Cynulliad Cenedlaethol Cymru

Bore da. Croeso, bawb. Welcome to the Health and Social Care Committee this morning. I move to item 1. We have apologies this morning from Mike Hedges and Jack Sargeant. Ken Skates is joining us today, substituting for Jack Sargeant. So, welcome to Ken. Are there any other declarations of interest? No. We are in hybrid format today, so some Members are here physically, some remotely, and the same for witnesses, but all our Standing Orders remain in place as normal. And just to remind all that we're operating bilingually today as always. I think that's all the housekeeping issues to go through.  

In that case, I move to item 2. Item 2 is our third dedicated session taking oral evidence from stakeholders to inform our inquiry on mental health inequalities. This morning I'd like to welcome Carolyn Wallace to be with us. Good morning, Carolyn. Thank you for being with us. Perhaps you could just introduce yourself briefly to us, but, in doing so, tell us a little bit about the Wales School for Social Prescribing Research. What is its purpose and remit? 

Diolch yn fawr. Thank you. I'm Carolyn Wallace, professor of community health and care services at the University of South Wales, and director of the Wales School for Social Prescribing Research. It's a virtual all-Wales school, building on the previous work completed by the Wales social prescribing research network, which was a group of people that came together in 2017-18 in order to build the evidence base for social prescribing in Wales. As I said, it's a virtual all-Wales school nested within PRIME Centre Wales, which is our primary and emergency care research centre. It's funded by Health and Care Research Wales until April of next year, 2023, and this funding includes myself at 10 per cent, one senior research assistant, currently Dr Simon Newstead, who is working on the glossary of terms for social prescribing, and 20 per cent for the Wales Council for Voluntary Action to co-ordinate the network.

The network, as I mentioned, which came together in 2017-18, comprises of practitioners and researchers who have an interest in social prescribing and want to build that evidence base. We work in partnership with the WCVA, with Bangor, Cardiff, Swansea, Trinity Saint David, Wrexham, Aberystwyth and Cardiff Met. As I said, it's to build that critical evidence base. In doing so, we develop and co-ordinate research proposals and publications, deliver on successful grant applications, and support research and research students. Research students are very much part of our role; we have nine. I say nine because we've just had a completion a fortnight ago—Megan Elliott, who was one of our previous senior research assistant, has just successfully completed her PhD. They're either self-funding, or we've had an awful lot of KES funding, which is the knowledge economy skills scholarship—European funding. Currently, we have one student who's got a Health and Care Research Wales scholarship, who's looking into an all-Wales approach to training for social prescribing. 

One of our roles is to link internationally. We have an international advisory board that meets once a year, and we are part of a European network. I was invited to Lisbon only a fortnight ago as part of the EuroHealthNet meeting, and that was because of the innovative work that we're doing in Wales. Emeritus Professor Joyce Kenkre leads on the WONCA—World Organization of Family Doctors—academic and scientific group, and leads the social prescribing interest group. And only this week, we're part of a global authorship in the BMJ Global Health journal on the global developments in social prescribing, which was led by Harvard University. 

So, in such a short time, we have connected with global leaders in social prescribing research. We are part of an editorial group with researchers such as Marie Polley, Marcello Bertotti, Kerryn Husk and other researchers, to develop the first publication in social prescribing.

Thanks, Carolyn. And tell us, as well, what's the definition of social prescribing?

Well, now then, you've asked me a question. I can talk for Wales on this, obviously—perhaps you can already tell. 

I should say, 'Briefly tell us'.

Well, in Wales—and there is a difference, and that's what has become apparent in not just the recent couple of years but really in the last few months as well, having engaged with international colleagues—it's defined as 

'connecting citizens to community support to better manage their health and well-being'.

Who defined it as that?

Actually, we did. 

Okay. Right.

It's based on research funded by Health and Care Research Wales. Working with communities and working with the social prescribing community. Sally Rees, who was part of WSSPR and now works for Welsh Government, led on a piece of work in which we developed that definition and also a model for social prescribing in Wales. The reason for that is because social prescribing has developed from the ground in Wales. It is not the same model that we see in England. The dominant model in England, which you also see reflected within the literature, is of primary care referring to a link worker who then engages with the community and community activities. In Wales, that's a little different. From the piece of work that we did last summer in partnership with Data Cymru and commissioned by Public Health Wales, we now know that our assumptions are correct that social prescribing is very much based in the community, with the third sector and the local authorities, and that they work in partnership with primary care, but referrals from primary care and the social prescribers based in primary care are not the dominant model.

Okay. Thanks, Carolyn. I appreciate your definition in answer to that. That's helpful. We'll move on. Ken Skates.

Thank you, Chair. I'm not sure, do I need to unmute myself? No, it's done already. Thank you.

Yes, it's always automatic, Ken.

Wonderful. Thank you. Can I just ask a few questions about social prescribing and how it can improve mental health and well-being and address mental health inequalities? First of all, would you agree that social prescribing is more effective in preventing mental illness than in treating mental illness, or is there no evidence available to ascertain the effectiveness of social prescribing in preventing mental ill health?

Secondly, with regard to the WCVA's Wales well-being bond, that's a bond, a scheme, that was designed to significantly increase preventative support for citizens in Wales by ensuring that a greater degree of health spend is attributed to schemes and activities that social prescribing could steer people towards. Do you feel that the Wales well-being bond is something that should be embraced and extended as fast as possible?

There are lots of things there. What needs to be made clear at this point is that there's growing evidence for social prescribing achieving mental well-being with citizens. If I can explain to you the dynamics of social prescribing. The referrer refers to a link worker or a community connector. We've got a lot of language here that needs explaining. The link worker or community connector then has a 'what matters' conversation with the citizen, the service user, the individual, and then develops an action plan, co-produces that action plan with that individual, and then refers to the community. This is a holistic model in Wales. Improving mental well-being not only occurs within that interface between the link worker or community connector and the individual, but actually in the community activity itself. So, there's a great importance on securing the sustainability of those community activities. Something like the bond that you talk about is really important to ensure that those activities are still there in the community.

What the whole pathway does is that it increases motivation, it increases confidence, it enables the individual to become empowered in order to problem solve for themselves and to engage far more within the community. Because that's what we want. We don't want to medicalise social prescribing; actually, we want it to be something that is normal and natural, that individuals will self-refer themselves to a link worker or a community connector, and they will go to the activities quite easily and voluntarily, in the sense that they volunteer themselves in the future and avoid that link worker and that community connector. It's about normalising this and strengthening the community activity and engagement of citizens with their own community, which is really important. 

There is increasing evidence, as I said, that social prescribing can have an effect on mental well-being. What we need to consider is the interface between social prescribing and mental health services. The role of social prescribing has been used in some cases to help manage waiting lists. Because the waiting lists are so long, then individuals are being referred to help alongside treatments that they're having from the GP in order to wait for that specialist treatment. But the problem with that is that, with social prescribers, this is an unregulated workforce, and there isn't any standard training for social prescribers across Wales. So, what you end up with is a requirement of some link workers, or community connectors, to have specialist knowledge about mental health working. What you can have is a danger that they also, because of that increased workload within primary care, have referrals that are inappropriate. We really must be careful with that interface. There's some work that needs to be done in this area, because community connectors and link workers are concerned about what happens if something goes wrong. Because they're not registered, they don't have a standardised qualification, so are they liable? I hope that helps. 

Yes, it does. It might be something for the committee to consider at a future date, as to whether social prescribing could be, and should be, mainstreamed as a preventative measure through initiatives such as the economic contract. Because, obviously, there is a risk that, if we place the onus on the individual to volunteer themselves for participation, a lot of people don't recognise that they have a mental illness until it's quite severe. So, to get that early intervention, you almost need avenues for people to go down whereby they improve their well-being before they actually get ill. That should be perhaps considered as part of those interventions that I've just mentioned—the economic contract, part of the new curriculum, national institutions that could be opening their doors, in the way that the Fusion programme has been designed to do. But what does social prescribing currently look like in Wales in terms of activity levels? Is there variation in how schemes are organised?

You've asked a lovely question; thank you very much. We did a piece of work last summer, as I mentioned, with Data Cymru, commissioned by Public Health Wales. It was based on three pieces of work that we did within the programme—there was a survey, there were focus groups, and there was a workshop. And bringing all that work together, we came up with four key messages, and one of them was that we have a great variation in provision of social prescribing across Wales. And, as always, those sorts of things provide opportunities and challenges. We know that, if we consider the total number of organisations that cover each local authority, Wrexham, at that point in time provided the highest number of organisations providing social prescribing, whilst Neath Port Talbot provided the lowest number. But when you adjusted that per hundred thousand population, Merthyr had the most, with approximately 28 organisations, and Cardiff the fewest—though I'm sure that's changing at the moment, because I know there's a lot of work going on in Cardiff. What we know about it is that, as I mentioned earlier on, it's a growth activity, and we have some high expectations.

But, in the variability, what we have is social prescriber link workers with a salary range of between £16,000 and £36,000. So, when I say that we've got this great variability, the variability is not just in the provision of the service, where the majority of the model is a holistic model, and what I mean by that is, as I described before, the What Matters conversation, the co-produced action plan, and the signposting to the activity. They also may work with the individual and hold them as a case, and that could be for up to 12 weeks; very often, there's no limit on how long they stay on the case. And that's because, for some people, signposting to an activity is just not enough. If we think about the examples that we have of individuals, the hard-to-reach group, who find it very difficult to go out into the community, then, for example, in Llanelli, I came across a case study of a young man in his early 20s who had autism, and the social prescriber realised there was an issue between his carers and him, and he was lonely and feeling isolated, but loved running. So, the social prescriber took him running on an individual basis, before he could introduce him to the group, because it was a step-by-step approach. And once he'd got him into the group, he then was able to establish and help him get that connectivity between the group, that interaction. Of course, that improved his mental well-being and improved his relationship with his carer, and so forth.

On the other hard-to-reach groups that we've got, for example, in Gwynedd and Môn, there was an example of a lady who had suffered from bereavement—whilst moving house with her husband, her husband had died—and so, unable to step outside the home for a long time because of this issue, and still living with boxes around her, unable to unpack, unable to buy carpet, couldn't move forward. The community connector saw her in her own home and helped her through that process. And the outcome of that was that the lady then engaged with her community as well, and ended up with a part-time job, working. A really successful example.

But these are workers who are working with differing contracts. They're on short-term contracts—the average is six to 12 months—because of the nature of the short-term funding. They're also individuals who are managed in a variable way. So, sometimes they're managing their own projects, sometimes they're actually writing their own grant applications, in order to sustain the link worker, community connector role. So, that takes away from the actual job of work. So, we have a real issue here around sustainability. We have variability right across Wales and, so, what's most important and what's heartening to see is the work being undertaken by Welsh Government in the development of the national framework, which will help us with those issues, but there is a lot of work to be done.

That's incredibly helpful, what you've just shared with us. We should perhaps take it then that, as things stand at the moment, there are no mechanisms, or there are insufficient mechanisms in place to share learning and good practice across Wales. And alongside or perhaps even above a framework, should there be some form of national social prescribing service that could drive consistency and excellence and sustainability within the sector and in terms of the services that are provided?

My understanding is that the national framework is not to develop a national service as such, but to provide principles and guidance and pillars around—. And I'm not sure there would be an appetite for a national service as such, but there are certain principles that need to be put in place. 

We do have an issue, and it's not only in Wales, but in England as well, which NASP—the National Academy of Social Prescribing—has evidenced in their platform. But you're correct in the sense that gathering evidence, outcome measures, is variable. We're trying to measure apples with pears. We have an issue with evaluation and we've recently published a paper on evaluation in the BMJ Open only last month. There's a great variability around the outcome measures that we collect—they tend to be skewed towards health measures as opposed to social measures. And if what we're trying to do is strengthen community and engage people with their community, then we need to understand how they're engaging and we need to measure their social well-being as well as their mental or emotional well-being and of course their physical well-being as well. 

So, there are issues around technology. What would help us massively would be developing or creating the opportunity for organisations to be able to purchase digital platforms. An example of that is Elemental, and we see Elemental in Cardiff with the Lansdowne Road surgery. There's a very good example there of GPs working with link workers, linking out to Grow Well, which is a Grow Cardiff scheme. But we've also got Elemental right across north Wales. Betsi Cadwaladr University Health Board have purchased Elemental to link up their activities and that's under the 2025 programme as well, and that's linked with Wrexham Glyndŵr University. Wrexham Glyndŵr University have purchased Elemental, because we have social prescribing in universities now, as they look at the student services and want to connect their student services out into the community so that they can support their students who live in their communities to improve their mental well-being. And, as we know, there's a massive issue there with students and their well-being. So, they're creating their social prescribing services with Elemental. And we've got Hywel Dda—sorry, I could go on. Sorry, I do apologise.

No, Carolyn—Professor Wallace, your answers are so helpful to us, so we really appreciate it. They might have to be a little shorter just so that we can get through all the questions—

Yes, I do apologise.

—but we really appreciate your full answers as well, and I'll ask those who are asking the questions to jump in, to get through their questions as well.

Yes, please—please stop me.

No, not at all. Rhun ap Iorwerth.

What it does is it enables us to be able to look at services that are very different—so, social prescribing for not necessarily young people, but over the age of 18, shall we say, and people with dementia, people with learning disabilities, who are engaging with social prescribing, and it enables us to be able to pull together a matrix and a core data set that is common to all. And so, what we're starting to look at is: can we monitor social prescribing generally, bearing in mind there will be specifics that each service wants to collect that describe their uniqueness? But that would give us some way of understanding and being able to make some decisions around the individual services themselves.

Then, from an evaluation perspective, we have conducted what's called a realist review—that's equivalent to a systematic review—where we conducted the review on international literature, but also took grey literature from Wales, to be able to understand what the issues were about evaluation internationally. And what we're doing with that is, having developed a model of evaluation that is very person centred, we are now developing a standard for reporting evaluation for the national and international community. So, our intention is to be able to test that in the future, beyond 2023, if possible. We're also in the process of developing outcome measures. We have the south Wales social well-being tool. We identified that there was an issue, as I mentioned earlier on, with measuring, as it skewed towards health, and we know the evidence towards health is building quite nicely. But from a social well-being perspective, there was a gap. There wasn't a measurement tool. There was one back in the 1990s but it hasn't been updated and not used. So, we conducted an international study to develop that, and we've tested that.

The SROI, yes. So, again, there are issues. So, on the SROI, there is evidence to suggest that, depending on the type of activity and the model, the SROI will vary. So, we have SROI returns saying that it's £1.50 per pound, but increasingly it's £3.55 return on investment per pound spent. So, there is evidence there to say that it is a worthwhile service to deliver.

Ad hoc.

Thanks, Rhun. Joyce Watson. Okay, Joyce Watson.

Good morning. I just want to go back to engaging with the stakeholders and ask you some questions around that. You did start to talk about buy-in from GPs, but I'd like to explore that a little bit more, and know what that looks like, and also with healthcare workforce and other stakeholder professional organisations that might value the work of a community connector or link worker.

So, there are lots of stakeholders involved, as you know, in social prescribing, who have an interest in social prescribing, and there's a great opportunity here. What we're talking about here is a very complex space where multiple organisations come together, and some community connectors engage in that space, perhaps in virtual multidisciplinary teams at the interface with community hospital services or sometimes secondary care, but also with a GP, with housing, with our ambulance services—all sorts. So, it's a very complex space. GPs in particular, if they have that arrangement in place, may refer to a link worker, community connector.

Anecdotally, of late, I've heard that GPs are losing interest in this, but some, and a lot of GPs, find it increasingly valuable, when they identify that there is a social issue and there's an underlying social issue with regard to maybe a mental health problem, that they can refer to the social connector. An example of that, pre pandemic, is the Red Kite organisation—GP surgeries up in mid Wales—who refer to Mind when they've identified that there is an issue. And sometimes it's not a mental health issue; sometimes it's a welfare issue, and so community connectors can refer to debt advice, to housing advice, which again may be connected to a mental health problem.

So, what you've got is sometimes the distinct referral to, because it's a underlying social issue, but also as I mentioned earlier on, it's working in parallel, or working together, whereby the GP is delivering a clinical response to the issue that's presented, with the social prescriber working alongside and delivering on that social issue, and hopefully them getting a very holistic response.

So, engagement with stakeholders, we ourselves, as WSSPR, engage with all sorts of stakeholders, all sorts of practitioners who are part of the research network, and in doing so, we tend to get problems, such as the issue with social well-being that I identified earlier on, and the development of the social well-being tool was as an interaction with a GP, with Karen Pardy in Cardiff, who identified such an issue.

