mean? What does mental health inequalities mean?

I'm happy to start.

Absolutely. Define it for us. Thank you.

That's what we both do, anyway. Mental health inequality, essentially, at its core, is referring to anything that might place people at an unequal risk of experiencing mental health problems, at the very simplest. The issue with mental health inequality is really what sometimes is hidden within that word—the inequity. It is an issue that, essentially, means that some people, some population groups, are systematically disproportionately affected by mental health problems because of disadvantage. So, that's the broad definition, but I think there's an issue of fairness and human rights when we talk more about inequity, as opposed to the broader term of inequality.

Andy Bell, if you want to come in. I suppose I'm just adding to that question about how, perhaps, inequalities exist in society and lead to poorer mental health outcomes as well.

Thank you. Broadly, mental health inequalities are economic and social inequalities. They map very closely onto, for example, inequalities in wealth, inequalities in power, inequalities in status in society. We often hear that anyone can experience a mental illness, and of course that is true, but we know your chances are very, very much greater of having a mental health difficulty if you come from a deprived background, if you are a member of a racialised community. Any kind of disadvantage and discrimination in society is associated with a higher risk of poor mental health. And that's nothing innate about people living in those circumstances; it's about the way society works—the structures, the processes—that puts some people at a far greater risk than others. As Antonis says, we know it's systemic, and we know, crucially, it links to what's going on in society more broadly.

You talk about different groups at risk. Do you think we have enough data that helps us to identify particular groups that are at higher risk in terms of mental health inequalities?

Up to a point, yes. I think we're very, very clear, with all the research evidence we've got, with all the data we get from regular surveys, that rates of poor mental health are higher among some groups than others. In some ways, that's very, very clear. We don't need to be told, we don't need to collate more data to find that out. I think the difficulty is, we often don't have routine data that allows us to track changes in that and to identify what might make a difference.

One thing that, perhaps, is really crucial is that as well as inequalities in what determines our chances of having good or poor mental health, we often see those same inequalities in terms of getting access to support for your mental health and indeed the outcomes and experiences you have if you do get support. We call this a triple barrier. It really does work its way all the way through the system. And again, that's really important, because we need data to know how well public services are meeting people's mental health needs and what they're doing to help reduce that dynamic.

Just to add to what Andy said—I agree with everything—we now have, essentially, decades of evidence. It's very clear on how some groups are systematically disproportionately affected. We know that people living in poverty in more deprived areas have a higher risk of mental health problems. We know about people living in loneliness, in social isolation, people facing discrimination on the basis of what we tend to call 'protected characteristics'—there is very clear evidence specifically within those groups, for example, and for racialised communities. We also know that people who in some shape or form are more likely to be exposed to trauma—and this happens more often in deprived areas—are much more likely to develop a mental health problem. So, there's very clear evidence of the problem, if you like. As Andy said, sometimes the issue we have is translating this problem into accessing the good support, or in fact, even better, preventing the extent of some of the problems.

Thank you. You've both set the scene well there. I know there'll be follow-up questions on your initial answers. Jack Sargeant.

Can I firstly come on to community solutions, please, and where we're looking—?

Sorry, I can see you were startled. It was my fault; I should have come to Joyce first. I do apologise, Jack, I put you on the spot there. You should have said to me, 'Isn't Joyce next?' Joyce Watson. My apologies, Jack.

Okay. Good morning, both. What is the most recent evidence telling us about the impact of COVID-19 on mental health? And what do you think that will mean in the long term?

I can share some of the intelligence we have from our own research. We've been running a study in collaboration with Swansea University and four other universities across the UK, looking into what are the key sources, what have been the key sources of stress for people, and the key coping mechanisms over the past couple of years.

We have seen certain groups disproportionately affected. Very clearly, the young adults have been there since the start of the pandemic: obviously, disruption in education, in life opportunities, opportunities for connection with their peers. We've seen very clear evidence on single parents. We've seen a difference in the mental health experiences during the pandemic of women versus men. We've seen a disproportionate impact on carers, but in particular informal carers, people working in health and social care, so, the workers, we know—I think this has been extensively mentioned in the news as well. So, these are just some of the groups.

I think what we have seen with COVID, and in many ways we have been expecting this, because this has been a feature of all previous pandemics in the history of the world, is that they exacerbate inequalities. They come in and they don't necessarily cause new inequalities, but they make everything worse where there is fertile ground to make things worse, and this has very much been the case in mental health.

Yes, I completely agree with that. I think there are short-term impacts that we could see straight away. We know that, during the lockdowns, well-being went down for everybody, but particularly those most strongly affected. I think what we know from evidence from previous pandemics, as well as what's emerging from this one, is that the groups of people most directly affected by it, either by the virus itself or by the measures put in place to protect people, are particularly likely to be badly affected in terms of their long-term impacts.

One of the crucial things to say is, as the lockdown restrictions end, as all restrictions end, that doesn't mean the mental health impacts go away, because we know what we're left with is people who've suffered extremely traumatic events in their lives, obviously those particularly who have been treated in hospital in frightening circumstances, people who've lost loved ones, people who've potentially lost their livelihoods, particularly with the cost-of-living crisis, which will be exacerbating that. And so it's really important to understand that the mental health impacts are going to be there for some time afterwards, and we forecast that, across the UK, around about 10 million people will need extra support for their mental health because of the pandemic, and a lot of that has come from the after-effects rather than the immediate impacts of the restrictions that we've all had to live through.

Yes, and they've been well documented. But are there any new or emerging areas of concern that you've been tracking as a consequence? You've just mentioned that it will be ongoing. Ten million, I think you said, which is a huge figure. Obviously, that's UK wide. But there are particular groups of people that you think have been affected by the societal impact of that pandemic that perhaps need a particular focus.

I think it's been really striking that, overall, across society as a whole, it seems that children and young people have been affected probably more than older age groups, and I think that wasn't necessarily what we expected early on, but it's been very, very clear through every bit of evidence. So, particularly children who have been in very frightening circumstances, those who perhaps have lost loved ones and may have found it really hard to understand what's going on. I think we've seen—. Certainly some work we've been doing with young people in Birmingham suggests that particularly young black men have been overly policed, policed more strictly in terms of lockdown restrictions, than other groups of people. And that has certainly, again, exacerbated an inequality that was there already. And I think it's important to understand the impact on people who have been in prison. For obvious safety reasons, prisoners have been under conditions that, effectively, are equivalent to solitary confinement, often for very, very long periods, and we need to be mindful of the effect that that will have on anyone who has been in that situation.

Thank you.

I would just add to that, if I may, the issue of employment. Many people have been unemployed or in precarious employment during the course of the pandemic, and we know that precarious employment is likely to continue for some time. So, I would like to add that as a consideration. Specifically thinking about Wales, people living in rural areas. We've done work in the past with Public Health Wales on farming and fishing communities. We knew that they were entering the pandemic at a disadvantage, with uncertainty on the back of Brexit, certainly about contracts and making their livelihoods, and this has become worse, with greater isolation and poorer access to services that would be appropriate for them, especially if you consider transport links and the need for services in the Welsh language and things like that for those communities. So, I would just add those as well.

Joyce.

Okay, thank you.

Thank you. Gareth Davies.

Thank you very much, Chair, and good morning to both the witnesses today. Written evidence we've received describes an outdated medical model for mental health that fails to address broader needs. I'm just seeking the witnesses' views on this and what a more effective model of support would look like.

So, an effective model of support. Who wants to go first? Dr Kousoulis?

I suppose I can throw that out to both.

Yes, I'm happy to, but do you want to go first, Andy, because I think I've gone first in all questions?

There we are. Andy first and then Dr Kousoulis. Andy Bell.

Okay. I think we're both being really polite. [Laughter.]

It's a really important point, and again the more we understand about what affects our mental health and the way in which we can support people either to live well with mental health difficulty or to recover, the more we realise that we really do need a more holistic approach than simply seeing it as faulty brain chemistry, if you like. So, we know, for example, that if the things that cause us poor mental health in the first place are about the precariousness of our lives, if they're about our relationships, if they're about experiences of discrimination, those are the things we need to tackle in order to support people to live well and to recover.

So, some people talk about a social model of mental health, some people use very big, long words like 'biopsychosocial' to talk about mixing together the medical stuff, which still has a place for many, many people. For example, using medication to manage your mental health is an incredibly important part of staying well and, of course, it can be life-saving, but I think we also know increasingly that that's not the only approach that works and, for many, many people, it's actually support to live well, to be safe, to have enough money coming in and, crucially, I think, we increasingly recognise how important trauma is in terms of causing poor mental health in the first place and how we really need services to come with what is called a trauma-informed approach. That's a bit of jargon, but what it really means is that all of your services understand the traumatic events people have been through and what you need in terms of providing support to do the opposite. You need to create safe spaces for people to be in, particularly if they need to be in hospital or in another environment away from home, you give people proper choice in their treatment and the support that they get, and you focus on building relationships.