Technology is a major issue as well when engaging with stakeholders. There has been some work about facilitating social prescribing through technology, and Patel 2021 identified that there were some issues with regard to the virtual delivery of social prescribing. That's been an issue through the pandemic as well, of course, whereby it's the way in which we engage with stakeholders that's really important, and individuals engaging with stakeholders. I'm not sure if I've answered your question really, but hopefully I have.

I want to move on to the public's attitude towards social prescribing, because, obviously, if it's going to be successful, that's where it has to be successful. Do you think people are aware, that their awareness is where it should be in terms of social prescribing as an alternative to the more  traditional prescribing, the medical prescribing?

I don't think the public are wholly aware of social prescribing. There's evidence to suggest that when they're presented with going to a social prescriber, community connector, link worker, that some people are happy to do that, others question why they're doing it and feel they're getting an inferior service. And I think that's because they probably don't know about social prescribing, and what we need is a really good campaign around social prescribing in Wales, to engage people, to help them understand what fantastic offers are out there and what a fantastic service social prescribing provides.

Do you think—? Because you said that this is a two-way street. You said some of the GPs had shown initial interest, but now that interest had declined. Is it because there's a sort of mutual attitude that might be a little bit less enthusiastic towards social prescribing as against the medical prescribing that people have grown accustomed to and think they understand? 

Well, there are some issues with social prescribing and trust. This is a relationship-based service delivery, and when you—. There are all sorts of issues around trust. First of all, we know that GPs need to know that the service that they're getting is exactly what it says on the tin. We don't have a national qualification for social prescribing, so how can they know whether or not that is exactly what it is? When they refer to the link worker, if you're on temporary contracts of six to 12 months, how do they know that that link worker or social prescriber is going to be there? How do they know that the activity in the community is going to be there?

That's one of the issues we've seen with Dewis and Infoengine—those are the digital directories that social prescribers have access to. And one of the issues for not only GPs, but also the community connectors, link workers, is that sometimes with Dewis and Infoengine, but Dewis in particular, the activities are not there when they're searching. I'll explain. When you're a community connector, part of that role is to map out assets in the community. What we have in Wales is the fantastic resource of Dewis and Infoengine. They are digital directories of activities and third sector organisations, community activities. But the quality control on Dewis has been challenged and was challenged in the piece of work that we did last summer.

And so, when you have these issues along the pathway, the relationship can be challenged, and that trust element can be lost if we're not careful. So, I'm not surprised that some GPs may say, 'Actually, I'm not sure that I want to send somebody to social prescribing, because I'm not sure that it's going to be there, because the funding's not there to make it sustainable. It might be there tomorrow, but is it still going to be there in six months' time?' And that's the issue.

Okay. Thank you.

Thank you, Joyce. And Gareth Davies.

Thank you very much, Chair, and good morning, Carolyn. I'd like to aim my questioning towards vulnerable groups and ask for further information about your work with vulnerable groups and what you define to be a vulnerable group, and whether that's an in-house definition or whether you adopt wider definitions of vulnerable groups in order to tailor your work effectively.

Can I ask you what you mean by 'vulnerable groups'?

Well, in my mind, it would be non-exhaustive. It would include a lot of people, but my question is what yours are. You know, we could go on—

I know. I just wanted to make sure that I wasn't—

Yes. You know, just to sort of tailor it to the work that WSSPR is doing in terms of how you deal with vulnerable people. As I understand it, there's a funded project aimed at students in particular. So, could you just let us know a bit more about some of that work that you're doing?

Yes. So, we have tended to concentrate on work around evaluation, the infrastructure around social prescribing and the role of the link worker and the community connector—I use both those words for fear of alienating anybody—and this issue around the variability in language and the glossary of terms. So, we've tended to focus our work on that. However, in doing so, as well, through testing and doing work, like with Grow Well in Cardiff, we're working with individuals who have low-level mental health issues, emotional well-being issues, loneliness, social isolation, and also, we've been working with, as I mentioned, students. And we've had some funding, which ended most recently; we were doing an evaluation with Wrexham Glyndŵr University around enhancing student well-being, because of the issues that have been presenting in higher education around student well-being.

So, we've been doing all of that sort of work, but our work has been around evaluating the projects. We have something called the Re-Live project at the moment, whereby we have a student who is Knowledge Economy Skills Scholarships 2 funded, who is doing a Master's in research, working with a Cardiff project, with older people who are engaging online through digital activities with facilitators. So, our work has been to understand how these activities work, what is the uniqueness, what is the underlying framework. Because, as somebody asked me last week, 'What's the difference between social prescribing and the ordinary work that the third sector does anyway?' Well, there's a big difference, because these activities that, like Coed Lleol, which is all across Wales now, like Re-Live, like Grow Well, like the museum work, all sorts of work, working with individuals who have got chronic health problems, mental health and mental well-being issues, loneliness, social isolation, they have to have an underlying framework in order to make sure that they deliver what is required for that individual. And that might be they're working to develop, as I mentioned before, motivation, it might be—. And there are real skills in delivering that, where you've got occupational therapists working within these activities. It's not just a case of sending somebody off to the park and do a run, it's about developing that framework and making sure that it delivers on what that individual needs, because otherwise that individual won't go back again and won't trust social prescribing again.

Yes, absolutely. I think you're right there in terms of wherever somebody is signposted and socially prescribed, it has to be appropriate for that individual. I'm glad you've been able to enlighten us further about some of those groups that you've—

And it's getting that feedback as well. I haven't mentioned this before, but the feedback loops, and it goes back to that question around the GPs and engaging with stakeholders. Stakeholders want to know if this is working, how it's working, and these feedback loops are really important. And that goes back to the digital technology. You can't do that, collect all those outcome measures, create those feedback loops without technology. And you know, it's just in areas dotted across Wales, it's not a consistent approach. So, we do need to do some work around that.

And with those feedback loops in mind, are there any examples of effective social prescribing or any specific cases—? We have to be careful of privacy and things, but are there any positive stories that you can share around children in particular, or the student groups, to show us how that's worked well in some parts?

There are lots of stories with young people developing. The evidence base for children and young people is growing. With children, it's very—it's quite sparse, but there's evidence of young people engaging with social prescribing and benefiting from social prescribing. But, again, it depends on whether either the social prescribing organisations have got the technology to be able to do it, or they spend the time to be able to do it. But what we do know, through the evidence, is that if—. I think it's in the—[Inaudible.]—paper that if we actually promote group interaction for young people, and also for adults as well, which leads to community connectedness, that can reduce loneliness and in turn can reduce the service use in primary care. So, we do know that that is possible. What we don't have is a systematic collection of data to enable us to say, 'That is definitely happening across Wales.'

Thank you very much.

Thank you, Gareth. Thank you, Professor Wallace. You've given us so much information today that we'll have to digest. I just want you to give us your key message to go away with. In terms of a recommendation, in terms of developing social prescribing and reducing mental health inequalities in Wales, what's your one key message to us, if you can encapsulate that in—

Just one?

Well, if you want to, you can do three, but they've got to be really bullet pointed.

Okay. So, sustainability is key. Sustainability across the pathway is key, because we're in a complex area, we have a fantastic opportunity to integrate across that pathway. We need to make sure that the link worker, community connector, feels comfortable and safe in the work environment that they're working in, and that's about making sure that we provide them with the appropriate infrastructure to work safely. Thirdly, we need a matrix, we need core data sets, we need technology to be able to deliver on that. We need to be able to evaluate. We're small enough, we're only 3.1 million people. We're small enough to be able to do this, but we do need investment in technology, sustainability and the link workers to be able to do it.

Thank you, and you were succinct enough as well, so thank you, Professor Wallace. Thanks ever so much for your time with us today, it's been really, really helpful to our work. We'll send you a copy of the transcript after the meeting as well, so look over that. If you have any further thoughts that would help our work, then please do let us know. Thank you for being with us today. Diolch yn fawr iawn.

Croeso, diolch yn fawr.

Right, we'll take a 15-minute break, so we'll be back at 10.35 a.m. So, back at 10.35 a.m.

Croeso, bawb. Welcome back to the Health and Social Care Committee. I move to item 3, and this is in regard to our mental health inequalities evidence sessions. This is our third meeting dedicated to taking evidence, and we've got a panel today from Public Health Wales. So, thank you very much for being with us this morning. Perhaps you could just introduce yourselves for the public record. I'll start with you, Julie.

I'm Julie Bishop. I'm the director of the health improvement division at Public Health Wales.

Bore da. I'm Tracey Cooper, chief executive of Public Health Wales.

Bore da. Joanne Hopkins, programme director for adverse childhood experiences, criminal justice and violence prevention at Public Health Wales.

Lovely, thanks ever so much for being with us today. Right, can I ask what is meant by a public health approach to improving mental health? And what is Public Health Wales's role in tackling mental health inequalities? Who would like to start with that? Tracey.

If I kick off, Chair, just to say it's just really nice to be here face to face and seeing people on such an important area. So, taking a public health approach is a holistic approach to any individual looking at physical health, mental health and their well-being, and understanding firstly what is the data saying, what does it look like in Wales, synthesising the evidence of what works, supporting partners in collaboration to implement change that will support people's mental health, their well-being, their resilience, but in a very community-focused approach. And then evaluating that, seeing what works and scaling it up. But it has to be focused across all of the wider determinants to take a whole-of-society approach. And I wonder—Julie's been leading a lot of this for us, and I'm sure Julie would want to add to that.

Okay, thanks. I think one of the essences, as Tracey has said, is that a public health approach typically looks at the underlying causes of health and disease. So, from our point of view, we've been looking at the underlying causes of mental health and well-being, and I think one of the early things that we recognised was that when people talk about mental health, actually what they often talk about is mental illness. And when you're actually trying to focus people and the wider system on thinking about what we can do to create the conditions to build good mental health as a preventative action, we found it's better to talk about mental well-being, and that's something that people seem to recognise and understand. And that focus is really quite important, because there's a lot we can do to build mental well-being, and that underpins not just our mental health, but our physical health. And as Tracey said, that raises issues around things like the wider determinants—income, employment, housing—but also we can then focus on what we can do to prevent mental illness and understand some of the specific actions, for example in relation to something like suicide, that can be taken that would actually reduce the ultimate burden of mental health on the population and tackle some of those issues around inequalities.

And, again, Chair, I wonder if Jo can give us an example. Adverse childhood experiences, which have got such a close relationship with mental health—there's a really good example of taking a public health approach to ACEs. I wonder if I may just invite Jo to respond.

Thank you. Thank you, Tracey. Yes, so I think, for me, in terms of the work on adverse childhood experiences and the work that we're doing currently on Wales, a trauma-informed nation, so developing a framework that encompasses mental health, physical health and well-being, it's thinking about what does the evidence say, how do we actually look at what people understand by the terminology we use—so, being really clear, clarifying and getting a common understanding across all of the society about what we mean when we use such terminology. So, for me, as well, a public health approach is looking at that evidence base, understanding what people understand and then identifying where the gaps are, where are the things that we need to find more evidence of to support our understanding and that common approach going forward. One of the things that we've been really, really clear on is, when we talk about the whole of society, we have to include communities, we have to include organisations and systems. It's individuals within the context of all of those things. So, it's about an integrated approach that brings them all together and understands how they work together, but also that a public health approach applies to each of those areas at the same time.

Thank you, that's helpful to set the scene as well. Members will want to dive into some of that a bit later on, I expect, as well. Rhun ap Iorwerth.

I think part of the challenge is that we're talking about a whole spectrum. So, I think you're right to say that we don't have the data that we would like to have. So, if we go right through from the well-being to the illness side, we do collect information about well-being in the population. It's included in the national survey, and it's also part of something that is regularly monitored by the Office for National Statistics, and we have that information in a way that means that we can look at it in terms of what that tells us about different population groups, so we can look at inequalities. So, that's not too bad; we've got quite good data there. We've got very good data for children and young people.

When we start to think about what we understand about people experiencing mental health problems, that's where it starts to get a lot more difficult. We don't have really good systems for actually systematically collecting that. So, there is information collected in primary care, there's information in terms of the access to different types of services, but we don't actually regularly survey the population in a way that we can use validated tools to understand the level of people experiencing depression or anxiety or something like that. Though, interestingly, that has been done as part of the COVID response, so there have been some regular surveys that have looked at anxiety and depression, and that tells us, obviously in a particular context, that, typically, about 16 per cent of the population, perhaps, report those sorts of symptoms, and it also illustrates the really wide inequalities that there are, particularly around age—so, younger people experiencing much more problematic presentation and older people much, much less. But we don't do that routinely, so it's something we could definitely strengthen.

And then I think when we think about the more acute experience of more complex mental health problems, a lot of work has been done over recent years to try and improve data collection, but it isn't particularly helpful, and it certainly doesn't tell us a great deal either about how different groups of the population experience those services, or even access those services, because we don't routinely collect information about things like ethnicity or occupation or the kinds of things that would actually enable us to drill down further. So, there is some work going on at the moment through the mental health network to develop an outcomes framework for mental health in Wales, and I think that's a really positive development that should be supported.

In the paper that you gave us—and thanks for the paper—in the section near the top on 'Public health approaches' to tackling inequalities in mental health, the first words in the first bullet point are 'improving population-level data collection', so it's clearly a priority of yours. I think it's true right across healthcare in Wales that we need to strengthen data collection and analysis significantly. Where does that—? Where is the weakness? Is it in the structures, the technical structures? Is it in our understanding of the potential of data and putting in the investment in order to get the most out of it?

I think it's a combination, and there are quite a few players who collect data. The challenge is that, even though there may be in some settings the right data being collected, it's not necessarily being used. So, there's a whole behaviour and business change aspect to this. We collect population-level data. We've recently recruited a national director for public health knowledge and research, from the ONS, actually, and part of his particular focus is about data linkages, so that we can ask really important questions around inequalities, for example in mental health, or inequalities in accessing services for mental health, and identify what are the pieces of data that we can pull together.

There have been some reasonably helpful studies going on around primary care and mental health and understanding the presentation of people into primary care, but what isn't as good is the linkage of that individual being tracked from their presentation in primary care to then what necessarily happens to them in hospital. And when you're looking at a population level, which is how do we shift the numbers for population outcomes, we need to look at all of those steps. So, I think it's a combination. I would say there's quite a lot of data captured; it's actually how it's being used and how it's being mined, and are we asking ourselves the right questions. 

Yes, and in the paper you refer to research that you're doing on inequalities and who actually accesses mental health support. If you had the data, you wouldn't have to be doing that sort of research, it would just be ongoing analysis, presumably, wouldn't it?

I think that's a really good point. We use data for three basic purposes. One of them is what we would call surveillance. So, that's, I think, the point that you're making: it's the routine tracking of what's happening in the population. We use data to assess need, which tends to be a much more in-depth drill down, so we can look at particular population groups or particular areas in a lot more detail, but you do that periodically to help inform action. And obviously we use data for evaluation: are the things that we're doing as a society having the impact we'd expect? And I think it's that first one about routine surveillance that means that that data is there and systematically collected that is probably where we could do more work. 

And just to add to that, I used an example of healthcare access, but actually it's about connecting data with emergency services, with police, with housing. And in one of the first adverse childhood experiences programmes we did with South Wales Police and the south Wales police and crime commissioner, the purpose was to break the generational cycle of crime, where we brought the data together of people with mental health presentation, children and young people presenting in a more subtle and typical manifestation of ACEs through a variety of different settings, and you have to bring that data together to understand what does that harmful print look like. 

Can I add as well that, in terms of thinking of how we do data collection, the violence prevention unit has a link to this as well, because obviously people who are presenting to the criminal justice system or are on the cusp of entering into it may also have a number of different issues for them and at the same time be experiencing the broader adversities and the root causes and the social determinants that we're talking about? So, there is a violence surveillance system that's looking at that, but it has to take account of all the other things that feed into that. So, it's no good just saying, 'Well, we understand how many people are committing this form of crime', if we don't have the back story, effectively, of what's happened to them. So, I think there are some real examples of where we're getting better at this and using the learning from the last few years and what we've done from the ACEs work and broader to really get a sense of where those data systems are, how they should be connected together, and who we need to bring with us—so, the partners we need to work with and bring in in terms of an integrated model of working as well as just ensuring that that data is collected. 

So, let's move on, then, from the important principles of data collection and start looking at the picture that you are able to see from the research that you do, if not from easily accessible data. You mention in your paper that your own research shows real variation in the use of mental health services among specific groups. Do you want to talk to us about what that tells you about the unmet need and how the picture changes between various groups in society and what that needs to translate to in terms of action? 

I think that's work that's still being finalised, that particular piece of work, but typically what that research tends to show us is that you will get particular population groups who are less likely to present for services. And some of that depends on where in the spectrum they see themselves. So, older people often won't present for services. They're less comfortable, perhaps, about recognising mental health problems. Men, most definitely, typically don't come forward for help and support around their mental health, and we know that that is a significant issue. And we probably also know that people from socially and economically disadvantaged backgrounds will present to services, but not necessarily seeking mental health support, and I think that's partly the point that Tracey is making, that people are struggling and that they need help, they will be presenting to various different services, but they won't necessarily be articulating it in that way. 

And we—. I think we've mentioned before that, in Public Health Wales, we have a World Health Organization collaborating centre, and our focus is on investment for health and well-being, but health equity. So, during COVID, we published a health equity status report, which is basically a snapshot, like a school photograph, in Wales, of what does health equity look like. And it's health through the lens of income and social protection, living conditions, health services et cetera. And what was really clear was the interdependence that COVID has polarised around population and community, well-being, social cohesion and a prosperous economy.

And it also focused on the really consistent vulnerable groups that are right in the centre of inequities and inequalities—so, children and young people, women, marginalised communities, black, Asian and minority ethnic communities, homeless people et cetera. But we've always known that, and I think the issue now is—. One of the opportunities of COVID is that we had to scale up a lot of evidence, a lot of research, a lot of data, and however we approach this now—and I know the inquiry is looking at mental health inequalities—we've got to take what we call a proportionate universalism approach, which is what do we do for all the population to create mentally well, resilient individuals and communities, and what do we do for the targeted populations, and rapidly understand and working with them to co-design what are the interventions that are going to make a big difference.

With the cost-of-living crisis here, that is just going to increase inequities and inequalities, and it's going to be that population group. And it can't be us that says, 'This is what we have to do.' We've got to really shift to a way of working with the third sector, who are the trusted people, invited into people's homes, embedded in the community, to really co-design with those groups what do we need to do to mitigate the impacts that are coming, and also build resilience of what has passed in the last couple of years.  

Thank you, Rhun. Gareth Davies.

Thank you very much, Chair, and good morning, everybody. I did want to start off on specific groups, and your answer there leads on well to my question, which is around people living in rural areas—so, farmers, fishermen and people who might be isolated due to where they live or lack of public transport et cetera. And your paper references research that you've carried out into this. So, what were the findings of that work in terms of supporting mental health and building a bit of resilience in these communities? 

Yes, I'll start, and I'm sure Julie will want to pick up. So, we've done a couple of pieces of research. This kind of stems from Brexit. So, we were funded by Welsh Government a couple of years ago, before COVID, to undertake research into supporting farming and fishery communities, to look at what is the—. It was a health impact assessment of what the potential challenges and opportunities of Brexit would have on that population. And out of that, we identified a number of actions that were very much about creating community partnerships, consortia for farming, providing mental well-being resilience support within those communities.

And then, fast track a couple of years on, we did what we called the 'triple challenge', which we published last year, which was a health impact assessment on the compounding challenges and opportunities of COVID, of Brexit and climate change, and the overlaps of communities, as you say, that figure in all of those, both challenges and opportunities. Fishing and farming were part of that. Quite a lot of it is about community renewal, even linking into the foundational economy—we've got a third of the population in public services, so how public services spend money in those areas, stimulating income, purchasing food in those areas. So, we identified a tiering of recommendations from what can be done locally to support them economically, but also their mental well-being and resilience. 

As you know, different sectors have different cultural acceptances of coming forward and saying, 'I'm struggling. I've got a mental well-being challenge.' And farming has historically been one of those. So, there was quite a big focus on how we create that safe space within those communities. Julie, do you want to build on that?

I think what you see there is a combination of the wider determinants, the economic challenges that those groups and certain other groups of the population are likely to see. You've got a male-dominated workforce, who we know tend not to come forward for help. You've got not just isolated communities, potentially, but isolated employment. One of the things that we know protects people's mental health is our connections and social interactions with others. We've all really seen that writ large, haven't we, over the last couple of years in terms of the impact of the pandemic? We soon realised the impact it had on us when we couldn't see our friends and family on a face-to-face basis. It's all of those kinds of isolations where people are less likely to perhaps notice people working in isolation and less likely to notice the problems. Obviously, particularly in the farming community, suicide has been a long-standing concern and it's been a concern for a long time. A lot of that is about the access to opportunity as well as the conditions that increase the risk.

It illustrates quite well how you've got a really complex inter-relation of things. Because what you'll also see in rural communities is that although access to specialist services might be more challenging, it might be more distant, actually, there tends to be quite good community cohesion and people do work together and connect more with their neighbours. People are more likely to be lonely and isolated not far from here, in an urban community. It is really important that we drill down into the specifics of those kinds of circumstances so that we don't make assumptions that it's the same in every situation. It's a wide range of different things that we need to look at. But, what you tend to find, and that's probably the important bit, is that it's the same inequalities in the likelihood of developing a mental health problem as the inequalities in accessing help for that problem, and perhaps less likely to get it. So, at each stage of that journey, those inequalities become more significant because there's a compounding effect. 

Thank you. Gareth, do you have any further questions?

You mentioned some of the future trends that were coming along possibly, in terms of climate change, demographic changes, and the changing nature of work mostly down to the pandemic. Do you have any further information on that, on how likely it is to have a significant impact on mental health inequalities looking towards the future?

Yeah—. That's probably my response, as always. Obviously, we know nothing can be absolutely predicted at this point in time, but it's interesting that, within the last few months, the WHO has added significant mental illness as a global risk for the first time, because every country's been affected. Whether every country would have been perhaps so forthcoming about its mental health and mental well-being footprint before COVID, obviously, that would vary. But, the fact that we know COVID has polarised inequalities and has had the most significant impact on the five to 24-year-olds, or the under-24-year-olds, from a mental health perspective, is really setting the train of what we're anticipating.

We did a futures report as Public Health Wales back in 2018, and we predicted then a considerable increase for adults and children and young people with mental health challenges by 2035. That was before COVID. So, it has accelerated, I would say, the harm footprint of poor mental well-being and poor mental health. It's even more important for us to take a prevention and early-intervention approach to it. We know that, by the age of 14, 50 per cent of people have already developed their lifelong mental health illness, if they're going to get it. By the age of mid 20s, 75 per cent of people will. It's again really important for us to be focusing, although not solely, on those young people and adolescence. We know, from a mental health perspective, the future trends are probably going to expand.

Frankly, the cost-of-living crisis is dominating our conversations at the moment. We talked initially about what does a public health approach mean in this context. We had a meeting with the Minister for health recently, and with the chief medical officer, and the World Health Organization, actually, a week ago, saying we really need to think about, as a nation, taking a public health approach to the cost-of-living crisis. We would expect that pretty much everything we've been talking about for those vulnerable groups will deteriorate, potentially, over the coming months and years. But we do have knowledge about what can help mitigate that harm. 

That said, there are some opportunities that have come as well that we wouldn't have looked at in the future trends report. So, the whole balance of where work takes places can be opportunistic for people, gives people flexibility; for some people it improves their mental well-being because it helps them cope when you've got family pressures as well. So, I would say it's not all doom and gloom, but from a mental health perspective, I would say it will get worse unless we can really start to take a whole-of-society, a whole-of-Government approach around health in all policies, because everything is connected to everything else. 

Thank you very much. 

Thank you. Ken Skates, you wanted to come in on this. 

Thanks, Chair. Just two brief additional questions. Firstly, in terms of future ways of working, portfolio working lifestyles obviously offer people an opportunity to have multiple jobs that provide a fulfilling lifestyle, but also they risk, increasingly, job insecurity, do they not? Have you looked at, specifically, the increase in portfolio working lifestyles and the impact on mental health?

Then secondly, in terms of mental health inequalities, clearly social media is being embraced by certain demographics more than others. What's your view on the mental health impact? Do you believe it can be quite caustic as well as quite empowering? Have you taken a close look at the impact of social media specifically on certain groups such as young people and the elderly?

If I can pick up the last bit about social media, as with lots of the things we've talked about, it's not all good or all bad. So, what does social media bring for the, if you like, digital connectivity, if you look at it from that perspective? Then it actually helps people, particularly those in more isolated communities, or isolated circumstances, actually create social networks and connect with people in a way that they might not have done previously. It actually helped all of us stay connected during the pandemic. So, there are positive things about that. But the flip side of that, where the research is starting to emerge, is that, certainly with young people, what the research tends to show us is that, for those young people who are connecting online, or through social media, with people they know, there isn't harm associated with that; it's where people are connecting with people they don't know that the harm potentially arises. So, I think that's one particular dimension that we need to build on.

The other one I think that you're referring to is the somewhat unpleasant, or unkind, to put it mildly, culture that sometimes exists on social media. I think that's probably in everybody's hands, isn't it? The challenge we're all facing—and certainly, research does start to tease this out—is that the nature of the way we interact with others is one of the fundamental things about our well-being, both in terms of giving and receiving. And if we adopt behaviours in a digital space that are completely different to what we would adopt in a face-to-face space, then it's not unreasonable to think that that might lead to negative consequences. But, as we all know, the solutions to that are global, probably, and a big challenge that all countries are grappling with at the moment. 

I'd just like to add to that, in terms of a report that the ACE support hub did with Welsh Women's Aid a couple of years ago, which was asking children and young people where their trust was placed, where they went to for their sources of resilience. This was at a time when we'd been encountering the restrictions around COVID. It was really interesting because what they came back with wasn't necessarily unexpected. They didn't trust necessarily the police or teachers—they weren't seeing them. Where they went with trust was each other and social media space, and youth workers that they weren't engaging with, but they put them on a pedestal almost, in terms of, 'Well, if I was, then I would trust them.'

So, that made us think a little bit about, 'This is where children and young people go'—we can't change that, so how can we think about what the positive aspects of that interaction is. Because they are in a space where they are engaging with people they don't know, so how can we encourage the people that they don't know to give the right messages around this. I think there's something here around, if we are going to think about the use of social media as something that is not going away, how do we engage with it in a positive way, to manage the risks of the negative impacts of some of the exploitation and abuse that can go on there, and the wrong messages, even if they're given unintentionally, and to use that space, because that's where children and young people go, and that's what they've told us.

Just in relation to your first question, around the portfolio, I think this is a really interesting question; I'm going to take that back and ask the team to look at it. We haven't done any specific research around that kind of portfolio balance. But certainly, I know the World Economic Forum and other global research bodies had done a lot of research, before COVID, around Maslow's hierarchy for young people, and what do they want out of an employer. As you know, it's that, 'I want to experience, I don't want to get on the housing market, I want to try that for two years, I want to try that for two years, I want to not be tied down'. I think it would be interesting to go back and see how people feel now, because people who are now coming into their early 20s or late teens have had an insult over the last two years. Some of them have been in higher education, and perhaps have lost time, and then of course, we've got the pipeline of teenagers through. We have a young ambassadors network programme, who are amazing, in Public Health Wales, and a lot of their messages to us are around loss of confidence. I think it's a really interesting research question as to what's the impact and is that behaviour changing.

That said, and I can only give a local experience, we've recruited a lot of people in the last couple of years, and we've been far more flexible in where people are living. We've got a lot of people who are living outside of Wales but are still coming in to Wales. So,3 I think portfolio and balance probably means additional things as well now, following COVID. We did a health impact assessment on social isolation and working from home, which was, as Julie said, a very mixed picture. It's a bit prohibitive for people to have a portfolio opportunity, getting new jobs, when you're working from home; it's difficult, prohibitive. But, if you don't mind, we'll take that back to the ranch and see what that looks like now.

Thank you, Tracey. Joyce, you wanted to come in as well—. Sorry, Ken, did you want to come back? 

I was just going to say that the University of California, Berkeley has done a lot of research in this field, and in terms of the impact that social media has on all generations, not just young people. But you're absolutely right—there are two of Maslow's hierarchy of needs that are kind of in conflict here. There's security and control, in terms of portfolio lifestyles, where you can develop a feeling of control if you've got a portfolio lifestyle, jobs that you are selecting, but they don't necessarily offer the same sort of security that one single occupation does. So, it's a really interesting piece of work that could be done in this area. Over to Joyce.

I just wanted to go back very briefly to the rural nature of isolation. You've mentioned, quite rightly, certain groups that would be, and we know from history, subject to developing serious mental health issues. But there's another group that I would be interested to hear whether you've looked at, and that's those experiencing domestic abuse, particularly in a rural area—what the impact is, if you've looked at it, on that particular group, in terms of their networks, in terms of the stigma that is often associated with it, and particularly on not only those who are in that situation being subject to domestic abuse, but the children.

Jo, do you want to take that one?

Thank you very much, Joyce. A number of studies that we've undertaken, particularly by the violence prevention unit, have looked at the impact of COVID on domestic abuse in particular groups. You'll be unsurprised to hear that we continue to have concerns around the isolation factor for women who are experiencing abuse in rural communities—not just that it's more hidden perhaps than in other areas if they haven't got access to friends, family and the community visibly understanding what's going on, but also in the sense of access to services. And disclosures don't come immediately when someone's suffering abuse. It can be, as you well know, many, many incidents before they even manage to pluck up the courage to tell someone that something's going on, so, if that someone isn't there for much of their life, then that becomes extremely difficult.

One of the things that we have looked at, and it's been quite an important piece of work, is thinking about bystander interventions and what that actually means in terms of the response of anyone, whether that's somebody who comes to the house because they're a delivery driver, somebody who's in the community. Who are the people who do connect with people in more isolated communities? Health has a role in that. Other people will have to see a dentist and they will have to see a GP at some point in their lives. So, what are the different things and different techniques that anyone could use if they have a concern that something's just not quite right? And it's trying to get that building of confidence within communities that are traditionally perhaps less engaged or less included in some of the conversations that we have at a more national level in terms of how we encourage people to report what's happened to them. How do we build that confidence, and then how do we encourage those around them to support them if they do experience something? So, I think the effort really has been focused on that connection—ensuring that there is an understanding that, if you are connected to somebody and you see something that's going on that's not quite right, but you can't put your finger on it, what are the sorts of things and interventions that you can do usefully?

But I think it's more—as Joyce will be very aware of—complex than that, because women in rural communities are also older women, and women in rural communities are also sometimes from more marginalised, racially minoritised groups. So, you have those additionality of barriers to accessing support. And if it's a very small and very well known community, sometimes everybody has a collective experience of, 'This is kind of normal, isn't it?'. So, there are a lot of social and equality aspects to this as well, which, when you include that in the experience of women in rural communities, exacerbates that problem. So, we're really focused on this, but in a holistic view of what those other additional barriers are that women may be facing in those communities.

Thanks, Jo. Ken Skates.

Thanks, Chair. I'm just going to ask about unresolved trauma and therefore ACEs as well and life-course approaches. Could you just explain a little bit more about what you mean by 'life-course approach' to understanding and addressing mental health and also perhaps identify a few key opportunities that exist at different ages, or life stages, for prevention and intervention?

So, when we talk about a life-course approach, what that tends to mean is we're thinking about how we can understand the points of intervention when making an intervention will change the long-term trajectory. So, it's less about looking at particular stages of life; it's about thinking about the longer term.

So, in relation to mental health and well-being and inequalities, the fundamental starting point of that is the earlier years of life—the first 1,000 days. We know that focusing on that period has the biggest impact on what happens to people throughout the rest of their life of any point of the life course. So, emphasising, really creating good—. And I think we're really keen to talk about infant mental well-being rather than perinatal mental health services. One's a sort of medicalised way of thinking about illness for the mother, which is actually fundamentally important, but it's actually really thinking about how we create the conditions for good mental health in the infant. And that rolls forward in terms of the parenting experience, because parents, and how parents are supported to parent, are actually one of the fundamental things that will help us with those building blocks, building psychological well-being, building social well-being and emotional well-being in young people. So, that early stage of life is absolutely fundamental.

But what we also then know is that there are other key points when there are transitions that mean intervention is particularly key, and the next one's adolescence. So, there's a huge amount of brain development in adolescence—if that happens optimally, young people are likely to develop the skills to navigate the future, to develop resilience, but, as Tracy has already said, it's also the time period when we know the early signs of mental ill health or mental distress start to emerge. So, it's the best opportunity for early intervention to change that second trajectory.

And then I suppose the third area would be that end of life, or towards the latter end of life, as people move in that transition from employment to not being in employment and how people navigate that space, and obviously the concerns about some of the changes that happen in relation to mental health and dementia are obviously critical as well, as people get older. But those would be the three areas where we would say a life-course approach, an intervening really clearly in those areas, will impact across the whole of people's lives.

Thanks, Julie. Jo, do you want to that?

Thank you. Yes, I was just going to say as well, one of the things that we've been working on, particularly in the development of the national trauma practice framework, is that thinking about the prevention being critical, of course. If you can get there in those early years to tackle adverse childhood experiences and prevent them from happening in the first place, that is the ideal, of course. But I think we need to accept that, at the moment, whilst we are grappling with some of the wider adversities that we're all facing, and the exacerbating factors that they can cause of living in poverty or growing up in a household where there is domestic abuse, there will be children and young people who will go forward into life having had that experience and not having had, necessarily, the support put in place to help them to overcome it.