And of course, the more we see the use of coercion in the mental health system, the more people are detained under the Mental Health Act 1983, which sadly is rising year after year after year, we know that can do harm long term. It may be necessary to save a life, but potentially those experiences of coercion can reinforce some of those traumatic experiences people have been through, and we know that's used unequally. So, if you are from an African or Caribbean background, you're something like four times more likely than a white person to be subject to the mental health Act, and there's something deeply, deeply wrong about that.

I appreciate that, Andy, thanks very much. I was going to actually ask you to go more into detail about the trauma-informed approach. I'm glad you've been able to clarify that this morning. Just to push on that one a little bit more, because the Mental Health Foundation are calling for a trauma-informed approach across all public services, what does that mean in a practical sense and how would that contribute to reducing mental health inequality?

Thank you for this question. A trauma-informed approach essentially means listening, empathetic services that meet people where they are, that understand where people are coming from. So, this whole debate around medical or a different model, I think in some ways we have to think about things quite holistically. I see Wales as a real leader internationally in this space.

So, a very simple example of trauma-informed services is the whole-school approach that Wales has made statutory. So, children that are behaving differently, that are not doing well at school, that are struggling, we shouldn't see them as problem children, we should see them as children with problems and do something about that, increase their chances to complete their education, increase their life opportunities, ensure that they have a connection, ensure that someone is there to listen. Sometimes, there's no-one at home for these children. So, this is just the example of schools, but I think it's a great one for Wales because already a lot of that is being implemented.

I think, on the back of what has happened over the past couple of years, trauma-informed training should start to be offered. A lot of people are coming out of the pandemic traumatised and with some quite persistent causes for being retraumatised and triggered. So, starting from health and social care staff, we need to think about trauma-informed training as a starting point. But I think, referring to what Andy was saying, these skills are very relevant in other settings—criminal justice, blue-light services and areas like that.

I appreciate that clarity, thank you very much. One of the stakeholders' concerns is about an over-reliance on prescribing mediation for people presenting with mental health needs, when there's a limited availability of other options of support. Do you recognise that as a problem and what are the solutions? Apart from the obvious, of investing more into support services, are there any other options they can look at in terms of tackling that sort of issue that the stakeholders have raised about the over-reliance on medication?

I think Andy Bell responded a bit to that in an earlier answer.

I'm happy to have a go at this.

Yes, Andy.

Yes. So, if you look at data between local areas, what you see is antidepressant prescribing in particular really kind of aligns very closely with levels of poverty. One of the things we hear from lots of people who are prescribed antidepressants and GPs in more deprived areas of the country is that they feel that they've got nothing else. It's the only option, as you say. It's partly because poverty is so overwhelming and disadvantage is so overwhelming that, in a sense, it's the only response a GP has to somebody, to provide people with some medication that will manage that sense of despair, if you like. And of course, partly, that's due to the fact that we are making progress in terms of expanding access to talking therapies, but it's still a work in progress. And, of course, for many, many people, if you're living in situations of poverty and insecurity, you don't feel safe in your own home, you don't know when you're going to lose your tenancy, or default on your mortgage, unsurprisingly, talking therapies aren't going to make that go away any more than antidepressants are. So, again, it's about having a kind of response that, where possible, you try and prevent problems from happening in the first place, supporting people into work where possible, making sure you maximise people's incomes. Many people don't get the benefits that they're entitled to for various reasons, and in some ways, those levels of prescribing are a function of a society that is impoverishing people and leaving them with very few other options.

I appreciate you tackling that one, Andy. Thank you. And a particular issue we've heard about in the written evidence and focus group is a lack of support for people with co-occurring conditions, and neurodiversity conditions such as attention deficit hyperactivity disorder, autism, perhaps substance misuse as well. In regards to the lack of support for that, is there any particular view you have on that issue at all?

So, you're right for raising that, and this is also clear in the evidence. So, I appreciate that. There are two issues, I think, in relation to that I would like to raise. First, the issue of support and treatment. We see services that are quite often siloed. They don't take into account the whole presence of a person, their specific needs, and the adaptations that need to be considered for each individual. It is particularly important in issues like, as you raised, neurodiversity or, indeed, addiction.

But building on what Andy was saying earlier, there is a need for greater action earlier within the community that potentially could improve lives before they reach those crisis points. And this again is an area that is sometimes lacking, and people don't necessarily have the same understanding for those services. We know that addictions sometimes start as ways of coping. So, supporting people within local communities, within their contexts, to have positive coping mechanisms, and also protecting them from harms that are outside of their control—I think we've given some examples of that—would be, for me, the starting point.

Thank you very much.

Now I'll come to Jack Sargeant.

I'm very grateful, Chair, and grateful to the witnesses for being here. Can I first personally agree with the trauma-informed approach there, not as a member of the committee, but as a Member of the Senedd? I think Wales could lead the way with that. And for all public services actually—I think we could certainly lead the way there.

I'd like to focus on community solutions, and how we can further develop them and enhance the community solutions. I have a bit of an issue, and I make no apologies for this—I suffer with poor mental health, and I can tell the committee that this week for me has been particularly rubbish. But I do have a fear, if you like, that, because of COVID, because of other things, we are missing a trick with certain communities. We've already discussed some of those inequalities already. But just what you would call 'normal communities', Joe Bloggs from down the street—I think we're missing a trick here. And the traditional methods of perhaps picking up the phone and ringing the number to the mental health line, whilst it is very good—I would encourage everyone to do that—many people won't.

So, how do we further develop those integral parts, where community spaces are already out there? I look at Newport County as an excellent example of where a football club breaks down the barrier and stigma. How do we do that? Is there space for further development there? And what sort of role should local government and the third sector organisations, football teams, anyone—what sort of role should they play, and how does the Government enable that to happen? You're here, you're here in the room, so I will come to you first, Antonis, and perhaps we can pass over to Andy later on.

Thank you for this question, and thank you for sharing your own experience as well; that's always appreciated. So, first of all, if you're thinking about community solutions, they need to be finding people in the settings where we spend most of our time, so schools, workplaces—whatever kind of shape or form they're in—and other examples in local communities. So, we have to start with the people that hold power and influence over people's lives, and think about training, think about culture, think about benefits and support. We have done a lot of—. A big aspect of our work at the foundation is testing community programmes and seeing what works, so they're not on the treatment end, but more on the prevention and support end. We've worked in Wales quite extensively with population groups, like single parents, refugees, older people—actually, with sporting teams as well. And we have found some common characteristics that these community programmes need to have to be successful. So, they need to be culturally adapted, so really respond to the needs of different people. As we said, finding people where they're at, and meeting people where they're at. So, if it's a football club, let's do something there, in the space that is familiar, and use that positive asset, essentially. So, that asset-based approach is really important as well.

All of our work takes a peer leadership approach, so essentially empowering people from that community to be leaders, to be peer supporters, to have more confidence in supporting each other in many ways. Connection as well is really important. We know that mental health problems worsen and trauma has a more severe impact when they're experienced in isolation. So, connection is really important. And I think specifically for Wales, what we have seen, which I mentioned earlier, the need for support in the Welsh language, for some communities, especially rural and in the north, and the need for—. Some of these things work very well for a football club, for a school—they're a very well-contained geographical area—but for people like farmers, who work very far from each other, but they see themselves potentially as a community, we need to think about transport links and how people can come together. As well there's digital literacy.

Very grateful for that answer. Andy, would you like to comment further?

Yes. I completely agree with everything that's just been said. I think, put simply, mental health is made in communities. We often think about mental health as being a deficit—you either have perfect mental health or you have mental illness. And, of course, the reality is much more complex than that, and good mental health is something you have to go out and make—it doesn't just happen in the absence of mental illness, if you like. And one of the things that we observe is that it's in communities where you create the conditions for people to have good mental health, when that community is a local area or a neighbourhood, whether it's a school, whether it's a digital community—whatever it is, that's where we protect and promote good mental health.

I think what we've observed is, first of all, that community-led organisations, ones that almost spontaneously are created by communities for themselves, are often where you see the most interesting and innovative things happening. So, rather than this being about Government, or local government, or football clubs, or anything trying to create initiatives and do things to people, actually harnessing the energy that's already there in a community and supporting and enabling that is really important. We still often see that funding, particularly charitable funding, is very, very difficult for community-led organisations to get access to. And very often, bigger charities tend to get a much larger share of funding than organisations that come from communities themselves. And yet we know that it's often at that level, that quite micro-level, where the really interesting stuff is happening.