So, it is wrong to say that our only opportunity is to look at those early years, and one of the things that I've really been keen to understand as well and impress is that we understand that adverse childhood experiences affect people into adulthood, and therefore we need to think about how we mitigate the impact of those, provide those opportunities, and particularly for those marginalised communities who find it more difficult to access support. How do we overcome that barrier for them and assist them? The idea is to work with them. We can't do it ourselves; we need to understand particularly what their needs are. And then we get to a point, perhaps, where people who have experienced quite a lot of their life trying to overcome what they experienced in childhood perhaps going into using some of the coping strategies that are health harming, and some of the negative outcomes we wouldn't want to see, but it's still not too late. We can still do things to support people in later life, in terms of more specialist treatment.

So, what we're looking at, really, is a spectrum, from the universal approach where everyone has a role to play right through to additional support and interventions that will help people to identify how they overcome what they're experiencing themselves, and put in place the support that they need, right through to more specialist interventions. And through the life course, people will move. It's not a linear approach where you just start from the universal and work your way up to needing some really specialist help. People might get the specialist help. Then they might go back down, recover, take some time, and then something else might happen. So, we really need to be careful in terms of thinking about that overall life course and what opportunities there are at every stage to put in place the services and the support that people might need.

And if I can add just one final bit, we've talked a lot about people who have been on the receiving end of adverse childhood experiences and mental ill health, mental well-being, but it's also the teachers, police, fire, housing. So, how do we equip people who are going to be coming into contact? As Julie was saying earlier, or Jo, it's that 'making every contact count' opportunity. So, how do we raise awareness? How do we train people? Before COVID, we did extensive training around housing, for example, to make them ACE informed, and the evaluation of that shows the significant change of people who would have been evicted prior to that knowledge; now it's about solutions to keep people in that safe environment. So, what's so fundamental is: how do we systematise to become a trauma-informed Wales, because that's going to be really key for us at this point in time? And that is also about raising awareness, equipping people to different levels of expertise across public services and the third sector, particularly, I would say.

Excellent. Thank you. I'm just going to quickly ask about unresolved trauma and ACEs and the link between them. ACEs are, effectively, trauma events, and we know that there's a huge amount of research that shows that unresolved trauma leads to lifelong mental illnesses—an inexorable link between addiction and unresolved trauma. So, dealing with early life traumas at the earliest possible stage is really important. Can you give us an update, therefore, on the work of the adverse childhood experiences support hub and the development of a national trauma framework, and how you think this work is going to contribute to reducing mental health inequalities in Wales, and, indeed, will it only be successful if we see alongside it significant increase in resource in terms of school counsellors and talking therapists?

Thank you very much for that question. As director of the ACE support hub, I can say that we were very, very grateful for the continued investment in the hub for the next three years from the Welsh Government. This gives us an opportunity to think more longer term around how we get to that point of being able to describe Wales are a trauma-informed nation.

So, our work so far this year has been really focused on taking forward the principles that were set out in Deputy Minister Julie Morgan's review—or the independent review, but the principles that accompanied that, which was published in 2021, and really looking at the focus that we wanted to take forward, which is really thinking about how adverse childhood experiences are manifesting in communities, and what communities can do and need to think about to become trauma informed themselves. And that is the point again about bringing all of society together, from community, grass-roots organisations that are doing tremendous work—they may be third sector, but they may not even be third sector; they might just be good people really supporting their communities to overcome adversity—right through to public services, with which, as Tracey mentioned, we're doing significant amounts of work to try not only to make them ACE informed, but also give them those practical tools by which they can help support people through a trauma-informed approach.

So, this year, the focus, as I said, is a lot on communities and thinking a lot about who in those communities continue to be marginalised and how we work with them to co-produce a way of working that works for them, but also thinking about how we engage on a sectoral approach—so, some focus work on substance misuse with the substance misuse sector, which I think we all agree is a really important area to be looking at in terms of one of the coping mechanisms and one of the more negative outcomes that is co-occurring with mental health. But we're also thinking about how we work across sectors. So, we mentioned schools, but what about further education, what about higher education? So, we're looking at the education system as a whole, working with colleges across Wales, and in particular Wrexham Glyndŵr University, for them to become ACE-informed and trauma-informed organisations. So, we're looking at that sort of systemised level.

In terms of the framework itself, I think one the key elements of this is that we are looking at, as I said before, the individual, the organisations and the systems all in the same conversation, so we're not taking each one separately. We're looking at this as really needing to realise that—24/7, no wrong door, as we've talked about in a number of different programmes—where someone needs support, they are able to get it, and we are able, if it's not the immediate service they go to, to signpost and to work in that integrated way to ensure that people are able to get the support they need.

I think, in terms of that investment question, we shouldn't forget that there is a huge amount of work going on already, and one of the things that's been really important for us is getting that clarity of language so that we're all able to describe the stuff that's already happening across many of our services and many of our communities, and say, 'Actually, we're doing quite a good job here.' So, I think there is a collective understanding of that direction of travel and what we need to do, and we need to think about what's already happening and build into it, not to keep building onto it so that we're creating more things that perhaps are not needed, because we're already doing it but it just needs to be integrated.

Having said that, I do think there are some significant questions we need to ask ourselves around that workforce development element—so, have we got the tools and resources that organisations, once they've done an assessment of where they are on this journey, might need to have? Say, for example, you're working in an organisation that works directly with people that we know have had trauma in their lives—have they got a workforce that's skilled and equipped to be able to operate to provide the support that they need? If they haven't, how do they get access to that, and where might that investment be needed to support that? So, there's a whole range of things that we'll look at as part of the implementation of this framework, to think about where else that might need to be targeted.

But the ultimate bit, I think, is really the way that we can overcome the unmet need, but also, looking in terms of the future, to think about that investment in prevention, and how we make sure that, whilst we're trying to mitigate and support people, we're also thinking about—and this is where we bring into the framework specifically—the work of the future generations Act and working through those principles as part of it.

Okay. Thank you. I might have to ask you to be a little more succinct on the remaining replies, just so that we can get through all our questions. Joyce Watson.

[Inaudible.]—significantly your engagement with the community, which was one of my questions. So, what would success look like? How do you measure it?

I think Joyce was asking how do you measure success. Was that your question, Joyce? Yes. Great. Who would like to take that one?

Success in engaging with communities, or success in relation to mental health inequalities?

Success in engaging with communities who are dealing with mental health inequalities.

I think what we are trying to do, if you think about communities in the broadest sense—and I think Jo was just talking about it there when she was talking about embedding it in the systems and the organisational structures—is—. We need to have a common understanding, if you like, of what 'good' looks like—so, what are the conditions that you'd expect to see in a school, in a workplace, in a community, in a healthcare organisation, that would suggest that they have got the ingredients in place to either promote mental health and well-being or to address some of the trauma-informed issues that Jo was talking about. And so, once we can see that, we would need to see that we're moving towards a situation where more of our settings, more of our communities, more of our employers, more of our schools, can actually evidence that they have got those ingredients in place, because we can be more confident, if we're thinking about it from a population perspective, that more people will be living their lives in situations in their communities, when they go to school, when they go to work, where they will get a consistent and a supportive environment that helps them towards the right direction. But measuring that change is really quite tricky and quite difficult to do, and I think that, probably, it's fair to say, is something that we're all still grappling with.

Joyce.

Okay. So, you recognise that it's tricky, so what is it that needs to change to make it less tricky and more readable?

Can I pick that one up?

By all means, yes.

I promise I'll be brief; I know I talk a lot. I think one of the things that we've been thinking about in terms of the difference between hard measures—. So, when you do a theory of change and you're looking at, as a long-term outcome, that we see a reduction in people accessing mental health services, for example, or we see a reduction in violence, or whatever it might be, it's quite hard to quantify, then, what the specific role of specific interventions are in contributing to that overall. So, one of the things I think that we're investigating through the work we're doing with communities is the importance of story telling, the importance of understanding what is the experience of the person who is going through whatever it is that they are experiencing, whether it's mental health or some of those wider adversities, and bringing that story to life so that we can hear it in an accessible way. So, someone is able to say, 'This is what I was experiencing and, when I accessed this service, actually, nothing happened. It got worse. I didn't feel like I got what I want.' After having experienced something that's trauma informed, for example, then that story changes to, 'Well, actually, now I feel that I was listened to. Now I feel that I've that I've got the power and empowered myself.' Or something like that, so that we're able to capture that experience of the individual and take that to a broader level. That, I think, is in combination with those hard data levels, but that's the bit, I think, that would be really useful to explore in more detail, and make people feel part of the process.

Can I add really quickly? You were just mentioning about hard data; there's some really good examples of community work that is very much driven within the community, prioritised by the community. And if you asked, say, Greenwich, for example, which we visited just before COVID, what the people in various apartment complexes saw as success, they wanted to feel safer, they wanted to feel more engaged in the community, they wanted to know their children were attending school more than they had been, they wanted to know that they had more opportunities, they were more likely to get on to further education, they have more control over their environment. So, I think it really has to be balance of real success for citizens, and then aggregating that up to the population outcomes so that we can see things moving at a national level.

I'm going to ask about social prescribing and your role in that, if you have one. We've already had witnesses this morning that said that there are barriers. One of them, of course, was ongoing finance, because of the nature of short-term employment, 12 weeks to six months, and also, then, feeding into the confidence that GPs, for example, might have in referring people into that model for fear of letting those people down, because that system might not be in place for the length of time that the individual will be hoping that it would be to meet their particular needs.

Our primary care division has actually been working really closely with Government and a range of other organisations and agencies to actually develop a new framework for social prescribing in Wales, which is due to be launched shortly. And that's really involved engaging with a huge range of different parts of the system to think about what actually needs to be in place to make this work. And part of it's a shared understanding of the value and what we actually mean by it, and the term in itself brings challenges, unfortunately, but we've worked through that one. But then it's also about connecting the—. Essentially, the essence of social prescribing is connecting people to assets in the community. So, you need to understand that those assets are there and you need to understand how to make that happen. And the biggest challenge that I think we're seeing, and you've highlighted, is twofold: (1) those kinds of community activities are often funded through short-term, time-limited funding, and so people start to refer to something and they get benefit from it and then the funding ends and the practice stops. So, we need to think a little bit about that and how, collectively, we sustain some of those assets as a system. But I think you're also right about the confidence of the practitioners who are engaged with the individuals in being that bridge, and recognising that it isn't just about the medical profession. One of the things that we've really tried to build into the approach that we've been taking is much more of a social model, and recognising that there are lots of professionals who engage with the public who can have a role in connecting people into support services. And very often, it's those kinds of services that are actually going to bring the biggest benefit. They don't often need clinical intervention; what they actually need is something that supports them in sustaining their well-being. So, that's one part of the solution. But I think if you look at the experience that we've had with the exercise referral programme that's been running in Wales for a number of years, and one of the programmes that we, obviously, co-ordinate as Public Health Wales, we know from the evidence that that improves people's well-being. So, we know that it does that; we've got good evidence that it does that.

And we've had to work quite a lot over the years to tackle all of those issues that you've mentioned. It is perfectly possible to achieve, because now GPs are familiar with the programme and they recognise that—. The critical thing, I think, is that we were able to provide assurance that the people who they were recommending that people went to were safe, reliable and could meet core standards. And so the essence is going to be about that. It's about how do we make sure that the community activities that people might be encouraged to join, whether it's a walking group or a crafting group or anything like that has actually got—without making it too burdensome, that it actually operates in a way that's going to be beneficial to people.

Okay. There are a number of questions on this, but we can't go into it, because time isn't going to allow us. We might write to you, because there was a series of questions raised.

Very happy to receive any questions.

Thank you for that, Joyce. And thank you, all. Gareth Davies.

Thank you, Chair. I want to move on quickly to Welsh Government strategy and what further actions you think the Welsh Government should be taking to maximise the use of all levers, including some legislation, to address some of the mental health inequalities we see.

Yes, thanks. It's interesting. I was in the Public Accounts Committee, I don't know, a year or so ago, and we were talking about the Well-being of Future Generations (Wales) Act 2015 implementation. I can remember saying that—because we link in with colleagues internationally a lot and the World Health Organization a lot—the presence of the Act is really well respected by many countries worldwide, and I was making the point that that has to be our compass to navigate through the pandemic and other harms. We've now got the conflict in Ukraine and the impact that that's having, and the five ways of working for me are just fundamental, because finances, resources, are tight, and we need to know and work with our population and understand what's happening, the future trends, where we're at, invest in prevention and invest in long term, so that we can shift to be a much more resilient Wales. So, I think that we're very fortunate, personally, to have the well-being of future generations Act, which, to me, is the epitome of a public health piece of legislation. Speaking honestly, I think that we need to push that further, because I think, with COVID, understandably, everything has been about responding to a pandemic. Well, we've got a piece of legislation that can give us a compass to navigate through, and, I think, repositioning the structures that were in place, the public services boards, their importance around well-being plans, joint investment, using their assets, focusing on the needs of the community, incorporating everything that we've been saying for the last 45 minutes or so.

We've also got the socioeconomic duty, which, again, embedded properly, should really ensure that there is an inequality and an inequity lens that goes across decision making, particularly big decisions by public bodies, ours included. Because what we can't do is to whack ourselves on the back and say, 'Oh, look, we've done really well', but all we're doing is improving people who are living in areas of low deprivation and increasing the inequality for those in high deprivation. And we know we've got the marginalised, vulnerable groups as well and their mental health, mental well-being imprint, in the stepladder of inequalities.

There's also a couple of other things that should make a difference. There's health impact assessment legislation in the Public Health (Wales) Act 2017. We do the health impact assessments for Wales. That will mean that they are done and people are equipped to do rapid health impact assessments for their population at a local level, because that will help inform decisions. So, I think that's quite a helpful piece of legislation.

And I guess the final point from me—and I know Julie and Jo may want to contribute—is we worked quite closely with Welsh Government colleagues in the development of 'Together for a safer future: Wales' Covid-19 transition from pandemic to endemic'. Our focus very, very much was about that there are three facets here. There is continuing the response to the pandemic in the communicable disease element; there is tackling the burden of disease, the accrued harms, the backlogs and the potential impacts of different healthy behaviours through COVID that will transpire into communicable disease, and then the broader population health harms that are fundamental. So, I think there are plug-ins there in that document that have to allow us, then, to build the data we've talked about, to rapidly assimilate evidence that's missing, to work with communities to implement and create that sustainable social, health, fiscal stability that we need. So, I think we're fortunate that we've got the ingredients there.

And my final point is that the proof's in the pudding. I think there are a couple of elements—we've talked about the first 1,000 days, we've talked about ACEs. We haven't talked about employability, but cost of living and employability are similar. If you ask me what I think the golden thread here is, if we had three things like that that are common outcomes across every Government department, across every public sector, with indicators for different sectors to achieve those two or three outcomes, investment, decisions locally focused around those areas, then we could really start to move things forward. So, we've got the policies and the strategies. I think the key is health in all policies across Government, but health in all policies across public services, within those regional structures as well. I don't know if—

Can I just—? We're pushing it for time, so, Gareth, do you have any final questions?

No, that was it; that was everything.

Sorry.

I suppose, just to add myself, if Julie or Jo want to come in on this, but, particularly, tell us what further areas the Welsh Government can do. Is there any further legislation that is required? Is there anything that the Welsh Government, where they have levers at their disposal—what else can the Welsh Government do to support those mental health inequalities?

I don't think it's legislation; I agree with Tracey. I think we've got to use the legislation we've got. What I would say about strategy—and we have been working on this—is that, historically, our mental health strategy has not been as strong as it could be on building mentally well people, prevention and inequalities. So, as that's refreshed, because we're at a point where that's about to be the next phase of that, I think there are opportunities to strengthen this.

Very quickly, could I just add as well the approach that's taken between criminal justice and the Welsh Government in the blueprints at the moment—women who are in justice and youth justice? I think that we mustn't forget that, actually, criminal justice and policing partners are picking up some of the end of this in terms of mental health, and we've been working really hard to create this way of working that crosses that devolved/non-devolved, and I think that's a really important model to think about in the areas where we will see mental health manifesting as a cause and consequence of some of the things that we're trying to tackle. So, that blueprint approach, and the continuation of that model of working across those areas, and using legislation, as we should, because the Social Services and Well-being (Wales) Act 2016 gives the power for people to come together and work in an integrated way, and I think, sometimes, we lose sight of what it actually enables us to do, so, refreshing and rethinking what we've already got and making sure that it sits in policy and practice as we go forward.

Thank you, and as we come to conclude the session, you've given quite a few bullet points there in terms of what we need to do in terms of reducing mental health inequalities in Wales, but are there any other final points that you would like to make in bullet-point form that you'd like to leave with us in terms of our work on this and what recommendations we can be making to the Government?