But there are forms of allyship that we see. Some NHS mental health organisations, for example, work with local faith communities, to train up pastors or imams in some basic skills, to support mental health, which allows them to be ambassadors, if you like, and to provide some very low-level support. There are some great—. We published today a report about the Shifting the Dial project in Birmingham, which uses theatre workshops and mentoring. It's led by local community organisations—it's not done by us or any other big organisation. It comes from the community, and it has support from the local NHS trust, but actually it comes from, rather than being done to, and I think that's where you see great things. So, sometimes it's not about trying to scale things up, it's about trying to do things on the small scale, but making sure that there's that funding, whether it's grant funding, whether it's local government, which really allows those things to thrive and develop.

Thank you, Andy. And I suppose the Government's role in what you've both said would be to act as that enabler and perhaps it is the funding, then—the mechanism of funding needs to be much easier and much more accessible for these smaller groups. I can seen nodding on the screen and I can see nodding in front of me, so that's very useful for the committee.

Can I just touch, therefore, on social prescribing and whether you think there is a clear and shared understanding about what social prescribing actually is and whether there is an evidence base to support the roll-out of social prescribing as an effective intervention? I'll open it to the cameras and to you—whoever would like to go first.

I'm happy for Andy to go first.

Andy, would you like to come in first on that?

Sure. I know that the foundation have been doing some work on this so you'll have some good knowledge. As observers, we would say that there is an increasingly compelling evidence base for the benefits of social prescribing. We know, for example, that proximity to nature, physical activity, other things that you can kind of support through social prescribing, are both good for mental health generally and can support people in their recovery and so support people to live well—those who are living with poor mental heath.You may know that people living with a long-term mental illness have life expectancy that is shockingly 15 to 20 years shorter than other people in society, which is about the biggest inequality in health you can have—having two decades lost of life. And, of course, social prescribing creates the opportunity for physical activity, which is one means by which you can support people to have better physical health.

Needless to say, social prescribing can't change the economic and social conditions people are living in, but it can very, very significantly help to mitigate those and, indeed, it can put people in charge of their own lives as well, and if you combine that, for example, with personal budgeting—people being able to choose how they spend their funding through the NHS or through social care—you've potentially got many more opportunities for people to have much more agency in their lives. It's not just about creating activities for people to go and do and having no choice, it's about having all the possible options, and it's about a sense of belonging as well—being part of a community.

Thank you, Andy. Antonis.

I'll just briefly add the two big benefits that we're seeing of social prescribing: one is making such programmes, such community interventions, more accessible at a broader level; and the second is that they support—building on the back of the discussion we had earlier about the medical model—people struggling but also health and care staff to build a greater understanding of the influences on mental health and also what supports recovery.

Thank you. Thank you, Chair.

Thank you, Jack. Mike Hedges.

Diolch, Gadeirydd. I assume you agree with these statements—if you don't, please tell me: I think we need to increase public awareness, increase understanding of mental health and well-being, increase help-seeking behaviour and create compassionate communities. Assuming you agree with that, how do we go about it?

I'm happy to start. We have been running Mental Health Awareness Week for over 20 years. What we have—. I do agree with the statement. I think such statements need nuance when we go more public with them, and I think what we have seen, which has made me concerned over the course of the past couple of years of the pandemic, is that starting the pandemic and including a conversation about mental health in it has been a first—we've never talked about mental health in previous pandemics. But as the pandemic went on, we started using mental health as an argument against other public health measures, so we shouldn't take public health measures because they're bad for mental health or whatever. So, I think, for me, mental health awareness needs to go much deeper than this and really start with the sentence that Andy used at the start, which is, 'Everyone can experience a mental health problem, but that risk is not distributed equally.' And this is a key point about mental health awareness and also the issues of people who are at the more extreme end of the spectrum of risk and the experiences that those people have.

So, for me, this is quite fundamental when talking about mental health awareness. Obviously, the UK as a whole has one of the largest mental health awareness weeks that exists anywhere in the world, and this is a big opportunity every year to campaign, to share, to talk and really to move towards action. But I think a lot of that nuance of mental health awareness is coming more locally, is coming from within, is coming from and often led by mental health activists, people with lived experience, family experience, and, for me, a first step is to start empowering those activists more, because I think whenever we've seen change, social change, it's often led by the people who really have a stake—empowering people who have a stake in that change.

I'd only add to that that, actually, thanks to the Mental Health Foundation and others, we've probably got more mental health awareness than we've ever had right now, and that's come over many, many years, and often a lot of struggle has gone on behind that, and a lot of very, very hard work. In a sense, the challenge now is about turning that awareness into literacy and action, and mental health literacy is incredibly important. Often, we find when we're looking at the experiences of children and families, parents understand about mental health and about the importance of their children's mental health, but they don't necessarily have the tools to know how to support that in the best way that they'd like to be able to. So, there is something about turning from awareness to literacy.

I think the other thing is that mental health, of course, isn't a single, homogenous block. There are lots of different experiences of mental health and mental ill health, and there are certainly some groups of people who experience shocking levels of discrimination—actual discrimination and stigmatising treatment. Particularly, I think, we've heard a lot recently about the experiences of people who are diagnosed with a personality disorder, for example, sometimes known as complex emotional needs, and what we've seen from the experiences of people given those diagnoses, which are very controversial in themselves, are that, actually, the treatment they get from health professionals is extremely negative and is blaming them for their own difficulties—very, very poor access to support and a very opposite-to-compassionate approach. So, again, we need to make sure we're understanding the full range of experiences of mental health and illness, and tailoring action to ensure that we're tackling stigma, including from the mental health system itself.

One final question from me. How do we engage groups of people who do not see mental health services as designed or suitable for them? I'm thinking especially of working-class men who are relatively young and who are at higher risk of suicide than almost any other group. They don't seem to think that there's anything wrong with their mental health. How do we get through to them? It's that sort of male culture that is not beneficial to improving mental health.

I'm happy to have a first go at this, and then, Antonis, I'll let you come in. I think, first and fundamentally, mental health services work best if they're designed in partnership with the people they're designed to help, and very often, particularly with—. The most resistant to help-seeking, if you like, or the least help-seeking group in society is young adults, so people in their teenage years and early 20s, which is often when we see the onset of quite significant mental health difficulties. And the problem is that we tend to see services that just put their hands on their hips and say, 'Why don't they engage with us? They don't come through the door, or people do come through the door and they don't like the offer that's there and they don't come back.' The answer to that is not just to shout louder or to encourage people to come in; it's actually to change the offer. So, if the offer isn't working for a group of people, it's not the right offer. Again, looking at the work we've been doing with young black men in Birmingham, they're not interested in the traditional kind of 'go to your GP, get a referral, go to a mental health service' type model. They want support that is very different to that, which actually kind of builds their sense of community and belonging—it uses very different ways of providing support and promoting good mental health. And so, I think, with any group that's getting a poorer experience and not getting help, we've got to change the nature of the help, not just shout louder.

Can I just follow on from that? I think that we—men in general, and, as I say, working-class men—need to be more sympathetic to our friends and colleagues as well, and that everything isn't a potential for a joke; we've actually got to relate to the problems our friends are having. How do we get working-class men like me to do that?

I think you've just described what a trauma-informed approach is, essentially—so, being more sympathetic and relating to the problems someone else is experiencing. Building on what we said earlier, both Andy and I, the way to do this is essentially to work with men—so, design services or campaigns or programmes or policies within organisations or whatever else it may be, and work with the people who will be the beneficiaries. And I think it's the same at this early stage of what you were mentioning around talking to each other and asking for that support and relating to the problems that others are having. If we built those campaigns, those programmes together with people instead of doing things to people, then we have a much greater chance of success.

There's no escaping the fact that mental health has been misunderstood, mistreated, misdiagnosed for centuries, so there's a lot of catching up and we're constantly catching up, and there's a big deficit that exists in mental health that maybe does not exist in the same way in other areas, even though we've seen stigma in other areas of health. So, addressing stigma is still very much part of the picture, especially for identifying those early problems, and also for people living with severe and enduring mental illness.

Thanks, Mike. I was just considering yesterday, or in the Senedd yesterday, I talked about a group that had been set up in my area, which I represent, of men just meeting and going for a walk and talking, and it's not set up—. Those involved have come from professional backgrounds, but it's not set up in any particularly structured way; it's just we meet and talk and chat. I'm just wondering to what extent—we talk about programmes and interventions—it's just a case of us all, and society, changing to make us all a lot more willing to be able to talk to each other in a very normalised way and to make this a very normal part of life.

I think this is fundamental. It's essentially what we were discussing earlier around understanding the basic needs that we have as human beings. I'm glad that these groups exist and, for many of us, these are the most kind of protective things that we have in our lives for our well-being and our mental health; the issue being that there are people who don't have access to such informal groups of whatever. So, not everything has to be an intervention, not everything has to be a public health programme or whatever else. And I think, within communities with assets like these—we would probably call these 'assets', if you like—it's about building on those, creating those opportunities. So, if peer-to-peer, colleague support is important within an organisation, then the organisation can enable it by giving flexible hours, or good lunch breaks or creating communal spaces in the kitchen for people to eat together, as an example. Or if people join football teams as a way of socialising and looking after each other in ways that are very informal, then let's make joining such groups very accessible. So, it's about enabling that, not necessarily turning everything into an intervention, I agree.

Yes, interesting. Thank you. I can see Andy Bell nodding as well at that in agreement. Joyce Watson.

I just, with your allowance, Chair, want to tease out something that you touched on earlier, and there are two things together here. We talk about neurodivergent conditions and people therefore having labels as a consequence, and I just want to explore how much that is seen as the problem—that people have a condition—rather than the fact that, yes, they have a condition that is causing them to have some mental health issues as well as a consequence of dealing with that condition. Because you did talk about the horrendous treatment that's very often given to people as a consequence of having a condition. I just wanted to briefly explore that—whether you want to write to us or say something now.

I'm happy to say something brief—or Andy.

Dr Kousoulis.

I actually really agree. We, I think, historically, have made such diagnoses of such conditions equivalent to a mental health problem. We have started making some progress from this attitude, but, in fact, what we have seen is people that have those identities, experiences or conditions have very different treatment—they receive much different treatment from society, from different structures. They don't have access to the same tools, if you like, to the same opportunities and, in many ways, they're systematically missing those benefits that exist within our society that are available to others. So, I do agree with you, and I think it's really important that we shift the conversation to understand what people need and how we can enable them and empower them to have that, instead of seeing everything as a mental health problem, when we are, in many ways, causing that.

Thank you. Joyce.

I'll move on now to what they were expecting me to ask, and that was about the strategy for mental health. You've answered, of course, moving on from it being just a healthcare issue. I want to ask in terms of Government and organisations just seeing it sitting in health, rather than it being everybody's job to take note of it and have a truly cross-sector, cross-Government approach. What recommendations would you make to Government to make that happen?

So, what does Government need to do to make that happen?

Shall I go first this time?

There we are. Please, Andy Bell, yes.

There's so much to say here, so I'll try and keep it brief. I think the first thing is Government should set a clear ambition to reduce mental health inequality, and that's both improving mental health for all, for the whole population, but also reducing the gap in terms of what we see. And so, first of all, I think having a clear strategic goal to reduce the inequality and the inequities that lead to it would be a very powerful thing for Government to do. I think, secondly, it's then recognising that every single department in Government, every single part of Government, every decision made, has an effect on people's mental health one way or another. And so, decisions made by Government can both be very protective of good mental health and support people with mental health difficulties to live better, or they can cause significant harm—so, everything from setting budgets and what you decide to put money into, through to the ways in which different Government departments are prioritised, how schools work, how prisons work. All of these things will have a mental health impact one way or another. So, again, the crucial thing here is to do that consciously. And we've seen both at very local and national level, if you have a mental-health-in-all-policies approach, then you seek to ensure that every policy you put out, every decision you make, seeks to benefit mental health, reduce inequalities and improve the lives of people living with mental illness. And if you do that really deliberately and explicitly, then you start to change the game, and you start to change the way decisions get made and then we can really start to make some progress.

Just to give you my thoughts—and I do agree with Andy—in our recent research, we found that mental health problems cost the Wales economy £4.8 billion—I should say at least £4.8 billion—per year. About a third of that cost comes from economic inactivity, about a third of that cost is related to informal carers and what they're caring, essentially, for the systems. No more than 15 per cent of that cost is health and social care costs.

So, I think it's really important to really build on what you said and think about how a mental health strategy really needs to go beyond health and care. So, a few points on this. The previous mental health strategy in Wales was obviously before the Well-being of Future Generations (Wales) Act 2015. Again, I would say, for those of us who interact internationally with colleagues, Wales, again, is a pioneer, really, internationally, in having an Act like this. So, I think the new mental health strategy should really align itself with this piece of legislation and I would expect that it does. I think it's important to see, and I'm very encouraged that you're all very aware of this issue—. We would need to see a cross-Government plan that addresses health inequalities. And for this to happen, we would need to have some proper consultation with lived experience, I would say, of inequality, so we do have—. And I think Wales has done that really well—I know that there's a forum of people experiencing mental illness—but sometimes we need to go beyond that, especially in thinking about prevention and community, the topics raised today, we need to speak to people who experience inequality and not necessarily have had a diagnosis, if you like. I think that there are, potentially, some blind spots at the moment around the mental health of older people and the mental health of women and their gendered experiences of inequality and mental health compared to men, and also that of rural communities, and thinking about the professional community, as well, like farming and fishing communities. So, that would be great, I think, if that could be considered within the strategy.

We are involved at the moment in looking, alongside your colleagues, at the impact of previous strategies and evaluating those. So, building a strategy, I would encourage, from early on, to really consider what are the metrics, what are the outcomes, how would you like to evaluate its impact when that period is over, and we have seen some good approaches to doing that, sometimes using proxies and data that are not necessarily there for that purpose. But there are national data sets, there are local data sets, that could be used as proxies. So, really consider that impact evaluation.

Thank you. A final question from me is: are there other countries that have an approach that we could learn something from?

Yes. I would say—. I'll start with acknowledging, again, how much of a leader Wales is, including, for example, at the moment, being a nation of sanctuary. For me, Wales adds pressure to Westminster and others on such approaches and really important issues related to mental health. The most direct example I can think of is the trauma-informed approaches that have been piloted in Scotland, and that would be good, fertile ground to consider how this could be implemented in Wales. But, otherwise, we're happy to investigate and give you some suggestions at a later time.

Thank you, Joyce. A question from me, I suppose, just to ask you for your advice—to both of you—in terms of the rest of our inquiry. We've had a huge response to this inquiry; we've had over 90 responses. And I think I should put on record our thanks, really, to all those who have responded to our call for evidence, and we've undertaken some focus groups as well—so, many people contributing towards this piece of work, so I'd just put on the record our thanks to all those that have taken part and provided us with evidence. But, in terms of the remaining part of our inquiry, as we go beyond the Easter period into the summer, we continue with our inquiry, are there any areas you think that we need to particularly be focusing on when we're looking at inequalities within mental health?

Yes. I'm happy to go first. For me, this point about consultation is important—so, who are you speaking to. I think Andy and I represent a specific, maybe, profile of national charities that really look into this issue maybe from a very professional point of view. I think speaking to grass-roots organisations, maybe some of them have not responded to the inquiry, so perhaps engaging in different ways, and I know you're doing focus groups. So, I would add that aspect of the lived experience of inequality, not necessarily based on diagnosis.

And I would say, to kind of maintain this momentum, sometimes addressing those issues, and as clients work through those issues, we are drawn into false dichotomies: we either have to try to change some of the structural stuff, and this is too big, or we have to empower people to do certain things, and this will have a very small impact. I think the truth is somewhere in the middle. We have to look at those issues. They are complex and big issues, and, actually, quite common, and we have to look at them across the whole aspect of Welsh society.

Thank you Dr Kousoulis. And to Andy Bell, where next for our inquiry? What do you think should be our focus for the next phase of our work?

Mostly what he just said. I think that's absolutely right. I think there is no improvement on actually talking to people in groups and communities that are on the wrong end of mental health inequalities, understanding their perspectives—probably in a very different environment to one like this, where that can naturally come out and you can understand. I think there are a lot of narratives that have been produced about mental health inequalities that are very useful, because not everyone communicates in the same very formal way, and often you can get a lot from understanding lived experience and the journeys that people have gone on and their perspectives on those journeys. So, I think there is nothing like that.

I think also there are often hidden inequalities, and I think Antonis mentioned later life. Mental health inequalities among older people are often neglected, hidden, not talked about, and the extent is just as great there as it is for other age groups. And really think, I guess, about the resources that the Welsh Government has at its disposal to improve mental health, to go a different way, perhaps, from other parts of the UK, to build on the achievements that have already been made in schools and to really look at how that can become the beginning of something really special. The whole-school approach, for example, is often something that people talk about and use the language, but do we know they're really doing it, and do we know that that's really happening, and is that having an effect on the really pointy end when we're looking at things like behaviour? And so I think going from rhetoric to reality is incredibly important. And, clearly, there's still an enormous opportunity to be really innovative and to do this in a really systemic way rather than just doing it round the edges.