I think there's one that's overriding for me. We've talked a lot about prevention and early intervention for years. We've got to really do it and measure it, so that we can see the return on investment, and an investment in one sector or one organisation may realise a return on that investment in another sector. So, prevention and early intervention across policies, across decision making with public bodies, I think the rubber's got to hit the tarmac on that, and that's a job for all of us.

'The rubber's got to hit the tarmac.' That might end up in our report; I can see that now. [Laughter.] Thank you ever so much for your time this morning, and I'm so sorry for having to ask you to curtail your responses—

No, not at all, we're all enthusiastic on the subject.

It's not that we don't want to hear you, it's just having to get through all the questions. [Interruption.] No, not at all. It's so much data you've given us this morning in such a short amount of time, so we really, really appreciate your time with us this morning and your paper in advance as well. Thank you also for agreeing to come back to us in written form with any other questions that we've got.

On anything, just let us know.

We're very grateful for that. Diolch yn fawr iawn, thank you very much. Thank you now, take care, have a good journey back home.

We move to item 4, and I propose in accordance with Standing Order 17.42 that the committee resolves to exclude the public from items 5, 9 and 10 of today's meeting. Are Members content with that? Thank you very much. In that case, we will be back in public session at 1 o'clock today.

Good afternoon, and welcome back to the Health and Social Care Committee. I move to item 6, with regard to our mental health inequalities evidence session, and today we've got witnesses from Mind Cymru and Leonard Cheshire, and I'd be very grateful if the witnesses could introduce themselves for the public record.

Hi, I'm Rhian Stangroom-Teel. I'm the public engagement manager for Leonard Cheshire.

Hi, my name's Ashra Khanom, and I'm representing the Neath Port Talbot Black Minority Ethnic Community Association, and I've come along with Mind Cymru today.

Good afternoon, everybody. I'm Sue O'Leary, director of Mind Cymru.

Good afternoon. I'm Nia Golding, operations manager for Leonard Cheshire.

Right. Well, thank you all for being with us today. Can I ask: as a result of the pandemic, what's important, do you think, following the last two years that we've been through and on the issues around that in terms of isolation? What particularly do you think is relevant to people's mental health?

I would say, I think people recognise the importance of community and being together. We've run some workshops with Mind in Neath Port Talbot during COVID, and after COVID restrictions were lifted, and one of the key things that came across was that we want the community to be together and have activities together. Young people were saying they don't have anywhere to go to, and they were missing that as well. So, those were some of the key issues.

Just to add to that, I think some of what we've certainly seen throughout the pandemic is some of the inequalities that have existed pre pandemic have absolutely been exacerbated. And I think what we know is that there are certain groups who have a more negative experience of mental health and they're more at risk of experiencing mental health problems, and they're disproportionately represented. So, we know that people—. As Ashra mentioned, young people, people who are black and from ethnic minority communities, and also people who are experiencing financial hardship have had a much tougher time during the pandemic, and that has absolutely been highlighted. And then, I think in addition to that, we also know that the same people are having the greatest difficulty in accessing the right level of support to support them with their mental health and, when they do, their outcomes are also less favourable. So, it's a real interlinked issue between mental health and inequality that's absolutely been exacerbated.

And again to Rhian and Nia, I suppose: again, learning from that experience of the pandemic, what is important for people to have good mental health?

I think disabled people and those with sensory impairments were already more likely to be affected by poor mental health prior to the pandemic. A survey or research that we did showed that four out of 10 people with disabilities were anxious or feeling mentally unwell prior to the pandemic, and that's risen to six out of 10 through the pandemic. And many disabled people were obviously required to shield or isolate a lot longer in a lot harsher conditions, in some respects, than the rest of the population. What we've seen is that, actually, there is still an awful lot of anxiety in a post-pandemic scenario, where people are nervous to be in crowded places, particularly since mask mandates have changed, and people are more likely to still stay at home rather than go out and about. And actually, that has increased that feeling of loneliness and isolation to those sorts of issues, really. Fifty-five per cent of disabled people reported a continued impact on their well-being following the pandemic, and 18 per cent of disabled people reported continuing difficulties in accessing food because they didn't want to go into busy supermarkets—they still felt nervous about that. So, it's real, everyday things that are still being impacted.

I think, also, the access to services. Some people I know who were already with mental health care are really struggling to get access to services, because they're not face to face, appointments are always cancelled, with staff on leave or staff unwell. It's been quite a nightmare trying to support people with that.

And I think another thing that disabled people have talked about is the fact that, actually, they rely on people, sometimes, to come in and give them quite personal care, and then they're concerned that their care worker may be bringing COVID in, or they get told—. We have somebody who was telling us how their care worker had been in, delivered their personal care and then they found out two hours later that that individual had tested positive for COVID. They've already been in and given them the care and then they had to worry for a few days as to whether that meant that they were going to pick it up. But, equally, we have care staff who are also saying that they feel terribly guilty or terribly worried, and so, it's not just the disabled people, but it's also the people who are caring and giving care.

Thank you, Rhian. Nia, did you want to come in at all?

I think Rhian's covered a lot there, but also the lack of community access for the people living in social care. With day centres and things closing during the pandemic, a lot of their routine went out of the window, which, for people with autism and other disabilities like that, routine's so important that just those places closing had a huge impact on their mental health, and then there was the lack of mental health support at the time when they most needed it.

Okay, thank you, Nia. Okay. Thank you for those opening comments. Members will, perhaps, dive in to respond to some of those issues as well. Rhun ap Iorwerth.

Sue.

Yes. I think it's an absolutely crucial point. What we know is that stigma is a real issue and it's a real barrier in terms of people accessing the support that they need. And, despite the fact that a lot of work has been done over recent years through programmes like Time to Change and campaigns to tackle stigma and discrimination, there is still a long way to go. So, we know that that shame, that sense of not being believed, not being listened to, and feeling as if your problems are less important or less worthy of support than others, are significant barriers to accessing support. So, what we would say is that it is crucially important that we create circumstances and we create safe spaces to enable people to have that conversation about mental health, and that's both in the workplace and it's in our personal surroundings, so that we can, as you say, have that first conversation that enables you, then, to access the support that's needed to address those issues. And whilst we have seen quite a good shift in positive attitudes towards mental health, there's definitely entrenched stigma in certain communities, and some of the work we're looking at in Time to Change is how we particularly help in black and ethnic minority communities, so that those conversations about mental health where there are cultural challenges to having those conversations are more openly possible, and also there's an additional layer of stigma when you consider poverty and you consider people who are struggling to make ends meet, and the shame associated with that. So, we really need to enable those conversations to be had.

Before I bring the others in, that's what you mean when you use the term 'self-stigma', is it?

When I use the term 'self-stigma', I think, certainly through the pandemic, what we've heard from people is that there's a sense that, 'My problems, my issues, aren't as significant; they're not as important as others.' So, there's certainly been a reluctance to seek support, a reluctance to over-burden health services, to present to services, because people feel that it's not as important, 'I don't need support as much', despite the fact that they do, and their problems are equally important. So, self-stigma really is just stigmatising yourself and not enabling yourself to have the support that would best benefit you.

Okay, thank you. Can I invite further comments, then, on the barriers to just initiating that search for help? Nia's got her hand up first, if I could just come to Nia. Diolch yn fawr.

Yes, I think talking is very, very important, and it is definitely a first step, but, for a lot of our residents particularly, that talking via things like Zoom creates barriers for them, because they have communication difficulties anyway. So, when they're trying to have mental health appointments and whatever via Zoom appointments, they really, really struggle to actually get across how they're feeling. That's caused a lot of difficulties for people living in the homes, but also people living independently, where we provide a package of care, who may not have the technology, may not be able to afford the Wi-Fi connection. So, they were missing out on services because the face-to-face appointments weren't happening. That made it difficult.

Thank you. Rhian.

Yes, I was going to add that, with lots of people with disabilities, they might have had a life-changing diagnosis, their lives have been upended in lots of different ways, but currently it's the medical stuff that get discussed and prioritised and put forward, and actually you don't get a space within a lot of that. Sometimes there's a leaflet, maybe, but you don't get a space to talk about how that makes you feel—the grieving process that you might be going through as your life is altered or change. We have had lots of people talk to us about the fact that they had life-changing information—a gentleman with MS—and at no point did anybody ask him, 'How are you feeling about that?' He almost felt guilt for thinking, 'Oh, well maybe that's not important', but actually it got to the point where he was suicidally unwell before somebody finally said to him, 'Actually, how do you feel about all this?' So, sometimes it's the point of crisis before we actually get to the safe space that somebody feels like they can talk about a life-changing alteration.

Yes. Ashra.

I'll give a few examples around stigma, because a lot of it's recent work that we've done with Mind in Neath Port Talbot. At one of the young persons' workshops, one of the girls said, 'We don't want to talk about mental health because people call us "broken"', and one of the boys said, 'In school and everything, there's pressure to succeed, and your family saying'—especially with ethnic minorities—'if you don't succeed, you're going to be discriminated against. Life is just more difficult, and a challenge'. So, everybody's like pushing, pushing for them to be useful to society, be perfect, not 'broken', as they were saying, and that was such a big issue for them. The boys were saying they would never seek mental health support from their GP because they didn't want to seem weak. Also, we talked around the language of mental health, and people were saying, 'If you use "mental health" with us, it's a barrier for us, because it's too strong a term'. That's what their words were. They said, 'Use words like "stress", "worry", "feeling unwell"', which we were surprised about as well, and somebody said, 'Do you know what? Why can't we have mental health as one group and mental illness?' We know some people really do need their medical care, and in talking with asylum seekers and refugees, you know, they were saying they wouldn't go to their GP because they didn't want to have that conversation about medication. Everybody feared medication, and that was a strong thing from the ethnic minority groups that we spoke to. 

I think it's a very good point, actually. We talked a lot about this in the Senedd yesterday afternoon, differentiating between mental well-being, mental health problems that could develop into something more, and then the serious mental illnesses. 

But not speaking to their GP was a big thing, and I don't know how we overcome that. That's the next step. 

To me, this really describes inequality, because, quite often, we talk nowadays about a new willingness by some young people to talk about mental health, and this is good, whereas in the past perhaps everybody would have felt that way. Now, there is a group, there are young people who are willing to talk. So, we need to find out why others don't. 

We did some work with Cwm Brombil school in Port Talbot as well, where we got all the ethnic minority children together and we did a workshop. And Mind Neath Port Talbot said that some of the children wanted to walk out of the room because they didn't realise it was about mental health; they had said that it was just a group for children to get together and talk, that it was a talking group. And they wanted to leave the room. But, afterwards, the children were buzzing. They said it was the best thing they'd ever done, and then they said that they wanted that type of workshop across the whole school and that it might stop bullying, because one of the children was saying that they still get slurs around 9/11, even now. And she said, 'I wasn't even born, and it's 20 years later, and we're still getting this thrown at us.' So, there are a lot of things that they're having to deal with on top of that—the racism, school, family expectations. It's just so much. 

Yes. I think we could learn a lot more from the group of young people that you've described there. Just one last question from me, if I may, Chair, picking up on the comments that Nia made in particular about the challenges that doing things on digital platforms can present. Do the other three of you have thoughts on that, not just on what challenges are thrown up by digital, but also opportunities to reach out to some groups, and what the barriers might be for those opportunities to be available to all?

Certainly, from an opportunities perspective first of all, I think that what's opened up a lot during the pandemic is probably that option of choice. So, that blended offer of support, where both remote and online options are available alongside face to face. So, I think it isn't one size fits all, or having a preference for one over the other. I think we need to consider that, for some communities—. We've certainly heard from colleagues in the local Mind network in Carmarthen and Pembrokeshire that, where we've introduced online access to services, that's had a really positive impact in overcoming rurality and transport challenges in terms of accessing services. But then, on the flip side, there's obviously a consideration in terms of digital exclusion, and there will be people for whom connectivity and access to devices is a barrier. So, where there are barriers and where there are opportunities, we need to think about how we enable people to have choice to access support and services in the way that best suits their individual needs, and keeping away from a one-size-fits-all approach.  

I think we'd second that. A one-size-fits-all approach, which seems to be how things are applied at the moment, needs to be explored and changed. But, access to digital technology, again, has opportunities, but it's uneven in the way in which it's applied, and it can actually create more barriers and isolation. We already know that only 79 per cent of people with disabilities actually use the internet, are actually feeling safe and confident on it, know how to use the technology, compared to the 93 per cent of people who don't have long-term conditions or disabilities. There needs to be more investment in closing that gap and ensuring that people feel safe online, they know how to work through it, and all the rest of it.

And then there are some more pressing, immediate things. Already, people are making choices in the current climate in terms of heating, food, electricity, all of those sorts of things, and actually not everybody has enough money to have credit on their phone, even if they know how to use the technology and they can use it safely. If it's a choice between charging their powered wheelchair or using their breathing apparatus during the night versus topping up their phone to attend a medical appointment, whether that be a mental health one or a clinical one, they're going to choose the one that's going to enable them to access their life, but they shouldn't be making those choices. So, I think there are wider barriers there as well.

Really stark examples there. Thank you. Diolch.

Joyce Watson.

Good afternoon, everybody. I want to talk about community solutions and the role that the community can and does play in building mental health and well-being, and supporting those with mental ill health. Can you talk us through any examples of community projects that you're involved in that show potential, because we want to share best practice where that's possible? But, we particularly want to know about the success within the diverse groups. 

Who has an example to provide us with? Ashra. 

Well, I have mentioned the workshops that we've started in Neath Port Talbot, but also, before I came to the meeting, I asked Swansea bay asylum seekers groups to provide some recommendations for me to pass on to the committee. And they were saying that sport was one of the best ways that they found that mental health worked for them. They don't like the issue where you had to go into a darkened room and talk to somebody about your mental health. One person, I think a couple of years ago, said to me, 'If I was in Africa, we'd be in a community group and we'd drum our sorrows away'. Here, it's like you talk your sorrows away, and it's really difficult for them to understand that. 

The other thing I would say is just enabling community groups and faith groups, actually, to support people, and having those resources. Before we came in, we were talking about how a lot of these community groups are resource poor, and it's really difficult for them to have ongoing support and keep their staff going for the longer term. And then, once the key person that's built that relationship in the community has gone, that support has gone as well. 

It's also about the Wi-Fi issue. The Welsh Government tried to do a lot of good things around COVID to provide Wi-Fi, but asylum seekers and refugees are saying the quality of that service was really poor, the connectivity was really poor. The idea is good, but it needs to be improved. 

Sue.

Just to add to that, I think some of what we've mentioned, some of the root causes around people's mental health are very much rooted in our social circumstances and our financial circumstances. So, there's a real benefit to programmes like social prescribing in terms of getting in front of that support to people at that earliest point. And I think some of what we've learnt over recent years in running social prescribing schemes with local Minds across different areas of Wales is how, on the one hand, it breaks down some of those barriers—so, community support rooted in communities. Where there's trust in community providers, people are going to the people they know and trust and are accessing services in their local areas. And I think what we need to think about is how we fund the sustainability of some of those initiatives, because what they can do in a 'what matters' conversation, or an initial assessment with somebody, is ask what's the root of the issue for them, what are the things they need immediate support with, and then use the community assets and use the expertise as well of mental health practitioners to enable people, whether it's to access well-being initiatives, whether it's support with debt and benefits and financial support, or it may well be just enabling somebody to leave the house and access support through that supportive relationship that they'll have with a link worker or somebody who's supporting them specifically in that role. There's a lot that we can learn, I think, from those initiatives.

Thanks, Sue. Joyce, any further questions? 

Yes. You've all talked about sustainability through financial stability for those projects. So, would you say that that's one of the key elements of keeping community solutions and community programmes going to effect a good outcome for people with mental illness or for mental well-being?

[Inaudible] European funding has stopped and one of my questions to the committee is: what's the plan for Welsh Government to move on? How do we support our communities? I know one of our mental health cafes closed in Neath Port Talbot, and that was really good for people to actually come and do activities there. What do we do, going forward? 

That's something that we can ask the Minister when the Minister comes before us, as part of our work in this regard as well.

What would be helpful is if the funding cycles could be longer. Sometimes, you get seed funding for pilots, but then, actually, there's no real thought about how that then gets sustained moving forward, or funding cycles are on two or three-year cycles. Actually, what would be really good is to see a Senedd-term funding cycle; you invest in something right at the beginning and you know that at least it's got five years to run. I think that would be helpful, but it isn't just about funding.