Thank you. Thanks, both, for your advice in helping us with the rest of our inquiry. That's really much appreciated, and it was a fascinating session to help us go forward with our piece of work. So, can I thank you both as well for your written evidence as well? Very much appreciated. We'll send you a copy of the transcript of this morning's session, but, by all means, if you do follow the inquiry and the committee's work and you have further thoughts, then please, absolutely, let us know during the course of the work. So, thank you both again for your time this morning. So, diolch yn fawr iawn. There we are.

Thank you very much.

And that brings us to close the session, and we will be back at 1 o'clock when we'll have our next panel in regards to our inquiry on inequalities in mental health.

Welcome back to the Health and Social Care Committee. I move to item 6, and this is our second panel today of our inquiry into mental health inequalities, and we have a number of witnesses to help us in this next part of our inquiry for today's session. I'd just be ever so grateful if you could introduce yourselves for the public record.

I'm Sally Holland. I'm the Children's Commissioner for Wales.

Kirrin Spiby-Davidson, I'm a policy adviser to the children's commissioner.

I'm Heléna Herklots, the Older People's Commissioner for Wales.

Lovely. Thanks ever so much for being with us today. Just as a bit of scene setting at the beginning of this session, it might be helpful if each of you, respectively, talk about how mental health inequalities affect people in the various age ranges that you represent and different areas. Who would like to go first? There we are. I'll come to you then, Sally. Thank you.

I'm happy to, yes. So, when I'm thinking about children and young people's access to mental health services, I think I would divide that into two areas. One is the systematic inequalities that might be built into our services that children face, and then, secondly, the different inequalities facing different social groups of children. So, if I start with the first to think about how, actually, the way we organise our services might lead to some inequalities, I think the traditional model of child and adolescent mental health services has relied on the idea of having clinical appointments as being a bit of a golden ticket that children and their families really sort of strive for and wait for for a long time. And that required real tenacity, persistence and quite well-resourced families in terms of confidence in order to stick at it to get a referral and get a way to that appointment, which often has led to the child on the first appointment being told, 'Actually, there's nothing we can do to support you because you don't have the right kind of mental health problem.' So, that's why over the last few years myself and many other people have been trying to turn that system on its head. Dr Liz Gregory from Gwent psychology service calls it the iceberg model, as we will only see the tip of the iceberg for children, with actually those with often much greater need underneath the water. And many areas in Wales are now trying to turn the access model on its head, which is good news, although we haven't quite got there yet. I'm sure I'll have the chance to talk more about where we're at as the session goes on.

And just to stick with inequalities built into our systems, there's a couple of specific inequalities that really concern me, again, which I can enlarge on further during the session. One is for looked-after children, so children who are in foster care and the residential care system, where I think we've seen over the years really quite a poor response by our clinical services to presentations thought to arise from early trauma and where they've been told, 'You don't have a treatable mental health problem', but, actually, they have behaviours, thoughts and emotions that cause them and the people around them much distress, and that's included some real issues around access to in-patient services as well, where the children who have shown suicidal intent, for example, and severe self-harming have not been able to get admission to in-patient treatment and social care services have been left trying to keep those children safe.

The other key area and system I'm concerned about is neurodivergent conditions like ADHD and autism spectrum disorder where, again, children have been told they've got the wrong kind of problem or too many problems to be treated by clinical CAMHS in a straightforward way, and they have to often climb one ladder to be seen by one type of clinician only to be told, 'Well, we think you've all got ASD as well or instead, so you need to go back to your GP and get another referral to another bit of our system to be seen for your ASD condition, or your potential ASD condition.' So, that's just how systematically we've put in barriers and inequalities for children, but I will enlarge later on if possible on how we're working against that.

Sure. Please do, yes.

And then just very briefly on broader inequalities, as I'm sure you've heard a lot in this inquiry, our mental health inequalities for children are reflective of broader social inequalities. So, children who have experienced racism, homophobia, gender inequalities, we really see having more issues with mental health problems. Teenage girls are a particular issue, especially around concerns and anxieties around their looks. And then poverty is a key driver. So, socioeconomically disadvantaged children are two to three times more likely to develop mental health problems. And poverty that persists over time—that is a real issue for our children in Wales because we have more persistent poverty here than elsewhere in the UK. It's strongly related to higher rates of mental ill health. And falling into poverty during your childhood—this is something discovered by the millennium cohort study—is also a high-risk indicator for mental health problems, and, obviously, with the current cost-of-living crisis and issues during the pandemic, we're likely to have seen more children becoming poor during their childhoods in Wales.

Thanks, Sally. Heléna, what about your perspective in terms of older people?

Thank you. Let me just start by saying how much I welcome this inquiry, and just in almost a summary point to start with, I think I've probably never been more concerned about the situation regarding older people's mental health as I am right now. So, two areas to focus on. One is the determinants of mental health, and then secondly the access and availability of appropriate mental health services.

So, starting with those determinants, some of these are deep-rooted issues. Some of them have been exacerbated by the pandemic. But, certainly, we know that ageism and age discrimination has a significant detrimental impact on older people's mental health. The World Health Organization estimate that one in two people hold ageist views against older people—in other words, being discriminatory, stereotyping, not valuing, not being responsive. The Royal College of Psychiatrists, in its report in 2018, 'Suffering in silence', highlighted the discrimination also in the access and provision of mental health services. So, we have a situation where ageism is both a factor in poor mental health for older people, but also a factor, then, in meaning that older people can't access the support that they might need.

But, of course, there a number of other determinants, and one key thing to remember is the diversity of the older population. So, as older people's commissioner, my remit is everyone over the age of 60. That's over 800,000 people in Wales, and there's a huge diversity in difference of experience between people in their 60s who are in the workplace, for example people caring for others, and people in their 80s and 90s and so forth dealing with long-term conditions.

And some of the issues that Sally flagged certainly affect older people as well. I would highlight as recent things the impact of COVID, which I'm sure we will talk about later, and the cost-of-living crisis, which is probably one of the issues that older people talk to me most about at the moment. And to give you a flavour of that, people talk about their anxiety about how to afford food. One older person last week told me that she was terrified—terrified—about the future because of the cost-of-living crisis and not being able to make ends meet. But we also know that issues of digital exclusion mean that some of the services and support that others can access—and there is a lot of online services and support—many older people can't access. So, about 31 per cent of people over the age of 75 aren't online. We also know that poverty is increasing generally amongst older people.

And three other areas I would just highlight in terms of having a detrimental impact on mental health: the stresses of unpaid caring, particularly where people are caring for others with mental health problems; the issue of the abuse of older people, so we know that thousands of older people experience abuse in Wales, whether that's domestic abuse, financial, coercive control, for example, and that has severe impacts on their mental health; and then those issues that tend to affect us as we get older, so poverty, plus issues of bereavement, isolation and loneliness. So, these long-standing inequalities that many older people experience are also accentuated if, for example, you're in a black, Asian and minority ethnic community and an older person, or if you're an LGBTQ+ older person, where you may well have faced ongoing discrimination through your life, compounded by the discrimination you can face as an older person. So, that's why I very much welcome the attention now of this committee on these issues.

Thank you, Heléna. And in terms of—. You've outlined, both of you, a different range of areas, in terms of younger people and older people, but in terms of having data to know, in terms of people being able to assess mental health services in those different age groups—do you think there's enough data out there to determine that?

No.

To be honest, the answer was all I needed—'no'—because we're a bit short of time. Sally, have you got a one-word answer to that as well?

No.

Not 'no, you haven't got a one-word answer'—'no' is the answer?

No, there's not enough data. I think we've highlighted some of it in our written response.

That's it, you have, yes. Absolutely. Thank you ever so much, and I'm very grateful for the opening comments—that sets a scene for the rest of the session. Joyce Watson.

I would like to welcome you—thank you, both, for being here—and invite you to give some recent evidence about the impact that the pandemic has had on the mental health of older people and also children and young people, and whether you think that's a long-term impact. Is it a new and emerging area of concern, or is it just a heightened awareness of what was already there?

There we are. Who wants to go first? I'll encourage brief answers, only because I know we've got so many questions to get to before 2 o'clock. So, who would like to address that?

I'm happy to take that. So, thank you for that question. I referred to some of those issues earlier, so I'll therefore just add two or three more. We know that the impact of COVID-19, particularly for older people in care homes, has been acute, so the impact of being separated from people that matter most in your life has certainly led to issues around that isolation, around loneliness and poor mental health, so issues of anxiety and depression. I'm not yet seeing attention being given to the mental health of older people living in care homes and what can be done in terms of support and services, so I would highlight that issue.

There's also the issue, particularly for older people, of the combination of poor physical health and mental health. So, often older people won't necessarily distinguish between those two things. We know if you develop long-term conditions, for example, that can impact on your mental health. So, the impact of paused care—so, people not getting treatment during the pandemic—and now the backlog of not getting treatment means that many older people who were independent and looking after others, or doing volunteering and other things, are now facing difficulties and dependency because of what's happened, and that is definitely having an impact on their mental health.

And then finally I would say that the loss of role, of job, of volunteering, of things that people were able to do, has certainly had an impact, combined, of course, with bereavements, and not just that people have lost loved ones—many, many older people are suffering from bereavement—but the circumstances of that have been very difficult to manage. We know that many people haven't had the chance to be with their loved one when they died, they haven't been able to say goodbye in the way that they want to, and they might well have unanswered questions about what has happened. So, if you wrap all that up with the difficulty of accessing mental health services and support during the pandemic, we have a really, really serious situation in respect of many thousands of older people at the moment.

Thank you. And Sally and Kirrin, if you want to come in. Sally.

Yes, the pandemic impact we've measured during the pandemic and we're now looking at what the longer term impacts are. So, as I'm sure Members will be aware, we conducted some very large surveys with other partners, including the Welsh Government, during the pandemic—the first one in May 2020, so very early on in the pandemic, and we repeated it in January—and more than one in 20 children in Wales responded to the survey. And they did show some significant impact on children, which got worse by the second lockdown. I think it was a worse experience for the whole population, those dark days of January 2021, but children found it particularly hard, not knowing when schools might open again, and real concerns about loneliness and worry—particularly with older children, worry about their futures and about exam preparation and really low confidence in their education and keeping up with school work. Our surveys showed that the pandemic experience reinforced social inequality, so disabled children and ethnic minority children reported significantly more negative feelings across many indicators, and that included anxiety amongst children from black and ethnic minority backgrounds about the impact of the pandemic on their relatives, including their older relatives, with, obviously, the higher death rate amongst those communities.

Thank you, Sally.

If I could just say about what's happening now, we've seen a big increase in demand as children have emerged from lockdown, and we're seeing a huge increase in demand for clinical services, and that has unfortunately undone much of the good work that had been done in reducing waiting lists leading up to the pandemic. There's a particular issue in parts of Wales—Cardiff and Vale has had a very, very high demand for their services, for example. And we've had reports from—. We've seen measures as well that children's mental health reported problems have increased over the last two years. SHRN, the School Health Research Network, has done a huge survey of children—their biggest ever, involving the vast majority of secondary-school-age children—over the last few months, and we expect their data to come out this year, which will show us really systematically changes between pre and post pandemic. But we do expect there to be a significant change, and staff, teachers and social workers and clinicians are reporting more complex problems of children being really quite dysregulated following the pandemic.

Thank you, Sally. Joyce.

Do you think that there's too much of an emphasis on the medical model, as opposed to the social model? That's my question.

Go on, Sally, by all means. You look like you want to come in.

I'll go first this time, Heléna. Yes, definitely. It has been a real issue in children's mental health services and, of course, children—I think this probably applies to all ages—with a mental health problem, it doesn't usually exist separately from other social issues, like family problems, bullying, and some of the other issues that I've already mentioned today. And it is important that children do get the right clinical intervention when they need it, and some specific conditions can be treated very successfully using a medical model. But, in most circumstances, children need a much more holistic response. And I often hear clinicians say that it's sometimes expected that people send children to see them, as if they can fix children, when actually they can see that it's the broader social situation of the child that is having a big impact on their mental health.

There are some really good changes happening at the moment in our mental health services in Wales. I've been working with all of the regional partnership boards and monitoring their progress over the last three years, and pushing them to have what I call a 'no wrong door' approach, which is that children shouldn't have to keep knocking on lots of different doors to get the help that they need but that the services themselves need to come together. And that includes social services. By that, I mean not just children's services, but housing, leisure services and many others, as well as our clinical services, to respond to children's needs at the right level, and at as low a level as possible. And there are some fantastic examples right across Wales now, including the space and well-being panels in Gwent, which take a social model, but they also have medical interventions available as needed to all mental health referrals in the whole of the Gwent area. We're also seeing some really good work happening in north Wales with their local integrated family team project, and Cardiff and Vale, too, are working hard on developing a 'no wrong door' approach that doesn't involve sending children separately off to social and medical support. But what we're seeing is really good planning around that, but in most areas they haven't yet delivered that social model, compared to a medical model.

Thank you. Heléna, do you want to come in on that?

Yes, thank you. There are a couple of issues. First of all, I think many older people didn't grow up in a time when mental health was talked about. It was a taboo subject, actually. So, a lot of the way in which mental health services are configured or things are done is quite alien to older people and they might not therefore come forward. So, there's something much more about the inclusivity of services, whether they're about the medical model or the more social model.

But one particular issue I would like to highlight—and it's actually something that your predecessor committee looked at and reported on back in May 2018—is the use of antipsychotic medication, particularly in terms of people living with dementia and particularly in care homes. This has been an issue that my office has had concerns about for many years, and my predecessor did work on it. Your predecessor committee also highlighted that there were still concerns about the overprescription, in other words, of antipsychotic drugs. So, where people living with dementia have what might be presented as or called challenging behaviour, rather than getting a person-centred, holistic assessment of their needs, they are instead prescribed antipsychotic drugs, which can have all sorts of side effects and not be suitable for them. So, I remain concerned, coming back to the data point, about whether we know exactly what is now happening in terms of how much of that medication is being prescribed and whether the NICE guidelines are being followed and adhered to. I would suggest that I think this might be something the committee might just want to revisit, to make sure that the recommendations back in 2018 and the report that the Welsh Government made the following year, that those actions have actually been taken forward, because I'm concerned that we can't tell from existing data exactly what the situation is.

Okay, thank you. That's useful, Heléna. Any further questions, Joyce?

Just that, if you want to say more about the 'no wrong door', that would be worth us hearing about. I was going to ask about the neurodivergent, but you did mention that at the start. So, the 'no wrong door', I think, would be useful.

Yes. So, we've published two reports on this now. The last one was only published a couple of weeks ago, which was our follow-up report to see how well the regions were working on this. But it really came from a real frustration from the casework in our office coming in, which showed that families were getting into some really frustrating situations. We've put some case examples in our written evidence because I'm afraid it still does continue, for neurodivergent children in particular, where they were waiting on waiting lists for a long time and then, once they finally get that golden appointment, being told that, 'Actually you've been on the wrong waiting list all along. You don't have the right kind of problem for this service and you need to go somewhere else', and usually being told their problems weren't severe enough.

So, we've set a challenge, really, to every region, every regional partnership board. This committee will be familiar with those boards, which were for their first few years of operation not really doing any work on children's services at all. Since our first round of visits, they have now all set up children's structures as sub-committees to plan to respond to this 'no wrong door' challenge that I've set them. The Together for Children and Young People programme has developed their NEST model—NYTH yn Gymraeg—of which 'no wrong door' is one of the principles, which they're really trying to make sure that all regional boards are planning towards, with children having no doors slammed in their faces, really, when they're seeking to access services. And that's not saying we just need to create more and more and more mental health appointments; it's about making sure that children get a good response early on by the right people. So, it also means not having these very frustrating moments where children are being told, 'We can't deal with your kind of problems because you've got too many or the wrong types.' So, I've already mentioned the example of neurodivergent children. It can also happen to children with learning disabilities as well, where the CAMHS service will say, 'We don't have any specialists in this. Sorry, we just can't help you.' But also, families perhaps moving between one area and another and being told they have to start the system all over again.

But, we are seeing some really good attention to this now from each of the regions. I've already mentioned some examples. I haven't yet mentioned Powys, which has developed a missing-middle service. The 'missing middle' phrase comes from the Children and Young People's Committee in the last Senedd, about those children whose problems weren't deemed serious enough to qualify for a CAMHS threshold but where they do need extra support. And they've got youth work interventions going in to support those children, which I've heard have been really successful.

Yes, and the examples in the evidence that you provided were, I think, very helpful as well. So, thank you, Sally. Gareth Davies.

Thank you very much, Chair, and I welcome you all to the health committee this afternoon. Just to kick off, really, and I suppose, in some ways, it could be deemed as a silly question on how we need to address public awareness and understanding of mental health, because we all want to achieve better awareness to reduce stigma and increase help-seeking behaviour, but also, I suppose, it's a practical question about how do we achieve that. We've spoken a lot this afternoon about children and CAMHS services. So, is it necessarily more engagement with schools, making children more aware of some of the potential problems that people may face in order to try and reduce these stigmas, and reduce bullying in those settings, if you like?

Shall I respond to that? I'm sure, Heléna, you'll have a lot to say about this as well.

Go on, Sally. Thank you.

In contrast really to Heléna's evidence, the good news is that stigma on mental health issues has—. We've seen a substantial reduction amongst young people, and some of the demand comes from higher awareness and parents being more willing to say, 'I think my child's got mental health problems', and to come forward for referrals, et cetera.