It still feels that there is an element of one-size-fits-all—that actually it's not nuanced. We know that people with learning disabilities who find it more difficult to process language or those who are neurodiverse actually require slightly different activities, or they require different engagements and interactions, and at the moment they're not given that choice. There aren't those different activities and engagement, it's the same groups for a plethora of cohorts of people. There are some just simple accessibility issues that are also preventing people accessing some of the good community services that are out there. You've got the issue of somebody potentially finding difficulty just physically travelling to a socially prescribed activity, and then when they arrive they can't access it because the building's inaccessible, or there's a gardening group and there's no raised flower beds or whatever. It's these sorts of things we need to be thinking about. One-size-fits-all doesn't work. We do need much more bespoke—

On funding, is it an issue? Because it's often raised with me—I'm just seeing what your views are in this regard. Funding is often for new initiatives rather than for revenue for ongoing projects. That's often an issue that is raised.

I know the Welsh Government's agenda is capacity and capability. If you look all through the documents across Welsh Government everywhere you'll see 'capacity' and 'capability', but where is it on the ground in reality? Sometimes, we have really good staff members doing projects and then we can't keep them or they're not there anymore because the project finished and they've moved on, and then you have to go through the whole cycle to find somebody else who might not be of the same caliber. We've lost that capacity building.

So, what's the solution to address that?

I think what Rhian said, it's about the long-term funding. We need that. This constant innovation—I know innovation is brilliant, but I think there should be innovation, there should be sustainability and then it should be long term. Anything that really works well should be carried on. We don't need that reinvented again 30 years down the line.

Just to add to that, I totally echo what colleagues have said about the longer term nature of sustainable funding, but I think it's also thinking about the role that we as the third sector play in an integrated mental health pathway. It's looking at how we as third sector organisations and statutory services can work together. We look at what's the part in the process where we all best meet needs. I think certainly it's getting in front of some of those challenges around, certainly for young people, the wait time that they're experiencing to access assessment and to access intervention. There's a lot that third sector organisations do in that early intervention and that early support, if we can get in front of some of the primary care provision and invest in early intervention within the third sector. But as colleagues have said, having a more longer term sustainable nature to that investment prevents that stop-start nature of losing some of that innovation and not embedding it in the wider system.

Thank you, Sue. Joyce, have you asked all your questions? Yes, you're happy. There we are, thank you. Nia, please wave your pen or hand or something if you want to come in at any point. I don't want to forget you on the screen there. Gareth Davies.

Thank you very much, Chair, and good afternoon. I want to focus on social prescribing. We've taken a lot of evidence this morning on that theme. I'd like you to describe the role and the quality of social prescribing in addressing people's mental health and their broader needs. I suppose it's a question directed towards Sue for this one.

I think there's a huge range, first of all, in what falls under the umbrella of social prescribing. I think it's really encouraging that there's a ministerial task and finish group at the moment to look at developing a framework for social prescribing, which is due to go out to consultation fairly soon. We've done some work in Mind Cymru over the last probably three and a half years looking at what are some of the successful elements and the essential elements of a good social prescribing scheme, which was funded by Welsh Government. And I think what we've found is that, right at that outset, it's about having, as I mentioned earlier, that 'what matters' conversation with the person who's accessing the service, so that you can really root the response in that person-centred approach and the needs of that individual. It's about having that mental health expertise in the mental health practitioners who are delivering the service.

But I think really importantly in terms of community, you need to have that community-level support, and services that are invested in, which you can actually refer people to, because, if you're sitting on long wait lists to actually access community-level resources, it's not going to meet your needs. And there's a whole range of activity and support that, once people know what's available in local communities, which people can be supported via—. But we need to invest in those assets and those services within our communities across organisations locally to enable that to have the best effect. 

In terms of investment, would that mean going along the lines of the framework or further training for social prescribers, so they're getting that appropriate level of care put in place, and they're being directed to the right places?

I think it's both. I think, on the one hand, I suppose the best support that somebody will receive is if it's rooted in the local community. So, that person who's taking on the link work, or the social prescribing practitioner role, needs to know what's available within that local community. So, that could be a mapping exercise—that's how you connect and you refer through to community organisations. But I think, importantly, it's also about knowing the funding cycles or the availability of that resource, because if—. One of the things that we included in the model we ran in Mind was an uplift fund. So, where we identified that there was particular demand, for example for stress reduction or counselling, but actually where provision in the community wasn't such that anybody would be able to access that in a fast way, we could uplift or invest in that capacity so that people received support in a relatively quick period of time. So, I think it is about training, but it's also about having that knowledge of what are the best services that people can gain access to. 

Rhun ap Iorwerth. 

Diolch yn fawr iawn. Just to ask for a little bit more information on something that's already been touched on, which is the integration between different elements of support that people may need. We've heard people talking about the need to think beyond a person's mental health problems and look at the whole context, perhaps even co-locating housing and debt, and all these other support services, alongside mental health support. What are your thoughts on the extent to which that could even be a priority?

We had some feedback from that. So, with ethnic minorities, lots of people are working precarious hours and late nights and things, and they were saying they couldn't access services in the day because of their work patterns and shifts. Also, women were saying they're unable to access a mental health service, or even just go to a workshop or anything like that if there's no childcare provided. So, those barriers prevented people from accessing. 

I think with the services, a key one that came across with those who had accessed services was flexibility. So, the services are very quick to drop people off their list. I think one person gave an example where they had a WiFi issue the first week; the second week, the therapist gave the wrong Zoom link; they waited, they called the community mental health service and said, 'I couldn't get access to a therapist'; the following week, the therapist put down 'did not attend' and dropped them off the list. So, these little things actually add to the frustration in the community, and then people think, 'What's the point of accessing these services if they're not flexible and they don't meet our needs?' Also, sometimes, staff have their own issues as well. One girl said, 'They come across judgmental; I feel they're judging our culture', and that sort of thing. So, there's quite a lot to unpack. 

Any other thoughts on what would be the barriers to holistic working and agencies working together?

I think there would be a real need for disability awareness training for clinicians, or those delivering or socially prescribing. A lot of the time, there's actually a real lack of understanding of the person sat in front of them's needs, and—

And that could be easily done and we'd all benefit from broadening that.

Absolutely. There are lots of organisations out there that would be able to help and support in either providing toolkits or actual online training or in-person training. But, yes, we get feedback all the time that the clinician, or the person that they're sat there talking with, has no understanding of their wider needs and conditions, and therefore doesn't actually know where to refer them to, or what approach they need to take. Again, it's—

And I don't think that question's ever asked as well. Unless you know that social prescribing is available, and you go to your GP and say, 'Oh, can I access social prescribing?', then the GP will say, 'Oh, yes, let me have a look.' But, before that, that conversation never came up. That's from lots of experience; I take my mum to the GP a lot—never offered social prescribing, ever. I know it's there, but it's never offered.

And we're not just talking social prescribing here—it could be anything, a whole host of agencies working together.

I think, as Ashra mentions as well, there's a barrier, certainly around trust or that sense of not feeling that 'this service is one for me', or that sense of not belonging. So, I think we really do need to think about how we overcome that barrier, because I think some of the challenges are around the diversity of the workforce. I think what we hear a lot is that, 'It doesn't look like a service that I would want to engage with because there's nobody who works within that service that represents the cultural background that I come from.' What we're also hearing is that there's a kind of a re-traumatising element, that if you're continually trying to explain the cultural nuances or the experiences of racism that have been part of your life, but you're engaging with a mental health workforce that is primarily white and doesn't understand some of those nuances, it's a barrier before you even start to talk about what your particular mental health challenges are. So, we really need to think about how we make services both accessible but also inviting to the people we want to engage.

Yes. I'll come to you, Nia, as well. We're looking, quite rightly, at this from the point of view of the service user. Just flip it the other way round and look at it from the point of view of the agency that is trying to provide a service—and there are a whole host of agencies trying to provide a service—what's stopping those agencies from working together, hopefully in a way that does make them collectively more inviting? Why is there that silo working? Is that what it is, or lack of co-operation? Nia, any thoughts on that?

I think a lot of it is about people knowing what's actually out there, and actually how to access it, who to speak to, where to go. And even professionals—we have situations with residents where we try and access services, and even some of the professionals would say, 'Well, we need to refer them to somebody that can do X, Y, Z, but we don't know where to go.'

So, the agencies themselves don't know what the other agencies are.

The agencies themselves don't know where to signpost to.

So, identifying all the different agencies that can contribute towards that holistic approach is really important.

Yes.

That's pretty basic, actually, isn't it?

And quite often we're finding that some of our residents have been referred outside of Wales to get the services they need and to get the support they need. And that's quite disappointing, when you're having to travel, then, two or three hours to access a service.

Which may well exist here, but if you don't know about it—

It may exist, yes. It may exist on the doorstep, but nobody knows about it.

Okay, thank you.

That's a powerful point.

Sorry, I think Rhian wanted to—

I just wanted to say that there actually is no specialist deaf mental health service in Wales—it doesn't exist. Wales has very few deaf mental health clinicians, or people who understand sign language, or whatever, but we have nothing specialised for people with hearing impairments.

So, what do those who need support for deaf issues—

They travel outside of Wales, or they get not a pretty good service—they get pretty poor service.

I was trying to draw out, do they travel, or do they just not bother to travel?

I think it's a bit of everything. I think probably fewer people who are deaf access the services in the first place. Those that do then face numerous barriers, and there just aren't enough deaf mental health clinicians around.

And if we drilled down, I'm sure we'd find that people who are deaf would be more likely to have—

A mental health illness, because of the discrimination and the other barriers that they face in terms of society—barriers to employment, barriers to inclusion, having perhaps been taunted or bullied in schools. There are multiple, again, facets as to why they would then— 

Day-to-day challenges. 

—absolutely—why their mental health is going to be impaired. 

We had a solution. Basically, a lot of the asylum seekers and refugees were saying, 'We could be trained, there should be an easier training pathway for us to become local counsellors.' Not to a therapist level, but to help with that initial engagement with people. And if there could be some sort of—. I know Newport—one of the charities tried there, but it fell through, because there was something around data protection issues, and they couldn't work with one of the colleges in Newport to offer that training to their community. 

Thank you. Sue, briefly, now. We've just got an eye on time. 

Yes, just very briefly, I think one of the challenges in understanding inequality within mental health is definitely impaired by the lack of population-wide demographic data. There's a lack of prevalence data in terms of mental health in Wales. So, for example, we're not using the adult psychiatric morbidity survey in Wales, which is a key measure in England, in terms of understanding prevalence data for mental health, and similarly there's no commonly used measure across young people's experiences of mental health and prevalence either. So, there's been a commitment within the 'Together for Mental Health' strategy, over the last 10 years, to really invest in a mental health core data set. And I think one of the real challenges in us being able to understand what people's experiences are, what the link is between inequality and mental health, is underpinned in the need for that core data set. I think one of the things that we would certainly be pushing is for no further delays in that mental health core data set, because I think there's a possibility that not only do we not know the true extent of mental health inequality, in terms of demographics, but we could be masking inequalities that exist because of the lack of reliable data to be able to understand what that picture looks like. 

That's important, yes, absolutely. Joyce Watson.  

[Inaudible.]—area of that, of course, people feel left out, very often, is the geographic challenge of where they live and access to public transport. You've already mentioned limited online availability as well. So, how can we address this? Do people—have they come across this? And have they come up with different solutions and approaches that we could recommend to Government?

Because we're short of time, I don't think we can go to everybody for that, but who would like to address it? Rhian. 

We know that there are problems with accessing services because of poor accessible transport for people with disabilities—poor access to trains and step-free access to train stations, poor access to bus services, particularly in rural communities, and poor access to accessible taxis. So, one of the things that potentially we could look at would be asking more taxi providers to have accessible taxis within their fleets. It would be part and parcel of setting up a new taxi firm or an existing taxi firm being relicensed that part of their fleet have more accessible taxis. They did something in London where all black cabs have to be accessible—you can get a wheelchair on board; they've got drop-down ramps and things. If it can be done in a large urban area, we could, at least, try it in large urban areas in Wales, because it's not just rural areas that are lacking in accessible taxis, it's everywhere across Wales. And those that do exist, if you're somebody who's got a medical appointment when the school runs are being done, either in the morning or in the afternoon, all the accessible taxis are already pre-booked for school runs. 

Anything further, Joyce? 

Yes. Also, the availability of the services within the area, so not only getting to the services, but are the services there in the very first place? Or is there a dearth of services in some of those areas? 

Ashra, did you want to comment on that? 

I was just going to add that cost is becoming a big issue. I think what some people were saying was that during COVID—sorry, the asylum seekers and refugees were saying—they had free bus tickets, but that's come to an end now, and they wondered if that could be extended by the Welsh Government to take into account the cost-of-living issues that are happening.

Do you think—? Have you looked at Welsh Government policy on this issue, because lots of you do look at Welsh Government policy, and have you found that there is enough focus on rural transport or transport more generally?

Rhian.

A quick answer, given the time, is 'no', certainly not for people with disabilities, no. But one of the other things that I think Welsh Government could look at doing—going back into that cost-of-living crisis and benefits not having risen with inflation and things like that—is that, actually, when somebody is travelling, they have to think about also paying for their care worker's ticket as well. So, it's not just their cost to attend an appointment or access a service, it's also the cost of the person who is going to support them as well.

And similarly with ethnic minorities, if they need a translator, it's usually a family member. They hardly ever get an interpreter provided with the services, so they always have to take a family member, and then a child—it's like three or four tickets.

Thank you. Joyce, I think you've finished your questions. Lovely. Ken Skates.

Thanks, Chair. I'm just going to ask briefly about the workforce or give an opportunity to our contributors just to talk about the workforce and specifically what action is needed to diversify the mental health workforce that we have in Wales.

Workforce—who would like to tackle that question?

I think I mentioned it earlier, a suggestion, that training pathways need to be streamlined a bit more in allowing community members to become counsellors and therapists, and funding provided for that as well.

I'd certainly echo that in the sense of (a) disability awareness training for clinicians, but also using and utilising the great untapped talent pool that there is among disabled people to actually train and help them to deliver services would be another thing to do.

Yes, I'm echoing that as well. I think the workforce strategy, and absolutely having that focus on diversifying the mental health workforce—that being absolutely embedded in the next stage of the 'Together for Mental Health' strategy. And I think also thinking about how we enhance cultural competency within workforces, and I think I'd just really like to give absolute credit to the work that Diverse Cymru are doing in terms of the cultural competence certification scheme that many of us as organisations have signed up to. I think that's a really, really important and critical element to enabling workforces to both engage with people in a culturally competent way, but increase our knowledge and understanding alongside that.

I can give you an example of someone who said her therapist told her to leave the family home as a solution to her mental health. But that would have been a massive thing, because within Asian families, family and extended family are very important and for her to leave the family would be (a) a social stigma for the family, (b) how would she support herself, and (c) would be the parents', the family's view as well that they wanted to leave the family home, so making suggestions like this is not really helpful. And then she said, 'If I'd moved out on my own, I'd probably have killed myself by now, because there would be nobody there to help me when I needed help.' So, it's that cultural competency and understanding.

I think one other thing I would say as well is that within the ethnic minority community is the importance around—. It's not just about your mental health, it's not just about your physical health, it's also about your spiritual health, and they need all three therapies—a therapy that embodies all three elements. And dismissing one element or just talking about, 'Oh your mental health—how are you feeling today?', and not doing the exercises and going out for a walk, and then also missing out the spirituality and helping other people out of that are missing—. I think our services are not complete at the moment. You had a question around holistic care and I think the holistic care is missing at the moment, from what we've gathered anyway, from the information from people. 

And I think on a very basic level as well, just in terms of GP training and training for core healthcare staff, having that kind of mental health element within that training, which we know at the moment isn't a significant element of training, just to enable people to really understand what the, I suppose, underlying issues are, which impact on people's mental health—. And very many of those, as mentioned earlier, are linked to social and economic circumstances. They're not necessarily solutions that would require a health intervention.

I recently had an example that's come to mind. One of my colleagues who has friends who are GPs and A&E doctors, she's really into helping drug users and substance misusers and supporting them, and she said the negative stereotypes against those people, she says, are horrendous. She said, 'They were telling me, why am I wasting my time trying to help these people?', and I don't know how we overcome that as well—the whole workforce, and the cultural stereotypes they have around that. That's just one area. I'm sure it's across the board, with disability as well, with ethnic minorities. It's just across the board. How do we deal with it? It's a big problem, I think.

Ken.

Yes. It's fascinating what you say about the role of spirituality as well. Interventions are often directed toward alleviating strain and trauma in the brain, whereas actually it's in the heart and the gut, where spirituality often resides, that we need to target more resource, but it's kind of an entire different debate.

Just finally from me, the Welsh Government's new mental health strategy and delivery plan will be published; how would you wish to see it take better account of mental health inequality and, specifically, delivery of needs and diversity of needs amongst the population?

Sue, you go first.

Yes. I think the strategy at the moment does have mental health inequality and the importance of that within it, so I think what we'd want to see is that continued into the next 'Together for Mental Health' strategy, but importantly having a focus around how that translates into a plan, some outcomes as well as outputs, how that's prioritised and what that will look like in a more operational context. And I think in the development of the new strategy, it's critically important that there is a diverse range of voices feeding into the co-production of that, and really understanding the nuances of how that can be achieved and what needs to be put in place to deliver on those mental health inequality commitments and objectives.

Does anybody else want to come in on that?

I think we'd just echo that, really, in the sense that it's really important that there is a diverse voice being heard as these plans are being developed and that we are getting input, not just from organisations like ours but also from those who have got those lived experiences and from those who are more vulnerable and more likely to suffer the mental health inequalities as well, and I think the voice of the individuals on the receiving end of the service is just as important as a third sector organisation giving our views as well.

And I think prevention—. What came across from working with the young people and the women and the men—because we also had a men's group as well, and they found it such a cathartic experience coming to this group—was that prevention was the key. And how do we prevent the social problems, the workplace problems? There was a lot around racism within the workplace—how do we address those when they're little, when they're small, before they become big issues? I don't know how the mental health policy is going to fit into that prevention element, really. That's what I would like to say, I think.

I'd echo that. Far too often, it's at a point of crisis, so actually you finally get help, but we're not putting any kind of real effort—. I mean, we had a group that said there was no proactive, preventative support for the family or friends of a person who's going through mental problems either. You know, 30 per cent of carers in Wales categorise their mental health as bad or poor, and only 25 per cent define their mental health as good or very good. Unsurprisingly, over two thirds of carers in Wales—so, 69 per cent—reported that their mental health had worsened, and it gets worse when they're supporting somebody else who's got poor mental health, and the focus is on the person that they're supporting, and there's no real wraparound for them either. So, I think we need to be thinking about that in our strategies as well, moving forward, because otherwise you get a domino effect. You get the effect that you've got with the person that started with the mental health problem.

I was just going to say the children within the family as well—the siblings—they get missed out a lot.

Okay. Thanks, all. Ken, do you have any final questions? No. That's great.

I suppose from my perspective, just to finish off this session, if you've got anything that you think is useful for us that's not been imparted to us to help us with our report or inquiry, then please let us know now. This is your chance, really. But perhaps I'll come to each of you and just ask if you've got a key message for us, because, as a result of these evidence sessions, we'll be producing our own report and making recommendations to the Government, so I'm asking you: what are the key messages to be in our recommendations to Government? Give us perhaps a brief message each, and anything else you think that's perhaps useful to tell us that's not been drawn out through questions. Who would like to go first?

I'm happy to go first.

Thank you, Sue.

I think my key message would be ensuring that we deliver—or the Government delivers—on the core dataset, and I think that's about measuring and capturing demographic data across mental health, ensuring that we're encouraging statutory partners to be measuring that demographic data, so that we can really tell the picture of what mental health inequality looks like.

And then I think both reporting on that, but using that as a benchmark to understand as we move forward how the mental health and the prevalence of mental health within the population and within demographic groups is impacted. And I think that underpins everything in terms of us being able to really support the inequality that we're seeing within mental health.

Thank you, Sue.

I think we need some more—. I know the media—. There's a lot of portrayal of mental health, but I think people still need that opportunity to talk about their mental health and facilitate the opportunities for that. So, awareness raising, I think, is one thing, and then, again, having that diverse workforce that is also culturally competent to actually tackle some of the inequalities within society and be aware of that when they actually deliver that therapy, that people are coming from different backgrounds and there needs to be individualised care.

Okay. Rhian.

I think it's likely that the technology that we're using to access things is going to continue, so investment in reducing the digital divide is, I think, something that really needs to be taken forward. And I think better disability awareness training amongst practitioners and clinicians, so that people know how to interact and therefore prescribe and work with people with disabilities or neurodiverse. And I think, urgently, a deaf mental health service; it shouldn't be that we haven't got one in 2022. It's not fair.

And Nia.

It's very much like Rhian said. I know it's more about individualised care, but I think there needs to be a lot more information available around pathways and how to access them and what services are actually available, and the health boards need to be a lot more supportive of us, certainly as providers, in actually signposting us to what support we can get for the people that we're supporting.

Okay. Thank you, Nia. Thank you all for being with us today. Diolch yn fawr iawn. We really appreciate it, and we'll send you a transcript of the proceedings, and if you feel like you've missed something you wanted to say then let us know and we can add that to our evidence session as well. So, thank you very much.

Thank you very much.

Thank you.

Thank you.

Thank you.

We just need to take a 10-minute technical break, just to allow the team to make sure that our next witness virtually joins us all correctly. So, a 10-minute break.

Welcome back to the Health and Social Care Committee. We move to item 7. This is in regards to our mental health inquiry evidence session, and this afternoon we have our final session today with Professor Sir Sam Everington, who has kindly just informed us he's very happy just to be referred to as Sam. So, we're very pleased that you're with us this afternoon, Sam. I wonder if, just for the public record, you could just introduce yourself, but just tell us a little bit about your background and tell us a little bit about how you first got involved in the development of social prescribing approaches.

So, I'm Sam Everington. I started life as a barrister and came into medicine, ended in general practice—absolutely loved it. I've been a GP for 32 years, and work in the east end of London. It's very deprived, a very diverse community—50,000 patients, four sites. Our flagship is Bromley by Bow, with 100 different projects under one roof, looking and helping and serving patients in the wider determinants, the social determinants, of health. I always like to say that, actually, what we're taught as doctors is probably only to cover something like 20 per cent, and, even within the 20 per cent, we do a lot of biomedical stuff that we shouldn't be doing, because there should be an alternative, and then the 80 per cent is about somebody getting a job, their education, their environment and the creative or spiritual side of their life. And then, finally, the real purpose of the social prescribing, the real, I suppose, philosophy behind it, is not to focus so much on what the matter is with somebody—it's what matters to somebody. And that's a very different approach to the traditional training done at medical school.

I also am a non-executive director on a mental health trust, which is Care Quality Commission outstanding for the fourth time, and that's our local mental health trust. I'm on the board of NHS Resolution, which manages the negligence claims against the NHS, and I'm also the chair of the clinical commissioning group, which fundamentally—it's the model that's just about to end on 1 July, but, fundamentally, commissions all the health services for now the whole of the east end of London, so you're talking about something like 3 million to 4 million of population. 

Okay. Thank you, Sam. That's a good introduction to yourself, so I much appreciate it. Gareth Davies.

Thank you very much, Chair, and good afternoon, Sam. I was just wondering if you could provide a bit more detail about how social prescribing works in your own practice at Bromley by Bow Centre, including some referral routes, and the role of the prescriber and link worker, and some of the services and activities that are involved with that.

So, if it's just—. It's very complicated now, but, if you go back to when we started, about 10 years ago, it was really the GP who was doing the referral. There was a referral form on our system and you could tick various boxes, which might be financial issues, mental health, stress, weight—a whole raft of different issues. I would say, by the way, that it's almost impossible as a GP to distinguish between mental, physical and social. You actually have to do it all at the same time. And then there was in those days—. Because the GPs were very sceptical about social prescribing, because this was out of their comfort zone, we had a little box at the bottom, which was very engaging of them, and it was 'repeat attenders'. And this really focused the mind of the GPs, because these are the patients that, some of them, it's not a very nice term, but we use the term 'heartsink'; I like to use the term 'it's the patients we absolutely struggle to help'—fibromyalgia, chronic pain, all these sorts of issues, which are really difficult if you're just focusing on biomedicine. And quite often, if you do biomedicine, it can cause a lot of damage, hence the opioid crisis we've got around the country, the high use of opioids, because, actually, we don't have the alternatives. And, of course, the beauty of social prescribing is you then give the tool to every GP to have an alternative. Because there's a lot of pressure on clinicians and doctors and nurses to prescribe, and so that's why we came up with the term 'social prescribing', because we wanted them to carry on prescribing, but actually do something very different to what they were doing before.

Now, it's very much evolved so that, actually, there are all sorts of entrances to the social prescribing process, so it's not just reliant on the GP. Of course, general practice, certainly where we really are doing a lot of social prescribing, completely changed. The breadth of my team is now enormous. I have a pharmacist, for example, who is part of the social prescribing team but does all the repeat prescriptions. So, imagine a scenario where you're not just a GP, you're not just the practice nurse on your own, but, actually, you've got a whole wider team. So, we have a very specific social prescribing team, who, by the way, are at the front of our building, in our cafe, at the front of our cafe—they're called the 'connect zone'—where people can just walk in off the street, whatever their problem is. It might just be that they want to use the laptop, because they've got a problem they need to solve. Invariably, lots of conversations happen, and then our social prescribers can then help them with whatever is the problem. It might be the plumbing in the house, it might be another housing issue, it might be some education, they might need a job, they might want a better job. Whatever it is, the social prescribers are there to help you. And, obviously, a big amount of work around finance now; I think we're all worried enormously. One of our projects—you asked about the sort of things we refer to—one of our projects, 200 families, over a year period, managed to save their households £2,000 by looking at their energy bills, moving from Vodafone, whatever it was, which is quite stunning. And that's the difference between putting healthy food on the table or not, as the case may be. So, it's about people, it's about what matters to them.

And finally—I think this is the really important thing to grasp—. So, what is a social prescriber? What sort of characteristics do they have? And, for us, in a very deprived community, we actually have lots of people who don't have formal qualifications, often not a lot of GCSEs, but have fantastic talents—invariably, the significant majority of them women in our community—and they are emotionally intelligent, they like working with people. Most importantly, they're motivational coaches, and they are what I call a 'fixer', not in the sense—. If you know the east end of London tradition, not in the east end sense; I mean that person in your organisation—. For me, it's my personal assistant, Annie, who is just brilliant. I say, 'Look, Annie, I've got this problem. I don't know how to do it.' And she just goes away and she beavers away and finds the solution. And it's that sort of characteristic that you're looking for in social prescribers. And then, most importantly, as the chair of the CCG, I then put it in every practice in Tower Hamlets about 10 years ago, and then persuaded the English Government to put it in every practice in the country. It's still early days, but imagine what the potential is for that, what a support that is to the NHS, which is pressurised wherever you go, and how it engages patients. And guess what? Growing evidence of really good outcomes and reduced pressure on the NHS.

There we are. Any further questions, Gareth?

I appreciate that answer, Sam and, just to follow up on that one, really, is just to ask about the evidence around the quality of the outcomes for the individuals and then for things like return on investment and then reducing the pressure and the burden on the NHS and GP services like yourself.

So, I suppose it's about proving that where's an investment there's a saving coming through to the NHS.

Yes. So, it's much more difficult to prove than if you put somebody on a drug and their blood pressure goes down. But there is a whole raft of evidence we've got, and projects where we can show some amazing outcomes. So, one of our projects was called DIY Health, and basically, we took mums, dads and their young kids who had presented with minor ailments, and we basically did teaching sessions. And it included, by the way, skin disease: so, we got the young kids to get dinosaurs, and we called it the Eczemasaurus project, and then they bathed the dinosaurs in the various creams and things like that. But the main area of focus was actually how to manage minor ailments, and what was quite extraordinary was this reduced attendance in general practice by 30 per cent for minor ailments, which is significant. But, even more stunning in some ways, the same we found in the local casualty. That's just one example of a very powerful intervention where you get social prescribers involved. We're getting growing evidence now of a reduction in the use of things like opioids in prescribing, but there's a lot more work to be done around evaluation.

If you take one of our projects, which is knife crime in casualty with social prescribing, an amazing professor there, a surgeon, Martin Griffiths, just got fed up of just sewing people up and seeing them come back again. So, he set up social prescribing with a charity and followed people up to six months afterwards and reduced reattendance in casualty with a knife wound. And don't forget, quite often, people who are the victims sometimes are the perpetrators. A lot of it in our area is around gangs. It reduced reattendance in casualty from just over 30 per cent to near 1 per cent with knife crime—quite stunning. This is really, really powerful stuff.

I suppose the other thing I would say with all of this is that it brings a lot of joy, not just to patients, but actually teams, and that's really difficult to capture and evaluate. I can say to you there isn't a day I don't go in with a spring in my step to the Bromley by Bow Centre, because you never know what's going to be there. You're sitting down having cups of tea with a whole raft of amazing people who are doing different projects. That is just amazing, and that's a complete morale booster in a time where, actually, the burnout and stress of doctors and nurses in the NHS is pretty appalling.

There's some very clear evidence, and some of my colleagues can give you a lot more evidence around the country if there are very specific things you're interested in, but part of it is winning hearts and minds. It's why we learnt years ago, at Bromley by Bow, that you can always come up with the data and the figures, but winning hearts and minds is what's really important. So, we get governments from around the world now visiting us for half a day to a day and we just get them to taste and challenge what we're doing and question it, and that's incredibly powerful. It's not the traditional form of evaluation, but seeing, tasting, smelling is really, really important, actually, to get people to understand, and then to go away and do something very different.

A GP friend of mine in Leicester has got a police station in her waiting room. That's social prescribing. That came, as with a lot of social prescribing projects, just from having a dinner with the superintendent in Leicester and then saying, 'Well, why don't we try something different?' What is extraordinary is if you met, as I did a few years ago, those two policemen in the surgery, with a little blue light off their room. They sat down and had coffee in the waiting room, and they were liked by the community. This was a new experience for them. It's pretty difficult for police, actually, to be liked in deprived areas. But their bosses thought they were amazing because they reduced the crime rate on the local housing estate to 20 per cent of what it was before. And whereas houses were being boarded up, actually, there was now a queue to go on that estate. That's just one example.

The beauty of social prescribing is that people often come to Bromley by Bow and they say, 'Yes, but I haven't seen this anywhere else', and I say to them, 'Yes, it's different wherever you go'. The underlying philosophies are the same, but how it develops is by relationships and people's passions. You follow people's passions, and you'll get the most amazing innovation and co-operation. Those are the two, to me, key techniques of change management. If I'm being a bit tough, that's sometimes not always the focus of the NHS, which tends to rely on command and control as its main mechanism of change.

Thank you, Sam. I almost don't want to ask you any more questions—I just want you to talk to us for half an hour. It's fascinating. So, we'll treat this a bit like an ongoing conversation, perhaps, where Members dip in and dip out. Rhun, do you want to come in at this point?

You said at the outset that you can't distinguish between the emotional, the physical and the mental when you're looking at treating somebody and looking at how to deal with them. To what extent is injecting the social prescribing element key to ensuring you have that holistic broader view of a patient's well-being and seeking better outcomes for them?

Social prescribing is crucial to it. I mentioned the philosophy of it's not what's the matter with you. What do I mean by that? Well, we're taught to label people: 'You're a diabetic', 'You're an alcoholic', 'You've got mental health problems', 'You're a schizophrenic'. Social prescribing does the exact opposite. It says, 'That's just part of you. That's part of an issue for you, but it's the whole of you that counts'. So, in all of our various projects, there's not a disease label attached to them. For example, we have a 50-year-old patient—and she doesn't mind me telling you about this—and she got throat cancer. She had surgery, but of course couldn't speak afterwards, so she came to our art courses, because we've got various arts studios—stained glass windows and pottery—which work with the community care group. She didn't like it, and then came to our IT group, developed amazing IT skills and is back in employment. It's about looking at the individual and seeing what will motivate them, and what are their needs—coming from them, their needs, their family, the community that they are in, and absolutely focusing on that.

Traditionally as a doctor I would have been told to say to a patient, 'Well, what you need is to jog for five miles every day'. Well, you and I know this is massively unrealistic. Actually, the conversation you have is, 'Tell me a bit about yourself. What are your passions? Ah, so you like gardening. Ah, okay'. Or it's, 'You've got a young child; does your young child swim? Ah, you'd like to teach them to swim'. So, it's really looking at them as individuals and helping them through that process, and to get away from the label. Of course, we know this is really important, particularly in mental health, because particularly if you look at people with severe mental health, guess what, physical health goes hand in hand. And so, if you're not dealing with both at the same time, you're just not going to get anywhere at the end of the day.

And by the way, social prescribing is also about challenging—. It's very easy for me as a doctor; a patient comes in and their cholesterol is raised, and I can say, 'Well, I've got a magic cholesterol drug, a statin, to prescribe you'. The patient can think, 'Ah, that's wonderful—Sam's got a wonder drug', and people then go away happy. But it's incredibly superficial, and it's actually very dangerous, because the risk in all of that is that the patient will say, 'Well, that's great. I can carry on not exercising, eating chicken and chips every day and having lots of alcohol to drink because Sam's given me a wonder pill'. And it's very tempting then for me to be able to feel quite satisfied, because, guess what, I'm following NICE guidance. It's about really turning it on its head and supporting patients.