We've got some really good opportunities now to develop this even further. So, with the new curriculum, having health and well-being as a key strand of learning is going to make a real difference, but it also sits within—it's not just what's learnt in the classroom—the new statutory requirements for a whole-school approach to mental health and well-being, which I am pleased has finally made the statute book. It's something that I've pushed for very hard throughout my time as commissioner. The embedding on funding of that is the next challenge; I know there were some new funding announcements today on it. It's making sure that that stigma is reduced, that children come forward and talk about it openly, and get support as well, so that they also learn that many of our feelings are quite normal as well as we grow up. It's quite normal to perhaps have questions about one's identity as you grow up, and your sexuality. It's quite normal to feel anxious and stressed when you've got exams to sit, and that kind of thing. So, it's partly about not dismissing mental health concerns, but also saying that, actually, there are ways to live with these things and manage them as you go through life. I think we've got great potential now with the whole-school approach. Our schools are struggling so much at the moment as they come out of the pandemic, and still tackling it. There's very high teacher absence this week for example. We really need to properly invest in supporting our schools and wider community services to have this holistic approach, moving forward.

Lovely, thank you. Heléna.

Thank you. I would highlight cultural attitude as a particular problem, and come back to that point of ageism. So, the Royal College of Psychiatrists, when they looked at this issue of ageism in mental health services, found, for example, this preconception that depression is an inevitable part of growing older, and it's not. But if people assume it is, and if, as you are getting older, you assume it's normal for you to feel that way, you're unlikely to come forward. So, these cultural attitudes to growing older and ageing are deeply, deeply damaging for all of us.

I'd also say there's something about fear as well—fear of coming forward. And this is not just actually in relation to mental health services, but more broadly. Older people can feel, if they come forward to public services to say, 'Actually, I'm struggling to cope', that control will be taken away from them, that it will be seen as their failure, and their opportunity to take risks, to live independently, might be stopped or reduced. So, that's why the ways in which we talk about these issues need to be much more related to the diversity of our population. So, the messages that work for children won't necessarily work for older people or for me. So, how can we do more to engage older people directly in thinking about what's the language that's used and what are the trigger questions that could help people to come forward, and then, of course, making sure that, when they do, the right sort of support and appropriate support is available. And particularly on that, I would talk about the non-medical, so, those earlier interventions—the talking therapies, the things that enable people to work through difficult situations, which so often older people aren't able to access.

Thank you. Gareth.

I appreciate that answer. And quite often, with things around talking therapies, it's waiting times, isn't it, is a lot of the issue. But that's probably a discussion for another time. Where do you think we are in terms of the signposting of services and support, and do people know what help is available for their mental health, and, indeed, how to access it? We're obviously in a digital age, we've come through the pandemic. Are there innovative ways of signposting that people are generally aware of, or do we think there is area to improve in that and perhaps incorporate some of the digital age in that too?

Sally, I think you wanted to come in on the last point, but if you want to then move on to address Gareth's latest question as well. Thank you.

Thank you, Chair. It was just something Heléna said reminded me of another aspect I wanted to mention, around stigma, just because I've got the words of some young parents I met this week ringing in my ears, who are young care leavers who are parents. And they were very passionate about the fact that, as younger children in care, they experienced some of the things I've already talked about of being told, 'We can't support your mental health issues because it's related to trauma.' So, they felt that their mental health needs weren't met in their childhood and adolescence in the way that was needed, but, as soon as they—this is in their words, and their perception of it—. When they became pregnant, they felt that their mental health past issues were then brought out as a potential risk for them as parents. And they were then being told, 'Well, because of the mental health problems you reported as a child'—which they say, 'Our corporate parents didn't support us with at the time'—'it now means that you may be a risk to your baby and you're going to go through child protection proceedings.' And I have to say, although it was their perception of how they'd been treated, some of what they said about the difficulty of access in adolescence really rang true from my own data, and also their concern about the stigma then as expectant parents of disclosing mental health problems as well. So, how we respond to that and see it as, actually, you can be supported to be a young parent and have mental health conditions or ASD—some of the issues were ASD issues—without everyone bringing out the cavalry in terms of risk.

Thank you. And Heléna, did you want to perhaps address Gareth's last question as well?

Yes, I will. So, I think there has been a definite development and increase in online support available, and I know that some people have found that very helpful. There's been good publicity, I think, about that through the pandemic, and some of that promotion by Welsh Government, Public Health Wales, I think has been positive. It's encouraged people—us all—to look after our own mental health. And in terms of older people, some people have found that helpful. I've certainly heard where people have found some online group discussions particularly helpful; they've been able to share common issues with their peers and feel a sense of connection. However, we know that over 30 per cent of people over the age of 75 are not on the internet, and a great deal more than that are not digitally confident, so cannot access these services. But also they can't access, necessarily, other services, which, in order to find out about, you need to be online. So, a typical example is where a service may say, 'Oh well, we have a telephone number that you can call', and then you ask them, 'How do you find out the telephone number?', and they say, 'It's on the website.' Well, if you haven't got access to a website for the telephone number—. So, it's partly for this reason that I've issued formal guidance to local authorities and health boards about access to information services in a digital age, asking them to respond to me to set out what they're doing, both to help older people get online if they're not, but also to make sure that their information services continue to be provided without disadvantage in other means as well. And we're just going through that. We've had a very good response, I'm pleased to say; we're just going through that response now and I'll be following up over the next few months. But this will continue to be a key area of scrutiny for me.

So, a major problem is that older people do not know what services are available or how to get them and the system is very complicated. So, unless you have someone who can really help you through it, particularly when you're going through mental health difficulties and your confidence is low, it is very, very difficult. Sally talks about 'no wrong door', I think sometimes, for older people, it feels like there's just no door at all.

Thank you. Do you have any final questions, Gareth? I'll bring Sally in then. Did you have a final question, Gareth?

Yes, just one final one, Chair. It's just for a view on the need for the benefits of more community solutions in prevention and also supporting older people and young people with mental health needs in terms of social prescribing. Is there a general view on that at all, just to close my part of questioning?

Thanks, Gareth. If I can—. I'm really sorry for saying this, but we're really short of time and we've got a lot to get through before 2 p.m., so, if I can just ask for succinct answers and perhaps to focus on what your view is on the solutions. But, Sally, I think you wanted to come back in, if you want to address Gareth's last point.

Just on digital, because I didn't answer that bit, I'm sorry—I got carried away on the other issue. But, on digital, we monitored how good the digital information was during the pandemic for children and young people, who didn't have, at that point, access to schools and youth services easily. It was very poor to find out how to get access to CAMHS during the pandemic. I wrote formally to all of the health boards and there's been a really good improvement in children and young people's mental health services online, and they don't have the same issues as older people for accessing online. And I'd just particularly commend some of the areas like Cardiff and Vale and Swansea Bay, which have worked with young people to develop really accessible, informative websites on how to get mental health support.

Thank you. And on Gareth's last question.

And on community solutions, definitely, lots of exciting things under way again from each of the regions. So, just a couple of examples would be drop-in centres with multiple forms of help, including mental health, being developed in Wrexham and Cardiff and Vale and Swansea. And other solutions are things like—. I can think of one in Cynon Valley, for example, Cynon Valley Organic Adventures, where children can go, and it's a community-generated scheme, where they do gardening. These are children who are too anxious to go to school or have other issues that mean they aren't in school, and therapeutically are learning, doing qualifications and really thriving. So, there are lots of exciting schemes out there.

Thank you, Sally. Did you want to say anything on that, Heléna? But don't worry if you don't, we'll move on.

Just very briefly, yes, there are some very good examples. I think we need to make sure that the voluntary and community sector are able to have sustainable funding so that their role in this can continue. In particular, I think those community opportunities for older men to come together and to share issues and concerns—Men's Sheds et cetera—are a really important part of this fabric.

Thank you. Thanks ever so much. Jack Sargeant.

Thank you, Chair. Good afternoon, commissioners. I think a brief answer to this would be fine. It's just to try and understand your views on the mental health workforce we have in Wales and whether you think there is sufficient capacity and the appropriate skills among that workforce to address those diverse needs, both in older people and then, to you, Sally, in younger people. And if the answer is, perhaps, 'no', maybe you can give us a short line on what the solution is there.

Not that we want to pre-empt your answers though.

So, if I start, there are some gaps, particularly in terms of specialists in older people's mental health—so, old age psychiatry and other areas. So, that is definitely a gap. I think we need to view the workforce in its broadest sense, so including not just health and care but, actually, housing workers, who have a massive role to play, voluntary and community sectors and others. There is the mental health workforce consultation under way, which we're feeding into, so it gives an opportunity, I think, for some improvements to be made.