There is a very real reason why I'm Sam to all my patients, why I've never worn a tie, and this is about a partnership with patients. Actually, if you see me in my consulting room, I sit next to patients. This is really, really important, because when you get a patient engaged in managing their own care, the outcomes are amazing. If you just get a patient to measure their blood pressure, which is what we do now in the practice, with a machine themselves, the research in the British Medical Journal shows that their blood pressure is 5 mm lower. It doesn't matter where you look, whether it's diabetic care or any of these things, a patient engaged in managing their care is going to be far, far more successful. But we do have still, because of the training we've had, and because of the way we've always done things in this country, the great sense that, actually, 'All I've got to do is listen to the doctor'—well, it just doesn't work, particularly with long-term conditions. It's different if something's acute. Then you just want somebody to give you straight, simple advice. 

I was going to ask you exactly about that point, the short term versus the long term. Because if you're not feeling well today, you can have a pill that hopefully will make you feel better tomorrow. Hopefully there won't be a recurrence, and you'll be better in the long term. With social prescribing, is there a risk that it's a short-term answer to a problem faced by somebody at a particular point in their lives, or do you generally find that getting the social prescribing right, prescribing the right things in the right way, getting people to think in a different way, really does lead to longer term behavioural changes that have an impact for the rest of their lives?

Absolutely. I wanted to give you some other examples—actually, an example in the acute mental health care scenario, one of our vanguards. I was, for Simon Stevens, for NHS England, the clinical lead for the vanguards movement in England, of which there were 50. One of them was an amazing mental health trust that reduced acute admissions by a third with the social prescribing approach. What did they do? They opened up a cafe, seven days a week, staffed by mental health workers. Once you start taking on this social prescribing, it gives long-term benefits too, if you know you've got that support available anytime.

An example I would give you is that one of the things that's absolutely critical, and what we do in Tower Hamlets—although it's not spread across the country—is to manage that 5 per cent of patients who need proactive care. So, that's people with severe mental illness, those who are housebound, terminally ill and need really complex care. We then have a multidisciplinary team, including the social prescribers, psychiatrists, the geriatrician, the Macmillan nurse, the GP, the practice nurse, who meet once a month and go through all these patients in a room, with a screen, and proactively manage them. What comes out of that, particularly the social prescribing, and you see it at the fore in relation to terminal illness—and there's a big mental health element to that; it's really important not to forget that—is that, actually, people are supported to manage people dying at home. 

In England, 47 per cent of people with a terminal illness die in hospital. To me, that's shameful, and I don't think there's probably a single person here today who wouldn't choose instead to die at home, surrounded by their loved ones. We can do that. We do that with a multidisciplinary team, with the wraparound for patients with really complex and difficult problems. And it's simple things, like all of these patients get my mobile phone number, so they can ring me anytime. And actually, do you know what, it's less work. It's really extraordinary and it's counterintuitive to a lot of people, because they're really worried about that personal approach. But, they all get my e-mail and mobile phone. In fact, I got rung up out in the North sea when I was sailing on one occasion, and sorted out a problem. And you can sort it out, because they're ringing somebody they know and who they trust. It's often the very simple problems that need solving. If, by the way, you can help somebody die at home, the reduction in bereavement and getting rid of pathological bereavement is intensely powerful.

I had a 32-year-old woman who was terrified of managing her mother, who was dying at home. The mother died, and she range me in the middle of surgery, and she said, 'Sam, my mum's just died. Could you pop around at some point?' Now, listen to the calmness there. This was somebody who was terrified of managing the situation. So, I went around about an hour later, with the death certificate. They're a Muslim family, and it's very important they're able to bury their loved ones within the 24 hours. The house was full, as is typical in the Bangladeshi tradition. There were at least 50 people there, so you have to do the equivalent of the last rites in front of them. I sat down with this daughter, and we talked about what we were going to put on the death certificate. And then I looked at her and I said, 'Look, I need to say something on behalf of your mother. You have been amazing and you have given the best gift you could give to anyone that you love, and that's a good death.' I have seen her since, by the way, and of course there's sadness, and of course we all have guilt of something we did, something we said that was sharp a year or two years ago, but her bereavement is a hundred times better, and that all comes from this multidisciplinary team. The social prescriber is critical to that, and basically goes into the house and deals with all of those very simple, practical things that enable this to happen.

Sam, what needs to happen for you to come and work in mid Wales? [Laughter.] It's not a serious question, but I say that because my constituents contact me complaining about the triage system that they're practising. You're giving out your mobile number, so a staggering difference. Thanks, Sam. This is great, fascinating stuff. Ken, do you want to come in?

Yes. Thanks, Chair. It is absolutely fascinating. I remember speaking to someone in the medical field recently, and I was telling them about my interest in Gabor Maté, and his work that looks at the link between mental health, wellness, ill mental health and poor physical health, and, in particular, how isolation, along with raised levels of cortisol over a sustained period of time, can contribute to the development of cancer in a lot of people. But it was dismissed as just being wacky. What do you think needs to be done to get more buy-in from GPs and other stakeholders who might feel that social prescribing and the sort of success that you've had is not for them?

So, we gets lots of people to come to us at Bromley by Bow, and one of the key things that I do is not the command and control. I don't say, 'Do this.' We take them round, we get them to meet people completely spontaneously, and that's really powerful because they have conversations with people about what they're doing. And then, the second half of the day is getting them to think what have they learned and how do they apply that, and how do they follow their passions, and how do you say 'yes'. Our systems in the NHS are very good at saying, 'no': 'Give us a business case' or 'Yes, we'll send it to that committee.' You know all the ways people say 'no'.

Part of the culture that we engender is just a 'yes' culture, so that when a district nurse—. In fact, we don't have this clinic any more because we didn't need it, but a district nurse was really struggling with leg ulcers. Leg ulcers are mainly in women who are elderly—smelly wounds—who lost their self-esteem and confidence, and became increasingly housebound because of this. She said, 'We need to do something different. I can dress these wounds brilliantly, but I need something more.' So, she set up a leg ulcer and flower-arranging clinic. Now, you can imagine if you'd said that to some of our managers in the NHS, they'd probably—. You can understand what the response would be. What did we say? 'Absolutely yes'. Of course, she'd worked out exactly what needed to happen. She needed to bring the joy and then the mobility back into people's lives, because it was good dressing, but it was the mobility that was absolutely crucial to not just curing, but preventing the ulcers from coming back again. 

So, there's something about creating a culture of 'yes' and letting people follow their passions. I went out to Denmark a few years ago, and they're still behind us, I think, very much in general practice, and I did a work group with everyone where we literally sat around the room. The first question I asked all the GPs was, 'What is your passion in life?', because I'd set them the task of redesigning their waiting room. My passion is gemstones; I love going to auctions to get a gemstone, so you can imagine I'm very popular with my wife. [Laughter.] So, that was my passion. We went round the room and we talked about passions, and then we said to them, 'How are you going to bring that passion into your work, into the design, or setting up a voluntary group, or whatever it is?' The answer is always focused on the win-win, going back to that original referral form that I talked about. I'd gone to the GPs and I'd said, 'This is what I might want you to do, but what is it you want? What's your problem that we need to help you solve?' And if you do that, I think it can be really successful.

But, I suppose, finally I'd say they need to be able to taste it, and there are now friends of mine all over the country, and, actually, there are some fantastic projects in Wales. I think you should be really proud of some of the things that are going on in Wales. I would say probably of the nations, you've really picked up on this issue. I've always had the sense it's so natural to the Welsh culture to do this. So, there are lots of good examples, but people need to go and taste it. And I always say, if you've always drank plonk and never tasted champagne, how would you know the difference? So, there's something about going and actually sampling it, but not to be told what to do—not the traditional approach—but actually, 'So, what does that mean for you, and what could you do that would be very different in your particular health setting?'

Anything else, Ken, or shall I go on to Joyce?

On to Joyce is fine, thanks, Chair. Thanks, Sam.

Lovely. Joyce.

One of the challenges we've heard about, and of course you're right in the middle of it, the area, is reaching and giving appropriate services to culturally diverse groups of people. The other area, and you mentioned it, is reaching out to younger people, to children in some cases. We took evidence this morning that maybe the cultural diversity is being addressed to some degree, but it doesn't seem that the children are engaged in this, from the people we've spoken to before speaking to you. So, what advice could you give us to widen that availability?

On the cultural diversity thing, you can come to Bromley by Bow and you'll see a Muslim veiled woman sitting next to a white young man and it's not an issue. So, how do you make that sort of thing happen? There's something there about the trust people feel in the health setting. It's a very safe space. After all, something like 90 per cent of patients will come and see us in a year period. Once you have got that trust, you say, 'Well, how can we use it?'

For example, we have one of our advocates, Fatima, who's been with me for 20 years—absolutely amazing. She has got together a lot of Bangladeshi women and the project's called 'Grannies in the Kitchen', she also has a walking group with these women. She's incredible. When you start engaging with a community like that, it's amazing. Having her in the consultation is just incredible. You can have five minutes of conversation between her and the patient and then she turns to me and says, 'Sam, this person's got gastritis, you need to treat them with omeprazole.' So, it's about using the wider team. Using your community networks is really important.

Interestingly, the presumption often is, 'Here I am, a white male, I'm least likely to be consulted by a woman, a Muslim woman.' It's not the case. It's not the case, and it's partly because you're trusted, partly because I've been a GP in the community for 32 years. Actually, I'm here in social housing, I'm a leaseholder, right in the middle of my community, and most importantly, and particularly when you do the social prescribing, people get to know that you can help them fix their problems. Then, those barriers tend to drop and people stop seeing you as a white male; they actually see you as their doctor, as their social prescriber, as someone who can help them. So, that's the diversity thing, but it is a real challenge.

We had the highest COVID death rates in the country and the lowest COVID vaccinations, and that was actually driven by the fact that—. Despite the fact we kept on telling them at the centre that we needed to move the vaccination down to every practice level, it was too late by the time all the suspicions and the social media and everything like that—that had a very distortional, pernicious effect on the ethnic minority community.

On the children—. So, social prescribing, whenever you talk to people, it's mainly about people with long-term conditions and the elderly, but we're starting to do something on children. I'm passionate about this because, if you look at some of the stats, and it's clearly worsened during COVID, in London: 40 per cent overweight and obese; 40 per cent of five-year-olds with severe dental caries—it's normal for my generation, my children don't have any, even brought up in this area; about 25 per cent of teenage girls self-harming. And God knows what's happened under COVID, actually. The increase in the inequalities, and what's being done about it? The answer is, 'Very little.'

So, we're piloting social prescribing in three schools, including a secondary school where the chair of governors is one of my GP partners. I've just completed 10 years as the governor of a primary school. My challenge, actually, would be—. Look, I've got five children; yes, if they get grade 9s at GCSE and three A stars, great, but, do you know what, most of all, I want my 18-year-old coming out of the school system being happy and healthy and ready to face the challenges. So, why wouldn't you have a nurse in every school? In Tower Hamlets actually, interestingly, the GP runs the school nursing contract, but we only have one whole-time equivalent for six schools. And if you have that nurse—. And, by the way, I always use the word 'nurse' because that's very popular and people understand it; they don't always understand 'social prescriber'. But imagine our nurses now are actually skilled social prescribers too. So, imagine this person who does mental, physical and social health for all the pupils in the school, and imagine them sitting on the governing board. Yes, we have somebody responsible for safeguarding on the governing boards of schools, but why don't we have somebody very specifically focusing on health, ensuring that every meal they have in school is healthy, that they're outside every day for an hour? Half of my kids are vitamin D deficient. And, certainly, in my community, it's just awful. The amount of damage caused, both physical and mental, by them just being in lockdown in their high-rise flats with no access to gardens was just extraordinary.

And, so, the social prescribing project is very exciting. I'm absolutely clear, when the evaluation is done in a few months' time, that we will be able to show amazing outcomes. The challenge for us is to persuade Governments and Ministers that this is critical. And one of the challenges I've posed as a commissioner, and I've posed it actually to my financial director, is: ask the simple question, 'How much money in the NHS is spent by age?' They can't answer the question. And, really, that is pretty shocking, isn't it? And what I would say, and my son would say, because it's the sort of thing he says to me, is, 'Far too much is spent on old gits like me'—that's how he would put it. But he's right. He's right. It's not fair, it's not balanced and people don't even know the answer to that question.

And, so, we spend so much money in the NHS picking up the pieces of entirely preventable diseases because we don't intervene earlier. So, we have, by the way, a local contract that we developed between our commissioners and general practice to the tune of £11 million in Tower Hamlets alone, which focuses on immunisation, mental health, diabetes, and ensures that you're intervening earlier on in the illness. So, you're not picking up the pieces of somebody with diabetes, for example, when they're at the point they need an amputation. That should be something of the past.

Thank you, Sam. Do any Members want to come in? I think Ken might want to come in on a point, but does anybody else want to come in with a question to Sam, or are you happy just to sit back and listen to Sam talk? Ken, go for it.

No, I was just in agreement, based on a committee inquiry that we had on the children's committee recently. Sorry.

Do you have any other questions, Ken?

I've got one more, yes.

Go for it. 

Just a quick one. And it involves the provision of services and activities aligned with social prescribing. Is it more difficult to be able to offer patients social prescriptions in rural areas, where there may be more limited availability of services, or is it just a case of identifying their passions and then identifying what there is available locally?

It's different in rural areas, but it's exactly the same. So, I've got a friend who's a GP on the west coast of Scotland and is an amazing social prescriber. So, for example, he saw that his elderly patients, when they got very frail, moved to a nursing home 30 miles away. That's devastating for somebody. So, guess what? He built sheltered housing next to the surgery. The post office was going to close, so he turned it into a co-op owned by all the local community. It sits there and with the profit it makes now—. The post office is still going and it's got a van that takes people around the local community. It sits there, saying, 'How are we going to spend our money this year?' So, it's building, for example, a local garden.

So, I think, it's no different in community areas. I think one of the things you always need to think about is: it's very easy for a GP or a commissioner to automatically say, 'What can I do for you?' But, actually, what social prescribers also say is, 'What can you do for me?' So, actually, every patient is an opportunity, somebody who might want to lead a group or has a passion of their own.

The other thing is, obviously, critical to all of this is the financial resource, and I haven't talked much about that. But there are two elements to Bromley by Bow in governance terms. The first one is the general practice, and the second one is the charity. And the charity brings in something like £4 million a year. Now, the general practice, one of the partners is the director of the charity, who's not a GP and is not paid by the general practice, but, basically, votes on what we do and how we spend our money. And then we, in turn, pay one of my partners to be his deputy. What you get when you start then doing that and sharing space, is a—. And Bromley by Bow started originally as a church; I actually got married there seven years ago, much to the amusement, actually, of all my team, who always accuse me of being married to my work. Once you get that partnership between the private, the voluntary, the state sector, you get an absolutely amazing extra resource that comes out of that. So, if you think about it from the NHS's perspective, there's a charity there bringing £4 million in to serving all my patients, but actually much more than that, because behind that sits an enormous number of volunteers in the process.

And then we've got relationships. So, we've got what we call our social enterprise part. So, we set up social enterprises; we've set up about 70. Sixty are still going—that's an incredible success rate for a start-up. And that's a project with Investec in the City, which is a really good company, which gives about £17,000 for each project to support the teaching and training of somebody to set up their own social enterprise business over a year period. It's that combination that is really powerful.

And I'm also on the ministerial infrastructure group. I've been a non-executive director of something called Community Health Partnerships, which is an NHS body that builds GP surgeries across the country. And key to all of this is, if you're ever going to build a school or a health centre again, just think, 'Who else? Who else could share that space?' On one of our surgery sites, we've got a pharmacy who are a social enterprise. We've now set up a social enterprise with them that is training pharmacists. So, it's thinking about all your levers—your money, your estates. The IT, by the way, is absolutely critical—we don't use paper; the only paper we ever get is from hospitals. The IT that sits behind all of this is incredibly powerful; the data is rich. If somebody wants to set up a project and, for example, wanted to know about women aged 30 to 40 with a body mass index of 25 to 30, we know: we can send them a text, 'Are you interested? We've got a project in mind—is this of interest to you?' That data that sits behind all of this is incredibly powerful.

Thank you, Sam. It's a really fascinating session. I suppose we've just got a couple of minutes left. And our role as a committee here in the Welsh Parliament is to scrutinise the Welsh Government but to make suggestions to them as well. So, these evidence sessions will bring about our report, and we'll make a series of recommendations. But is there anything that you can suggest to us that we should be making as a recommendation to the Welsh Government?

I'd say, 'Come and spend a day with us in Bromley by Bow.' And hopefully—keep fingers crossed—my experience is always that some magic will come out of it.

One of our committee members just said, 'Can we come as well?' 

Very welcome, very welcome.