My last point, really, is about the workforce itself and supporting its own mental health, if you like, but also particularly understanding that a lot of the workforce, for example, in the NHS, are people over the age of 50, and they will have a number of issues to deal with, for example unpaid caring responsibilities. So, I think there needs to be done—. There's more to be done to enable the current workforce to continue to work well and to be supported in its work.

And in terms of children's services, there are some specific areas where there are problems. So, it's publicly available data to see that Cardiff and the Vale, at the moment, have the vast majority of issues around waiting lists and, when you investigate that further with the health board, they are trying all sorts of things to tackle it. It just is a real workforce issue for them, and they do have some significant specialist gaps. I think, as part of this 'no wrong door' approach and the whole-school approach, we need to be thinking about getting people skilled up at all levels of the workforce and not just child psychiatrists and other clinicians, for example. The more that we can support and empower our teachers, social workers, youth workers, youth justice workers to feel confident about responding to mental health concerns, not doing treatment as much as just supporting them better—. And that's where things like inreach services in schools and the single point of access that I've already mentioned, those helplines, can be a real help.

We have lots and lots of psychology graduates—I think it's still the most popular degree to be done in the UK—and lots of young people, young graduates, looking to train up to work in mental health services and we just need to make sure we're giving them those opportunities at the right levels.

Thank you, both. Chair, I might have pre-empted an answer, but also the commissioners pre-empted my second question on the wider workforce, so I'll hand back to the Chair.

Oh, thank you, Jack. That's helpful. Mike Hedges.

Diolch, Cadeirydd. To the children's commissioner: as you're well aware, the last CYPE committee's 'Mind over matter' report on children and the subsequent work on it, which has been talked a lot about in the Senedd and I'm sure in lots of other places as well, was influential in shaping mental health policy in Wales for this group of people. Do you think there are any outstanding areas of concern about progress in implementing the recommendations? Is there anything missing?

I think some of the key issues that I've already talked about today, actually. So, I don't want to over-repeat myself, but the neurodevelopmental pathways and their links with our clinical mental health services are a particular area, and making sure that we are responding to what that committee called the 'missing middle' is another area. We asked for the Together for Children and Young People programme to be extended again, this year particularly, to pick up on the neurodiversity issue and making sure that the NEST model, which has emerged out of that committee's work, and is, I think, really exciting, could make us world leading—sector leading, anyway—in Wales, if we get it right, this NEST model, just to make sure that all the regions are ready to run with it. Those are the two areas that we thought it needed a bit of an extension for. I think it has been extended, now, to the autumn.

I'm just looking at Kirrin, just in case there are any other areas of that 'missing middle' report that we'd want to pick up on.

Thanks, Sally. I think the only one was around, and this is—. The transitions to adult services was one I was going to mention.

Yes. Thanks, Kirrin. So, yes, transitions to adult services is still—. There's some good guidance out there now, but it's still a concern that we're coming across a lot and, when you've got waiting lists of two years for neurodiversity services and a child, a young person, is being referred to those services at 16, then they reach the point when they think, 'Well, I may not reach the threshold for adult services but I'm not going to be seen by child services before I'm 18.' So, that sort of age group is a real area for us to keep an eye on, because it can be a bit of a cliff edge at 18, because thresholds are higher usually for adult services.

I could wax lyrical, especially about autism and moving between under 18 and over 18, but I won't, if only so that I don't upset the Chair.

The last question I've got is: the new mental health strategy delivery plan, does it take into account enough, or should it take more account of mental health inequality and the diversity of needs amongst older people and children? Sometimes, I think an awful lot of strategies are written by people for them, not for the general public.

Heléna, do you agree?

Thanks for that. I think, quite often, strategies are fine, aren't they, but it's all about the delivery, really. So, I think some of what's in that strategy, it's probably still too early to say almost in terms of how that's gone. But I'd come back to that earlier discussion we had on data. I just don't think we've got the right kind of reporting framework, data or evidence gathering to really understand what's happening and whether those fine intentions are coming through, and what variation there might be across Wales.

And although the strategy is trying to deal with all ages, I'm not convinced it's specific enough in terms of the attention that needs to be given to older people, to the barriers that I mentioned. And also, we are an ageing society, so it's incredibly important that we get this right, because more and more of us may need access to these services in the future, and of course, we want to prevent the deterioration in mental health that can come, which I described earlier as well.

I think there is one specific area that I'd want to highlight, which is an increasing concern for me, and I think something that the strategy and its implementation need to look at, and that is the increase in suicide rates amongst older people, which is a concern. I know that South Wales Police are looking at this and Powys health board. Powys health board, for example, is seeing a significant trend in older suicides now, including, for example, people in their 90s, where there's been suspected suicide. So, I think this goes to the very, very extreme end really of just what many older people are grappling with. So, I do think there needs to be some specific attention given to why it looks as if we're seeing increasing levels of suicide amongst older people, certainly in some areas of Wales.

I would say, Mike, that I feel pretty positive about the Government's strategic direction on children's mental health, and that is as a result of all these years of work by the children's committee and my office, and some actually very innovative clinicians out there who are trying to take a much more holistic and systemic approach.

So, the vision, I think, is actually quite an exciting one, again around the NEST model that has at the heart of it a whole-school approach. I think, as I said already, we could be on the brink of something wonderful, but it really is that the proof will be in the implementation of that and the support of that, and keeping everyone on board as we struggle through everyday life, coping with the pandemic, et cetera; it's keeping that eye on the ball for that strategic direction.

I don't think the strategic direction's quite there yet for neurodiversity, which I've already mentioned several times. There is a new multidisciplinary team set up in the Welsh Government, which again is a great step forward, to look at how we respond to neurodivergent children, but I would like a bit more confidence that their needs are being seen as part of this wider strategy.

Do you have any further questions, Mike? No? That's great. Thank you.

Just, I suppose, a final question from me. We've had a great response to this inquiry, but just to get your advice in terms of where the next phase of our inquiry should explore, or what we should particularly focus on in terms of the rest of our evidence sessions as we move towards the summer. Any advice in terms of our approach or focus?

I'm sure you'll hear a lot of common themes coming through. I think that implementation is key and how we get those services closer to home for people. So, one of the issues for older people is sometimes those specialist services are some considerable distance away, so how can we make sure that the plans that Welsh Government and others have to have services closer to home really happen? I would certainly encourage the committee to focus in on this issue of data and monitoring and being clear about what's happening, but also further work about what works. So, what are the support, services and interventions that are proven to work, and how can those be better rolled out across Wales? And finally, from my perspective, I think, looking at the way in which we could be more inclusive in our language across all age groups and all communities, including people who need and want services provided in the Welsh language, I think that would be another area to look at.

Okay. Thank you. I appreciate that. And Kirrin or Sally, any advice from yourselves in terms of the focus?

Yes, I haven't mentioned Welsh language accessibility today as an inequality, but it certainly is one that I have discussed with the Welsh Language Commissioner, and with Mind as well, as a specific problem throughout Wales. I think, seeing some of these issues of—I've mentioned about social care services—children who have been looked after by our system in foster care and in residential care, and the particular issues of our social services and mental health services working together, using the best expertise from both services together, for me is a really key issue that we're making progress on, but haven't cracked yet, I've discovered in my visits to regional partnership boards.

Forgive me if you've already done this, I'm afraid I'm not quite sure, but making sure that you've heard directly from young people as well. And there are some wonderful support groups of young people who are very articulate, who we've involved in work with regional partnership boards, who would have a lot to say to you.

Absolutely, and I think we've done that through our focus groups, but there's more we can do in that area as well. So, thank you, Sally. Kirrin, any thoughts from you?

I think Sally's covered that very well. Thank you.

Lovely. Thank you ever so much. Well, thank you for this session today. Sorry if parts were rushed, it's just getting through all the questions we wanted to get through today. But, Sally, this is your last session with this committee or—

I think with any committee.

—past or predecessor committees, yes. So, we'd like to certainly wish you well for the future, Sally, and thank you for your work over the last several years.

Thank you very much.

So, thank you, Sally.

Thank you for the opportunity to take part today. Diolch.

Thank you. Right, thank you, all, very much, and also for your evidence papers. We'll send you a transcript of proceedings, and by all means, do follow the rest of the proceedings of the other work. And if you have any further thoughts that you think you need to draw to our attention as others give evidence, then please feel free to do so. So, thank you very much. Diolch yn fawr iawn. Take care. Thank you.

We move to item 7 today, and there are two papers to note: one from the Chair of the Petitions Committee, who is sat with us today, to this committee in regards to a petition, and one from the Welsh Government in terms of their response to the committee's report on the draft budget. So, there are two papers that are just to be noted today. Are Members happy to note those papers? 'Delighted' says the Chair of the Petitions Committee to note the letter from himself.

Right. Thank you. Diolch yn fawr iawn. Thank you very much. That draws our public session to a close today.